Medical Team Evaluation: Effect on Emergency Department Waiting Time and Length of Stay

Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment

PURPOSE

The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage.

METHODS

Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707).

RESULTS

We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage.

CONCLUSION

We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.

The utility of the abdominal series in the emergency setting: a retrospective review

PURPOSE

The abdominal series (AXR) remains a frequently ordered test in the emergency department (ED), despite existing literature questioning its utility. The aim of this study was to characterize the use of the AXR in the ED by quantifying how often it is ordered and the frequency of subsequent imaging. Additionally, a time estimate in ED associated with the AXR was quantified. We hypothesized that there would be a low clinical utility of the AXR, and long associated time period spent in the ED.

METHODS

A retrospective audit of AXRs performed in the ED from January to December 2019 was performed. The local picture archiving and communication system (PACS) and electronic medical record were used to collect the variables.

RESULTS

Of 701 AXRs, 438 (62.4%) were reported normal, and 263 (37.6%) were abnormal. A Chi Squared test showed that the two variables (abdominal series result and follow up imaging completion) were significantly related, with p < 0.001. However, the effect size was small (Nagelkerke R square = 0.022). The average time spent in the ED for these patients was 7.27 h, and the average time between the AXR being ordered and interpreted was 1.31 h.

CONCLUSION

The majority of AXRs were reported as normal. Our results showed that AXR had a statistically significant, but low clinically significant predictive ability on subsequent imaging ordering. This supports our hypothesis that the AXR is of low clinical utility with respect to the rate of ordering follow up imaging. The AXR also translated to a quantifiable time interval during the patient's stay in ED. Minimizing overuse of the AXR may result in a decrease in patient duration in the ED.

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data

Background

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program.

Methods

Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.

Results

The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.

Conclusion

Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

Impact of Care Initiation Model on Emergency Department Orders and Operational Metrics: Cohort Study

INTRODUCTION

Emergency departments (ED) employ many strategies to address crowding and prolonged wait times. They include front-end Care Initiation and clinician-in-triage models that start the diagnostic and therapeutic process while the patient waits for a care space in the ED. The objective of this study was to quantify the impact of a Care Initiation model on resource utilization and operational metrics in the ED.

METHODS

We performed a retrospective analysis of ED visits at our institution during October 2021. Baseline characteristics were compared with Chi-square and quantile regression. We used t-tests to calculate unadjusted difference in outcome measures, including number of laboratory tests ordered and average time patients spent in the waiting room and the ED treatment room, and the time from arrival until ED disposition. We performed propensity score analysis using matching and inverse probability weighting to quantify the direct impact of Care Initiation on outcome measures.

RESULTS

There were 2,407 ED patient encounters, 1,191 (49%) of whom arrived during the hours when Care Initiation was active. A total of 811 (68%) of these patients underwent Care Initiation, while the remainder proceeded directly to the main treatment area. Patients were more likely to undergo Care Initiation if they had lower acuity and lower risk of admission, and if the ED was busier as measured by the number of recent arrivals and percentage of occupied ED beds. After adjusting for patient-specific and department-level covariates, Care Initiation did not increase the number of diagnostic laboratory tests ordered. Care Initiation was associated with increased waiting room time by 1.8 hours and longer time from arrival until disposition by 1.3 hours, but with decreased time in the main treatment area by 0.6 hours, which represents a 15% reduction.

CONCLUSION

Care Initiation was associated with a 15% reduction in time spent in the main ED treatment area but longer waiting room time and longer time until ED disposition without significantly increasing the number of laboratory studies ordered. While previous studies produced similar results with Care Initiation models accessing all diagnostic modalities including imaging, our study demonstrates that a more limited Care Initiation model can still result in operational benefits for EDs.

The Impact of Team Triage Method on Emergency Department Performance Indexes: A quasi-interventional study

Introduction

One of the effective methods of patient triage in the emergency department (ED) is the use of team triage, including physicians and nurses. Considering that there is no conclusive evidence about the effectiveness of team triage, this study aimed to investigate the effect of the team triage method on ED performance indexes.

Methods

The present study is a quasi-interventional study in which 200 patients were referred to the ED in the hospitals of Tabriz in 2020. Participants were randomly assigned to two groups (team triage and conventional triage) and were evaluated. Data were collected by a three-part questionnaire including the participants' demographic characteristics, the five-level triage form, and Press-Ganey satisfaction questionnaire were used. Data were analyzed by SPSS.22 statistical software.

Results

The results showed that the mean score of waiting time for the first physician visit in team triage was statistically significantly lower than the conventional triage (P = 0.001). Furthermore, the mean score of waiting time for receiving the first treatment in team triage was statistically significantly lower than the conventional triage (P = 0.001). Finally, the mean score of patients' satisfaction in team and conventional triage was statistically significantly higher in team triage (P = 0.001).

Conclusion

The study findings revealed that the team triage method, in comparison to conventional triage, decrease the waiting time for receiving the first service and length of stay, but leads to more patient's satisfaction. Therefore, to improve the performance indicators of the ED, it is recommended that hospital managers use the team triage method.

Implementation of advanced triage in the Emergency Department of high complexity public hospital: Research protocol

AIM

To evaluate the efficacy of advanced nurse triage based on the quality of care outcomes of patients attending the Emergency Department of a high-complexity hospital. To analyse the concept of advanced triage and the essential elements of the construct.

DESIGN

Mixed longitudinal study, divided into 4 steps; which will include an initial qualitative step, two observational studies and finally, a quasi-experimental study.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05230108.

METHODS

Step 1 will consist of a concept analysis. Step 2 will include a mapping of advanced practice protocol terminologies. Step 3 will analyse the opinion of health professionals on advanced triage. In step 4: in the retrospective phase (n = 1095), sociodemographic and clinical variables and quality indicators such as waiting time will be analysed. After that, in the prospective phase (n = 547), advanced triage will be implemented and the two cohorts will be compared. The whole study will be carried out from January 2022 to January 2024.

DISCUSSION

Patients classified as low complexity at triage are more vulnerable to emergency department overcrowding. The implementation of advanced triage would make it possible to respond to patient needs by offering equitable and quality healthcare, facilitating accessibility, safety and humanization of the emergency department.

The multicenter impacts of an emergency physician lead on departmental flow and provider experiences

INTRODUCTION

Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences.

METHODS

Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact.

RESULTS

The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations.

CONCLUSION

In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.

Patient disposition using the Emergency Severity Index: a retrospective observational study at an interdisciplinary emergency department

OBJECTIVES

Early patient disposition is crucial to prevent crowding in emergency departments (EDs). Our study aimed to characterise the need of in-house resources for patients treated in the ED according to the Emergency Severity Index (ESI) and the presenting complaint at the timepoint of triage.

DESIGN

A retrospective single-centre study was conducted.

SETTING

Data of all patients who presented to the interdisciplinary ED of a tertiary care hospital in Munich, Germany, from 2014 to 2017 were analysed.

PARTICIPANTS

n=113 694 patients were included.

MEASURES

ESI Score, medical speciality according to the chief complaint, mode of arrival, admission rates and discharge destination from the ED were evaluated.

RESULTS

Patient disposition varied according to ESI scores in combination with the chief complaint. Patients with low ESI scores were more likely to be admitted after treatment in the ED than patients with high ESI scores. Highly prioritised patients (ESI 1) mainly required admission to an intensive care unit (ICU, 27%), intermediate care unit (IMC, 37%) or immediate intervention (11%). In this critical patient group, 30% of patients with neurological or medical symptoms required immediate intensive care, whereas only 17% of patients with surgical problems were admitted to an ICU. A significant number of patients (particularly with neurological or medical problems) required hospital (and in some cases even ICU or IMC) admission despite high ESI scores.

CONCLUSIONS

Overall, ESI seems to be a useful tool to anticipate the need for specialised in-hospital resources on arrival. Patients with symptoms pointing at neurological or medical problems need particular attention as ESI may fail to sufficiently predict the care facility level for this patient group.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding

PURPOSE

Access block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the "boarding restriction protocol" that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding.

MATERIALS AND METHODS

The primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated.

RESULTS

The mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4-1587.1) minutes to 630.2 (398.0-1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5-482.8) minutes to 344.7 (213.4-519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5-1149.0) minutes to 204.1 (98.7-545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period.

CONCLUSION

The boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays.

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

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

Implementation of a standardized pregnancy screening process to address gender disparities in radiology turn-around-time and ED length of stay

OBJECTIVE

The objective of this initiative was to quantify and intervene upon suspected gender disparities in CT turn-around-time and emergency department (ED) length of stay.

METHODS

This was a single-site before-after quality improvement initiative including patients aged 12-50 who underwent CT chest and/or abdomen/pelvis. The intervention included protocolization of the pregnancy screening process in triage. Primary outcomes included the difference between women of childbearing age and similarly aged men in regards to CT turn-around-time and ED length of stay. Pre- and post-intervention data were analyzed, including an "intensive intervention period" subanalysis.

RESULTS

CT turn-around-time for women of childbearing age was 19 min longer than for similarly aged men at baseline and did not change significantly post-intervention. ED length of stay was 27 min longer for women of childbearing age compared to similarly aged men at baseline and 7 min longer post-intervention, although this was still a significant difference. During the intensive intervention period, CT turn-around-time for women of childbearing age was 15 min longer than similarly aged men but the difference in ED length of stay of 10 min was no longer significant.

CONCLUSIONS

There is gender disparity in CT turn-around-time and ED length of stay in our ED, highlighting an important area for improvement to promote equitable care. A quality improvement initiative that aimed to protocolize pregnancy testing in triage did not show sustainable improvement in these outcomes but did result in increased pregnancy testing.

Rapid triage performed by nurses: Signs and symptoms associated with identifying critically ill patients in the emergency department

AIM

Aim of this study is to identify signs and symptoms associated with identifying critically ill patients by rapid triage assessment performed by nurses in an emergency department.

BACKGROUND

In some emergency services, the immediate assessment of critically ill patients occurs before opening the hospital formal registration and it is based on the nurse's experience. Studies on the topic are essential to improve this process.

DESIGN

This is a cross-sectional, quantitative study.

METHODS

This study was conducted in a Brazilian emergency department in 2017. Adult patients who presented potentially life-threatening symptoms underwent rapid triage to determine the medical urgency. Those identified as being critically ill were classified as high priority and streamed to the emergency room.

RESULTS

A total of 154 (84.6%) patients were classified as high priority from the total of 182 evaluations. Altered state of consciousness (35.2%) and altered skin perfusion (25.3%) were frequently identified. Signs and symptoms associated with identifying critically ill patients by rapid triage were alterations in ventilation (OR 6.09; p = 0.028), neurological dysfunction (OR 44.96; p < 0.001) and pain (OR 5.80; p = 0.004).

CONCLUSION

Nurses should value neurological and ventilation alterations and pain in patients during rapid triage, since these signs and symptoms are associated with high care priority.

What is the impact of team triage as an intervention on waiting times in an adult emergency department? - A systematic review

AIM

To examine the impact of team triage on waiting times in adult emergency departments.

DESIGN

A systematic review using narrative analysis.

METHOD

Systematic review methodology, which included quantitative research papers consisting of randomized control trials, cohort or quasi-experimental studies. The PICO framework was used to formulate the question. Using a structured search, databases were used to source the research papers. Databases searched were Cochrane, CINAHL and MEDLINE. Twelve (12) research papers met the inclusion criteria. Each of the 12 papers were quality appraised using a recognised checklist. Data extraction was carried out and the findings were analysed using a narrative approach.

RESULTS

It was found that senior emergency doctors in triage alongside the triage nurse allows for more timely decision making and appropriate investigation orders. Early bed requesting or referral to specialist consultation were also found to improve waiting times. Reduced numbers of patients who leave without being seen and lower mortality rates were recorded when using team triage. Patient satisfaction is also improved by team triage.

CONCLUSION

Team triage improves waiting times in the emergency department.

Utility of the Emergency Severity Index by Accuracy of Interrater Agreement by Expert Triage Nurses in a Simulated Scenario in Japan: A Randomized Controlled Trial

OBJECTIVE

The Emergency Severity Index (ESI) is a highly reliable and valid triage scale that is widely used in emergency departments in not only English language regions but also other countries. The Japan Triage and Acuity Scale (JTAS) is frequently used for emergency patients, and the ESI has not been evaluated against the JTAS in Japan. This study aimed to examine the decision accuracy of the ESI for simulated clinical scenarios among nursing specialists in Japan compared with the JTAS.

METHOD

A parallel group randomized trial was conducted. In total, 23 JTAS-trained triage nurses from 10 Japanese emergency departments were randomly assigned to the ESI or the JTAS group. Nurses independently assigned triage categories to 80 emergency cases for the assessment of interrater agreement.

RESULTS

Interrater agreement between the expert and triage nurses was κ = 0.82 (excellent) in the ESI group and κ = 0.74 (substantial) in the JTAS group. In addition, interrater agreement by acuity was level 2 = 0.42 (moderate) in the ESI group and level 2 = 0.31 (fair) in the JTAS group. Interrater agreement for triage decisions was classified in a higher category in the ESI group than in the JTAS Scale group at level 2. Triage decisions based on the ESI in Japan maintained the same level of interrater agreement and sensitivity as those in other countries.

CONCLUSION

These findings suggest that the ESI can be introduced in Japan, despite its different emergency medical background compared with other countries.

Barriers to Integration of Primary Care into Emergency Care: Experiences in Germany

Introduction

In response to emergency department over-crowding primary care practitioners (PCPs) have been incorporated into care pathways to provide integrated care. We consider why a pilot project of PCP-led streaming in a German emergency department failed, the challenges encountered transplanting models between differing systems and cultures, and if the concept constitutes integrated care.

Theory and Methods

The original design was a mixed methods data gather around PCP-streaming of non-urgent self-referrers in an emergency department.

Results

The demand for the PCP-streaming was low, which was at odds with pre-study estimates. The study was stopped prematurely without adequate data; this is an opinion-based article.

Discussion

A fundamental of emergency care is a central emergency department. An emergency department can be the fulcrum from which urgent inter-disciplinary hospital care is initiated and coordinated. Objective triage is fundamental to this and regional healthcare planning. With such fundamentals in place, PCP integration has the potential to facilitate and provide integrated care. Relevant elements of the Rainbow Model of Integrated Care frame the discussion.

Conclusion

The key element deficient in each barrier to our project, yet present in successful studies, was normative integration.

Exploring overcrowding trends in an inner city emergence department in the UK before and during COVID-19 epidemic

Background

The COVID-19 pandemic and the associated lockdowns have caused significant disruptions across society, including changes in the number of emergency department (ED) visits. This study aims to investigate the impact of three pre-COVID-19 interventions and of the COVID-19 UK-epidemic and the first UK national lockdown on overcrowding within University College London Hospital Emergency Department (UCLH ED). The three interventions: target the influx of patients at ED (A), reduce the pressure on in-patients’ beds (B) and improve ED processes to improve the flow of patents out from ED (C).

Methods

We collected overcrowding metrics (daily attendances, the proportion of people leaving within 4 h of arrival (four-hours target) and the reduction in overall waiting time) during 01/04/2017–31/05/2020. We then performed three different analyses, considering three different timeframes. The first analysis used data 01/04/2017–31/12–2019 to calculate changes over a period of 6 months before and after the start of interventions A-C. The second and third analyses focused on evaluating the impact of the COVID-19 epidemic, comparing the first 10 months in 2020 and 2019, and of the first national lockdown (23/03/2020–31/05/2020).

Results

Pre-COVID-19 all interventions led to small reductions in waiting time (17%, p < 0.001 for A and C; an 9%, p = 0.322 for B) but also to a small decrease in the number of patients leaving within 4 h of arrival (6.6,7.4,6.2% respectively A-C,p < 0.001).

In presence of the COVID-19 pandemic, attendance and waiting time were reduced (40% and 8%; p < 0.001), and the number of people leaving within 4 h of arrival was increased (6%,p < 0.001). During the first lockdown, there was 65% reduction in attendance, 22% reduction in waiting time and 8% increase in number of people leaving within 4 h of arrival (p < 0.001). Crucially, when the lockdown was lifted, there was an increase (6.5%,p < 0.001) in the percentage of people leaving within 4 h, together with a larger (12.5%,p < 0.001) decrease in waiting time. This occurred despite the increase of 49.6%(p < 0.001) in attendance after lockdown ended.

Conclusions

The mixed results pre-COVID-19 (significant improvements in waiting time with some interventions but not improvement in the four-hours target), may be due to indirect impacts of these interventions, where increasing pressure on one part of the ED system affected other parts. This underlines the need for multifaceted interventions and a system-wide approach to improve the pathway of flow through the ED system is necessary.

During 2020 and in presence of the COVID-19 epidemic, a shift in public behaviour with anxiety over attending hospitals and higher use of virtual consultations, led to notable drop in UCLH ED attendance and consequential curbing of overcrowding.

Importantly, once the lockdown was lifted, although there was an increase in arrivals at UCLH ED, overcrowding metrics were reduced. Thus, the combination of shifted public behaviour and the restructuring changes during COVID-19 epidemic, maybe be able to curb future ED overcrowding, but longer timeframe analysis is required to confirm this.

Team triage increases discharges and decreases time to discharge without increasing test ordering

OBJECTIVES

Emergency department (ED) crowding is detrimental to patients and staff. During traditional triage, nurses evaluate patients and identify their level of emergency. During team triage, physicians and/or nurse practitioners (NPs) and physician assistants (PAs) place orders, laboratory results, intravenous lines (IVs), and imaging in triage. Team triage improves access to testing and decreases length of stay. However, ordering practices in team triage may lead to overtesting.

METHODS

This is a retrospective review of patients seen before and after a team triage process was established. Percentage of patients receiving testing and the diagnostic yields of troponins, lactates, international normalized ratios (INRs), blood cultures, glomerular filtration rates (GFR), and head computed tomography (CT) images were studied.

RESULTS

A total of 704 traditionally triaged patients and 862 team triaged patients met inclusion criteria. Comparing traditional versus team triaged patients, the proportion of patients discharged was 0.44 versus 0.53 (P < 0.001), and the length of stay to discharge was 417 versus 375 minutes (P = 0.003). Comparing traditional versus team triage, a head CT was obtained 12.5% versus 5.7% (P < 0.001) of the time with diagnostic yield 45.5% versus 52% (not significant), troponin was obtained 51.3% versus 45.9% (not significant) of the time with diagnostic yield 14.9% versus 13.9% (not significant), lactate was obtained 41.6% versus 32.1% (P = 0.011) of the time with diagnostic yield 18.4% versus 12.3% (not significant), INR was obtained 70.2% versus 55.8% (P = 0.007) of the time with diagnostic yield 15.8% versus 10.5% (P = 0. 042), GFR was obtained 99.3% versus 98.4% (not significant) of the time with diagnostic yield 18.9% versus 13.7% (P = 0.02), and blood cultures were obtained 23.4% versus 7.3% (P < 0.001) of the time with diagnostic yield 7.3% versus 9.3% (not significant).

CONCLUSION

Compared with traditional triage, the team triage process increased discharges and decreased time to discharge, but did not lead to increased testing or decreased diagnostic yield.

Triage Accuracy and Its Association with Patient Factors Using Emergency Severity Index: Findings from United Arab Emirates

Introduction

The Ministry of Health and Prevention of the UAE acquired an electronic medical record system (Wareed) through which they incorporated the Emergency Severity Index as the standard triaging tool. This raised the need to review population dynamics and the accuracy of triage performed by the health-care providers utilizing the tool.

Objective

This research aimed to study demographics and dynamics of the population presenting to emergency departments (EDs) during 2018, evaluate the accuracy of triage assessment using comparative analysis techniques, and determine relationships between patient factors (severity of illness, age-group) and the accuracy of triage.

Methods

This was an observational study that aimed to ascertain findings from ED data over 1 year (January 2018-December 2018) and explore factors associated with reduced accuracy in acuity assignment. We employed comparative analysis to measure the level of agreement between standard guidelines and local findings.

Results

A total of 576,154 patients visited EDs in 2018, of which 54.4% were male. A statistically significant increase in length of stay with increasing severity of illness was observed (Kruskal-Wallis test). Overall triage accuracy was 41.6%, with a positive association with increasing severity of illness. We found a positive association between severity of illness and accuracy of triage (OR 0.14, p=0). We also found on logistic regression that the age-group 11-20 years had the highest probability of accurate triage acuity (R ²=0.41, p=0).

Conclusion

Conducted on a very large data set from the UAE, our study reflects upon population dynamics and triage accuracy distribution among different variables. This study paves the way for further in-depth analysis of factors that may impact triage accuracy within EDs, and utilizing a similar approach it can be replicated in other settings as well.

The challenge of interprofessional collaboration in emergency department team triage - An interpretive description

AIMS

To explore emergency nurses' and physicians' experience of collaboration and collective decision-making when triaging older Emergency Department patients within the interprofessional team triage system.

DESIGN

Qualitative.

METHODS

Semi-structured interviews were conducted with seven nurses and five physicians. Transcripts were analysed via Interpretive Description between September 2016-May 2017.

RESULTS

'Negotiating collaboration' was developed as the main theme. Three subthemes influenced the negotiation process: Participants described divergent opinions on how an optimal triage system should work ('preferences for triage systems'); they had conflicting perceptions of each profession's role ('role perceptions'); and they expressed different coping strategies regarding 'perceived time pressure'. The compatibility of participants' views on these sub-themes determined whether the nurse and physician were able to successfully negotiate their collaboration. These themes became more evident when the team triaged older ED patients.

CONCLUSION

Improving interprofessional team triage requires working with the involved nurses' and physicians' values and beliefs. The strengths of both professions need to be considered and a flexible approach to collaboration established according to the patients' situations.

IMPACT

Emergency Department leaders need to consider nurses' and physicians' values and beliefs to promote interprofessional collaboration in team triage.

Performance of the rapid triage conducted by nurses at the emergency entrance

Objective:

to compare the performance of the rapid triage conducted by nurses at the emergency entrance and of the Manchester Triage System (MTS) in identifying the priority level of care for patients with spontaneous demand and predicting variables related to hospitalization.

Method:

a cross-sectional study carried out in an Emergency Department (ED) of a university hospital in São Paulo. The priority levels established in the rapid triage performed by nurses were high priority (patients of spontaneous demand directed to the emergency room) or low priority (those referred to the institution’s usual flow). Diagnostic accuracy measures were calculated to assess the performance of the indexes.

Results:

of the 173 patients (52.0% female, with mean age of 60.4 ± 21.2 years old) evaluated, it was observed that rapid triage was more inclusive for high priority and had better sensitivity and worse specificity than the MTS. The probability of non-severe patients being admitted to the emergency observation unit was lower due to the rapid triage. For the prediction of the other variables, the systems presented unsatisfactory results.

Conclusion:

the nurses overestimated the classification of patients as high priority, and rapid triage performed better than MTS in predicting admission to the emergency observation unit.

Obstetric and fetal triage

Triage in healthcare is sorting patients by acuity to prioritize them for full evaluation. Standardizing this process with the use of triage acuity classification tools has been shown to improve patient flow and quality of care in the emergency department. The American College of Obstetricians and Gynecologists recommends that pregnant women be triaged based on acuity, rather than time of arrival, and that obstetric triage acuity scales can serve as templates for use at the facility level. Three obstetric triage acuity scales developed in North America are reviewed and the implementation of one in a system with 40 birth hospitals is described. Use of obstetric triage acuity scales resulted in timelier initial assessment and decreased wait times. Acuity, volume, and trends data helped improve nurse and provider staffing in triage units. These findings support the promise of obstetric triage acuity scales to promote efficient care.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

Physicians' Disease Severity Ratings are Non-Inferior to the Emergency Severity Index

Our objective was to compare informal physicians’ disease severity ratings (PDSR) at presentation with the well-established Emergency Severity Index (ESI) in order to test for non-inferiority of the discriminatory ability regarding hospitalization, intensive care, and mortality. We made a prospective observational study with consecutive enrollment. At presentation, the PDSR and subsequently Emergency Severity Index (ESI) levels were recorded. The primary outcome was the non-inferiority of the discriminatory ability (PDSR versus ESI) regarding hospitalization, intensive care, and mortality. The secondary outcomes were the reliability, the predictive validity, and the safety of PDSR. We included 6859 patients. The median age was 51 years (interquartile range (IQR) = 33 to 72 years); 51.4% were males. There were 159 non-survivors (2.4%) at the 30 day follow-up. The PDSR’s discriminatory ability was non-inferior to the ESI’s discriminatory ability. The safety assessment showed mortality of <0.5% in low-acuity patients in both tools. The predictive validity increased by 3.5 to 7 times if adding high-acuity PDSR to ESI in all categories with mortality of >1%. Our data showed the non-inferiority of PDSR compared with ESI regarding discriminatory ability, a moderate reliability, and an acceptable safety of both tools.

Defining "Swarming" as a New Model to Optimize Efficiency and Education in an Academic Emergency Department

BACKGROUND

Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model.

OBJECTIVES

To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model.

METHODS

This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori.

RESULTS

From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5).

CONCLUSIONS

Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.

Effectiveness of Implementing Emergency Severity Index Triage System in a Selected Primary Health Care Center in Oman: A Quasi-Experimental Study

BACKGROUND

Because most primary health care centers in Oman do not use a formal triage system, there are no available data on the effectiveness of implementing this system.

PURPOSE

To assess the effectiveness of implementing an Emergency Severity Index triage system in primary health care centers in Oman.

METHODS

A pretest/posttest quasi-experimental design was used. The sample comprised 187 patients before Emergency Severity Index implementation and 102 patients after implementation. Waiting time, length of stay, patient satisfaction, and accuracy of classification were compared across the 2 groups.

RESULTS

The mean time (hour:minute) from registration to triage was reduced in the post-Emergency Severity Index group (mean = 0:18, SD = 0:14) compared with the pre-Emergency Severity Index group (mean = 0:23, SD = 0:19) (t = 2.59, P = 0.01). Furthermore, the mean length of stay was reduced in the post-Emergency Severity Index group (mean = 1:09, SD = 0:37) compared with that of the preimplementation group (mean = 1:24, SD = 0:41) (t = 3.10, P = 0.002). Patient satisfaction in the postimplementation group was improved (mean = 66.95, SD = 8.33) compared with that of the Emergency Severity Index group (mean = 65.01, SD = 8.73), but it did not reach statistical significance (t = -1.83, P = 0.07). The inter-rater agreement of triage level in post-Emergency Severity Index implementation markedly improved in the postimplementation group (Cohen's kappa = 0.910, P < 0.001) compared with that of the preimplementation group (Cohen's kappa = 0.082, P = 0.005).

CONCLUSIONS

Although this is a single-setting study, the results have shown that the Emergency Severity Index system can contribute to a decrease in the negative crowding outcomes in primary health care centers in Oman.

Team Triage Intervention, Including Licensed Practical Nurse, to Increase HIV Testing Rates in the Emergency Department: A Quality Improvement Project

INTRODUCTION

Emergency departments have an important role in screening for human immunodeficiency virus infection and reducing the morbidity, mortality, and transmission of the human immunodeficiency virus. There are debates about human immunodeficiency virus screening, including opt-in, opt-out, and active choice models. Previous studies have shown that multiple factors affect the patient rate of acceptance, including where, when, and by whom the screening is offered. The purpose of this quality improvement project was to test a team-based triage intervention to improve the amount of HIV testing done in our emergency department.

METHODS

The design was a single site quality improvement intervention with post-intervention monthly rates compared to historic monthly rate controls. The intervention focused on the introduction of a Licensed Practical Nurse in addition to the current triage process and personnel. The percentage of patients receiving human immunodeficiency virus testing and the number of tests sent per month before and after the implementation of the intervention were measured.

RESULTS

Our results show that 0.6% (SD < 0.01) and 2.5% (SD 2.2) of patients received human immunodeficiency virus testing before and after implementation of the intervention, respectively (χ² = 501.76, P < 0.05). A mean of 37.4 (SD = 12.91) and 151.3 (SD = 33.34) human immunodeficiency virus tests were sent per month before and after implementation of the intervention, respectively (t = 8.53, P < 0.001).

DISCUSSION

This process intervention, in which licensed practical nurses offered human immunodeficiency virus screening tests during team triage, resulted in a 3-fold increase in the percentage of patients being tested for human immunodeficiency virus.

Clinical Scores and Formal Triage for Screening of Sepsis and Adverse Outcomes on Arrival in an Emergency Department All-Comer Cohort

BACKGROUND

Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown.

OBJECTIVE

Our aim was to compare the performance of qSOFA, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), and formal triage with the Emergency Severity Index (ESI) algorithm to identify patients with sepsis and predict adverse outcomes on arrival in an emergency department (ED) all-comer cohort.

METHODS

We included all patients presenting consecutively to the ED during a 3-week period. We used vital signs recorded at triage to calculate the study scores. Two independent assessors retrospectively assigned the primary outcome of sepsis according to Third International Consensus Definitions for Sepsis and Septic Shock criteria in a chart review process.

RESULTS

There were 2523 cases included in the analysis and 39 (1.6%) had the primary outcome of sepsis. The area under the curve for sepsis was 0.79 (95% confidence interval [CI] 0.71-0.86) for qSOFA, 0.81 (95% CI 0.73-0.87) for SIRS, 0.85 (95% CI 0.77-0.92) for NEWS, and 0.77 (95% CI 0.70-0.83) for ESI.

CONCLUSIONS

qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.

Older adults are prioritized in terms of waiting time under the emergency triage system in Guangzhou, China

AIM

To assess whether elderly patients are prioritized under the emergency triage system in Guangzhou, China.

METHODS

This was a cross-sectional survey of clinical data from adult visitors to the emergency department of the Third Affiliated Hospital of Sun Yat-sen University between 1 August 2015 and 31 December 2017. The primary end-point was receiving the first medical service within the target waiting time, which varied according to the triage level of the patient. Multivariate logistic regression was used to determine whether age was an independent predictor of a shorter waiting time.

RESULTS

Data from 262 282 emergency patients were analyzed. The mean age of patients was 35.97 years, and 7.5% were aged ≥65 years. In total, 88.3% of patients received medical service within the target waiting time, and 87.4% of elderly patients received medical service within the target waiting time. Multivariate logistic regression analysis showed that advanced age was independently associated with receiving medical service within the target waiting time (adjusted odds ratio 1.258, 95% confidence interval 1.198-1.321; P < 0.001). The triage level, type of emergency subdivision, availability of outpatient services and time of day were also associated with receiving medical service within the target waiting time.

CONCLUSION

Under the emergency triage system of the hospital, older adults are more likely to receive medical service within the target waiting time than younger patients. Geriatr Gerontol Int 2019; 19: 786-791.

Association between emergency department length of stay and adverse perioperative outcomes in emergency surgery: a cohort study in two Colombian University hospitals

BACKGROUND

In low- and middle-income countries emergency surgery represents a higher proportion of the total number of surgeries and is associated with greater morbidity/mortality. Study aims were to determine if emergency department length of stay (ED-LOS) was associated with adverse perioperative outcomes and if such association varied across patient's risk categories.

METHODS

A retrospective cohort study was conducted of adult patients who underwent orthopedic or abdominal emergency surgery at two Colombian University hospitals. The population comprised a mix of a representative sample of eligible cases, with unselected patients (2/3), enriched with a high-risk subset (1/3). ED-LOS was defined as the interval between emergency department arrival and surgery start time. Our primary outcome was an adverse perioperative outcome during hospitalization, which was a composite of in-hospital mortality or severe complications such as major cardiovascular adverse events, infection, renal failure and bleeding.

RESULTS

Among 1487 patients analyzed, there were 519 adverse perioperative outcomes including 150 deaths. In the unselected sample (n = 998) 17.9% of patients presented an adverse perioperative outcome with a mortality of 4.9%. The median ED-LOS was 24.6 (IQR 12.5-53.2) hours. ED-LOS was associated with age, comorbidities and known risk factors for 30-day mortality. Patients developing an adverse perioperative outcome started surgery 27.1 h later than their counterparts. Prolonged ED-LOS increased the risk of an adverse perioperative outcome in patients without risk factors (covariate-adjusted OR = 2.52), while having 1-2 or 3+ risk factors was negatively associated (OR = 0.87 and 0.72, respectively, p < 0.001 for the interaction).

CONCLUSION

Prolonged ED-LOS is associated with increased adverse perioperative outcome for patients without risk factors for mortality, but seems protective and medically justified for more complex cases.

Impact of a patient-flow physician coordinator on waiting times and length of stay in an emergency department: A before-after cohort study

OBJECTIVE

Overcrowding is common in most emergency departments (ED). Despite the use of validated triage systems, some patients are at risk of delayed medical evaluation. The objective of this study was to assess the impact of a patient-flow physician coordinator (PFPC) on the proportion of patients offered medical evaluation within time limits imposed by the Swiss Emergency Triage Scale (SETS) and on patient flow within the emergency department of a teaching urban hospital.

METHODS

In this before-after retrospective cohort study, we compared the proportions of patients who received their first medical contact within SETS-imposed time limits, mean waiting times before first medical consultation, mean length of stay, and number of patients who left without being seen by a physician, between two periods before and after introducing a PFPC. The PFPC was a senior physician charged with quickly assessing in the waiting area patients who could not immediately be seen and managing patient flow within the department.

RESULTS

Before introducing the PFPC position, 33,605 patients were admitted, versus 36,288 after. Introducing a PFPC enabled the department to increase the proportion of patients seen within the SETS-imposed time limits from 60.1% to 69.0% (p <0.0001). Waiting times until first medical consultation were reduced on average by 27.7 minutes (95% confidence interval [95% CI]: 25.9-29.5, p < .0001). No significant differences were observed as to length of stay or number of patients who left without being seen between the two study periods.

CONCLUSIONS

Introducing a physician dedicated to managing patient flow enabled waiting times until first medical consultation to be reduced, yet had no significant benefit for patient flow within the ED, nor did it reduce the number of patients who left without being seen.

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.

Emergency department crowding: A systematic review of causes, consequences and solutions

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.

Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department

OBJECTIVE

To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork.

DESIGN

Single-centre before-and-after study.

SETTING

Adult ED of a Swedish urban hospital.

PARTICIPANTS

Patients arriving on weekdays 08:00 to 21:00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included.

INTERVENTIONS

Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08:00 to 21:00 November 2014 to November 2015.

MAIN OUTCOME MEASURES

Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate.

RESULTS

The crude median LOS was shortest for teamwork, 228 min (95% CI 226.4 to 230.5) compared with 232 min (95% CI 230.8 to 233.9) for nurse-led and 250 min (95% CI 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% CI 54.5 to 56.6) compared with 116 min (95% CI 114.4 to 117.5) for nurse-led triage and 74 min (95% CI 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values<0.01.

CONCLUSIONS

Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times.

Patient waiting time in hospital emergency departments of Iran: A systematic review and meta-analysis

Background: Waiting time in emergency department is a key indicator in measuring the quality of hospital services and has a significant impact on patient satisfaction The purpose of this study was to conduct a systematic review and meta-analysis of the patients' waiting time in hospital emergency departments in Iran. Methods: Data were collected from databases of Web of Science, Embase, PubMed, Scopus, Google scholar, SID, and Iran Medex using the following key words: "emergency ward", "emergency room", "waiting time", " time delay", "first visit", "first treatment" , "emergency department", "Iran", and their Persian equivalents. The timeframe of 2000 to 2016 was selected to search the articles. CMA 2 (Comprehensive Meta-Analysis) software was used in this meta-analysis. Results: A total of 236 articles were extracted from databases and other sources, and finally 17 articles were included in the analysis. In total, waiting time in different parts of the emergency department was measured for 15 943 patients. Mean±SD waiting time was 5.9 ± 0.6 minutes from the arrival to the first visit by a physician, it was 45 ± 5 minutes between the first visit and the first therapeutic steps, 94± 33.9 minutes between referring to the laboratory and receiving the result, 23.2 ± 3 minutes between referring to the radiology and receiving the result, and 32.2 ± 7 minutes between referring to ECG and receiving the result; moreover, waiting time for the first specialist consultation was 99.3 ± 32.8 minutes. Conclusion: The results demonstrated that waiting time in the emergency rooms of Iranian hospitals was higher than the national and international standards. According to the high rate of heterogeneity in the results and probability of publication bias, we highly recommend that readers use the results of this study and pay sufficient attention to this issue.

Preventative measures taken against hypothermia in selected Durban hospitals' emergency centres and operating theatres

Introduction

Hypothermia is common in emergency general surgical patients. It is known to be associated with major complications in multiple organ systems. It is also easily preventable with the use of safe and cost-effective equipment. However, by observation, it appears that this equipment is used too infrequently thus resulting in unnecessary harm to patients.

Methods

This descriptive, observational, cross-sectional study was conducted in two arms to evaluate both emergency centres and operating theatres in the major state hospitals in Durban. It was conducted as an audit as well as a questionnaire-based study, to ascertain the availability of equipment used to prevent hypothermia and also how appropriately the equipment was being used.

Results

There was good availability of equipment in both the operating theatres and the emergency centres. However it was being used very poorly, particularly in emergency centres (41% of responses deemed not beneficial to patients versus 29% from operating theatres; 39% of answers beneficial versus 54% from operating theatres). Institutions with hypothermia-prevention protocols scored significantly better than those without a protocol (59% versus 25% beneficial; p = 0.01).

Conclusion

In the field of hypothermia prevention, there was sufficient equipment to result in optimal patient care. However there appears to be a lack of knowledge amongst health care providers, resulting in suboptimal use of this equipment. Protocolised management may provide a solution to this problem and improve patient outcomes.