Impact of process improvements on measures of emergency department efficiency

AbstractObjectiveTo study the operational impact of process improvements on emergency department (ED) patient flow. The changes did not require any increase in resources or expenditures.MethodsThis was a 36-month pre- and post-intervention study to evaluate the effect of implementing process improvements at a community ED from January 2010 to December 2012. The intervention comprised streamlining triage by having patients accepted into internal waiting areas immediately after triage. Within the ED, parallel processes unfolded, and there was no restriction on when registration occurred or which health care provider a patient saw first. Flexible nursing ratios allowed nursing staff to redeploy and move to areas of highest demand. Last, demand-based physician scheduling was implemented. The main outcome was length of stay (LOS). Secondary outcomes included time to physician initial assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed to quantify the impact of the intervention, and whether it was sustained.ResultsPatients totalling 251,899 attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, mean LOS decreased by 0.64 hours (p<0.005). LOS for non-admitted Canadian Triage and Acuity Scale 2 (-0.58 hours, p<0.005), 3 (-0.75 hours, p<0.005), and 4 (-0.32 hours, p<0.005) patients also decreased. There were reductions in PIA (43.81 minutes, p<0.005), LWBS (35.2%, p<0.005), and LAMA (61.9%, p<0.005).ConclusionA combination of process improvements in the ED was associated with clinically significant reductions in LOS, PIA, LWBS, and LAMA for non-resuscitative patients.

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PL003: Impact of process improvements on measures of emergency department efficiency

CJEM ◽

10.1017/cem.2016.36 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S29-S30

Author(s):

A. Leung ◽

M. Duic ◽

D. Gao ◽

S. Whatley

Keyword(s):

Emergency Department ◽

Patient Flow ◽

Retrospective Chart Review ◽

Interrupted Time Series ◽

Initial Assessment ◽

Interrupted Time Series Analysis ◽

Post Intervention ◽

Process Improvements ◽

Secondary Outcomes ◽

Physician Scheduling

Introduction: The objective was to study the operational impact of an intervention comprised of simultaneous process improvements to triage, patient inflow, and physician scheduling patterns on emergency department (ED) patient flow. The intervention did not require any increase in ED resources or expenditures. Methods: A 36-month pre-/post-intervention retrospective chart review at an urban community emergency department from January 2010 to December 2012. The ED process improvements started on June 6, 2011 and involved streamlining triage, parallel processing, flexible nurse-patient ratios, flexible exam spaces, and flexible physician scheduling. The main outcomes were ED length-of-stay (LOS). Secondary outcomes included time to physician-initial-assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed on Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether there were changes in the trend between pre-intervention and post-intervention segments. Results: 251,899 patients attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.64 hours (p<0.001), and 90th-percentile LOS by 0.81 hours (p=0.024). When separated by acuity and disposition, there were reductions in LOS for non-admitted CTAS 2 (-0.58 hours, p <0.001), 3 (-0.75 hours, p <0.001), 4 (-0.32 hours, p=0.002), and 5 (-0.28 hours, p=0.008) patients. For secondary outcomes, there was a decrease in overall average PIA by 43.81 minutes (p<0.001), and 90th-percentile PIA by 91.39 minutes (p<0.001). LWBS and LAMA rates decreased by 35.2% (p<0.001) and 61.9% (p<0.001), respectively. Conclusion: A series of process improvements meant to optimize flow in the ED without the addition of resources was associated with clinically significant reductions in LOS, PIA, LWBS and LAMA rates for non-resuscitative patients.

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Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow

Canadian Association of Radiologists Journal ◽

10.1177/08465371211023861 ◽

2021 ◽

pp. 084653712110238

Author(s):

Francesco Macri ◽

Bonnie T. Niu ◽

Shannon Erdelyi ◽

John R. Mayo ◽

Faisal Khosa ◽

...

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Patient Flow ◽

Interrupted Time Series ◽

Trauma Patients ◽

Linear Regression Models ◽

High Acuity ◽

Time Series Approach ◽

Comparison Series ◽

The Impact

Purpose: Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. Methods: Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. Results: During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. Conclusions: At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

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Management of non-traumatic epistaxis in adults in the emergency department

British Journal of Hospital Medicine ◽

10.12968/hmed.2021.0033 ◽

2021 ◽

pp. 1-6

Author(s):

Ashley Reed ◽

Martyn Barnes ◽

Caroline Howard

Keyword(s):

Emergency Department ◽

Hospital Admissions ◽

Interrupted Time Series ◽

University Teaching ◽

Attendance Rate ◽

Interrupted Time Series Analysis ◽

Current Management ◽

Emergency Ambulance ◽

Bed Days ◽

The Impact

Background/aims Despite epistaxis being a common presentation to emergency departments there is a lack of guidelines, both nationally and internationally, for its management. The authors reviewed the current management of epistaxis and then introduced a new pathway for management to see if care could be improved. The aims were to evaluate the impact of the pathway on reduction of emergency department breaches, emergency ambulance transfers and hospital admissions. Methods The study was an interrupted time series analysis over 29 months and included 903 participants. A pathway for the management of adults with non-traumatic epistaxis was designed and implemented in a university teaching hospital with an emergency department annual attendance rate of 105 495 in 2019–20. Results The pathway led to a 14-minute longer stay in the emergency department, a 5% increase in emergency department breaches, an 8.2% reduction in admissions, a 3.6% reduction in emergency ambulance transfers, a 14.1% increase in nasal cautery and a 3.2% reduction in nasal packing. Conclusions The authors calculate that these results equate to roughly 56 hospital bed days saved, providing better care closer to home for patients, in addition to beneficial knock-on effects for other emergency department and admitted patients.

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The Impact of the Change in Payment System for German Psychiatric Clinics on Treatment Success: An Interrupted Time Series Analysis

Das Gesundheitswesen ◽

10.1055/a-0828-7504 ◽

2019 ◽

Vol 82 (06) ◽

pp. 559-567

Author(s):

Christina Niedermeier ◽

Andrea Barrera ◽

Eva Esteban ◽

Ivana Ivandic ◽

Carla Sabariego

Keyword(s):

Time Series ◽

Negative Impact ◽

Treatment Success ◽

Interrupted Time Series ◽

Sensitivity Analyses ◽

Interrupted Time Series Analysis ◽

Post Intervention ◽

Intervention Point ◽

The Impact ◽

New System

Abstract Background In Germany a new reimbursement system for psychiatric clinics was proposed in 2009 based on the § 17d KHG Psych-Entgeltsystem. The system can be voluntary implemented by clinics since 2013 but therapists are frequently afraid it might affect treatment negatively. Objectives To evaluate whether the new system has a negative impact on treatment success by analysing routinely collected data in a Bavarian clinic. Material and methods Aggregated data of 1760 patients treated in the years 2007–2016 was analysed with segmented regression analysis of interrupted time series to assess the effects of the system on treatment success, operationalized with three outcome variables. A negative change in level after a lag period was hypothesized. The robustness of results was tested by sensitivity analyses. Results The percentage of patients with treatment success tends to increase after the new system but no significant change in level was observed. The sensitivity analyses corroborate results for 2 outcomes but when the intervention point was shifted, the positive change in level for the third outcome became significant. Conclusions Our initial hypothesis is not supported. However, the sensitivity analyses disclosed uncertainties and our study has limitations, such as a short observation time post intervention. Results are not generalizable as data of a single clinic was analysed. Nevertheless, we show the importance of collecting and analysing routine data to assess the impact of policy changes on patient outcomes.

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The impact of computerized provider order entry on emergency department flow

CJEM ◽

10.1017/cem.2016.11 ◽

2016 ◽

Vol 18 (4) ◽

pp. 264-269 ◽

Cited By ~ 4

Author(s):

Andrew Gray ◽

Christopher M.B. Fernandes ◽

Kristine Van Aarsen ◽

Melanie Columbus

Keyword(s):

Emergency Department ◽

Patient Safety ◽

Improve Patient Safety ◽

Patient Flow ◽

Wait Time ◽

Order Entry ◽

Computerized Provider Order Entry ◽

Left Without Being Seen ◽

Before And After ◽

The Impact

AbstractObjectivesComputerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS).MethodsWe conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1–5) individually, as well as for admitted patients only.ResultsA significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients’ LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3–5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically.ConclusionsCPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

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The impact of China’s lockdown policy on the incidence of CoVID-19: An Interrupted time series analysis

10.21203/rs.3.rs-32944/v1 ◽

2020 ◽

Author(s):

Mooketsi Molefi ◽

John Tlhakanelo ◽

Thabo Phologolo ◽

Shimeles G. Hamda ◽

Tiny Masupe ◽

...

Keyword(s):

Time Series ◽

Linear Trend ◽

Effective Means ◽

Interrupted Time Series ◽

Ordinary Least Squares ◽

World Health ◽

Least Squares Regression ◽

Interrupted Time Series Analysis ◽

Post Intervention ◽

The Impact

Abstract BackgroundPolicy changes are often necessary to contain the detrimental impact of epidemics such as the coronavirus disease (COVID-19). China imposed strict restrictions on movement on January 23rd, 2020.Interrupted time series methods were used to study the impact of the lockdown on the incidence of COVID-19. MethodsThe number of cases of COVID-19 reported daily from January 12thto March 30th, 2020 were extracted from the World Health Organization (WHO) COVID-19 dashboard ArcGIS® and matched to China’s projected population of 1 408 526 449 for 2020 in order to estimate daily incidences. Data were plotted to reflect daily incidences as data points in the series. A deferred interruption point of 6thFebruary was used to allow a 14-day period of diffusion. The magnitude of change and linear trend analyses were evaluated using the itsafunction with ordinary least-squares regression coefficients in Stata® yielding Newey-West standard errors.ResultsSeventy-eight (78) daily incidence points were used for the analysis, with 11(14.10%) before the intervention. There was a daily increase of 163 cases (β=1.16*10-07, p=0.00) in the pre-intervention period. Although there was no statistically significant drop in the number of cases reported daily in the immediate period following 6thFebruary 2020 when compared to the counterfactual (p=0.832), there was a 241 decrease (β=-1.71*10-07, p=0.00) in cases reported daily when comparing the pre-intervention and post-intervention periods. A deceleration of 78(47%) cases reported daily. ConclusionThe lockdown policy managed to significantly decrease the incidence of CoVID-19 in China. Lockdown provides an effective means of curtailing the incidence of COVID-19.

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Education and devices to prevent blood and body fluid exposures

Occupational Medicine ◽

10.1093/occmed/kqz156 ◽

2019 ◽

Vol 70 (1) ◽

pp. 38-44 ◽

Cited By ~ 1

Author(s):

S Cheetham ◽

H Ngo ◽

J Liira ◽

E Lee ◽

C Pethrick ◽

...

Keyword(s):

Body Fluid ◽

Interrupted Time Series ◽

Hospital Staff ◽

Incidence Rates ◽

Full Time ◽

Interrupted Time Series Analysis ◽

Short Term ◽

Full Time Equivalent ◽

Post Intervention ◽

The Impact

Abstract Background Healthcare workers are at risk of blood and body fluid exposures (BBFE) while delivering care to patients. Despite recent technological advances such as safety-engineered devices (SEDs), these injuries continue to occur in healthcare facilities worldwide. Aims To assess the impact of an education and SEDs workplace programme on rates of reported exposures. Methods A retrospective cohort study, utilizing interrupted time series analysis to examine reported exposures between 2005 and 2015 at a 600-bed hospital in Perth, Western Australia. The hospital wards were divided into four cohorts. Results A total of 2223 records were available for analysis. The intervention was most effective for the first cohort, with significant improvements both short-term (reduction of 12 (95% CI 7–17) incidents per 1000 full-time equivalent (FTE) hospital staff) and long-term (reduction of 2 (CI 0.6–4) incidents per 1000 FTE per year). Less significant or consistent impacts were observed for the other three cohorts. Overall, the intervention decreased BBFE exposure rates at the hospital level from 19 (CI 18–20) incidents per 1000 FTE pre-intervention to 11 (CI 10–12) incidents per 1000 FTE post-intervention, a 41% reduction. No exposures resulted in a blood-borne virus infection. Conclusions The intervention was most effective in reducing exposures at a time when incidence rates were increasing. The overall effect was short-term and did not further reduce an already stabilized trend, which was likely due to improved safety awareness and practice, induced by the first cohort intervention.

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LB-16. Association Between Universal Face Shield in a Quaternary Care Center and Reduction of SARS-COV2 Infections Among Healthcare Personnel and Hospitalized Patients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa515.1913 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S851-S851

Author(s):

Vagesh Hemmige ◽

Becky Winterer ◽

Todd Lasco ◽

Bradley Lembcke

Keyword(s):

Time Series ◽

Care Center ◽

Interrupted Time Series ◽

Hospitalized Patients ◽

Healthcare Personnel ◽

Segmented Regression ◽

Intervention Period ◽

Interrupted Time Series Analysis ◽

Post Intervention ◽

The Impact

Abstract Background SARS-COV2 transmission to healthcare personnel (HCP) and hospitalized patients is a significant challenge. Our hospital is a quaternary healthcare system with more than 500 beds and 8,000 HCP. Between April 1 and April 17, 2020, we instituted several infection prevention strategies to limit transmission of SARS-COV2 including universal masking of HCP and patients, surveillance testing every two weeks for high-risk HCP and every week for cluster units, and surveillance testing for all patients on admission and prior to invasive procedures. On July 6, 2020, we implemented universal face shield for all healthcare personnel upon entry to facility. The aim of this study is to assess the impact of face shield policy on SARS-COV2 infection among HCP and hospitalized patients. Figure 1- Interrupted time series Methods The preintervention period (April 17, 2020-July 5, 2020) included implementation of universal face masks and surveillance testing of HCP and patients. The intervention period (July 6, 2020-July 26, 2020) included the addition of face shield to all HCP (for patient encounters and staff-to-staff encounters). We used interrupted time series analysis with segmented regression to examine the effect of our intervention on the difference in proportion of HCP positive for SARS-COV2 (using logistic regression) and HAI (using Poisson regression). We defined significance as p values < 0.05. Results Of 4731 HCP tested, 192 tested positive for SARS-COV2 (4.1%). In the preintervention period, the weekly positivity rate among HCP increased from 0% to 12.9%. During the intervention period, the weekly positivity rate among HCP decreased to 2.3%, with segmented regression showing a change in predicted proportion positive in week 13 (18.0% to 3.7%, p< 0.001) and change in the post-intervention slope on the log odds scale (p< 0.001). A total of 14 HAI cases were identified. In the preintervention period, HAI cases increased from 0 to 5. During the intervention period, HAI cases decreased to 0. There was a change between pre-intervention and post-intervention slope on the log scale was significant (p< 0.01). Conclusion Our study showed that the universal use of face shield was associated with significant reduction in SARS-COV2 infection among HCP and hospitalized patients. Disclosures All Authors: No reported disclosures

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Effect of the Colombian Emergency Department Triage Policy on the timeliness of ED care and the mortality in patients with cerebrovascular attack: A controlled interrupted time series analysis

10.21203/rs.3.rs-55373/v1 ◽

2020 ◽

Author(s):

Carlos Eduardo Vallejo ◽

Daniel Felipe Patiño-Lugo ◽

Daniel Camilo Aguirre-Acevedo ◽

Juan Pablo Acosta

Keyword(s):

Emergency Department ◽

Time Series ◽

Time Series Analysis ◽

Interrupted Time Series ◽

Reperfusion Therapy ◽

Intervention Period ◽

Interrupted Time Series Analysis ◽

Post Intervention ◽

Emergency Department Triage ◽

The City

Abstract Background: Ischemic Cerebrovascular Accident (CVA) is the second cause of death and one of the leading causes of disability in the world. In Colombia, there is a prevalence of 0.16% and a mortality rate of 16.82 deaths per 100,000 inhabitants. This study assessed the Colombian Ministry of Health’s Emergency Department Triage Policy (TP) on the timeliness of hospital care, the mortality, and change in reperfusion therapy of patients with the first episode of an CVA in the Emergency Department (ED) of a hospital in the city of Medellín.Methods: A controlled interrupted time series analysis between January 2011 and November 2017 was performed in one emergency department using segmented regression analysis. The emergency department of other hospital was used as a control. Data were aggregated by month for both ED, including 60 pre-intervention and 23 intervention points.Results: No decrease in the timeliness of care in the ED was found in patients with a stroke after implementing the Colombian Ministry of Health’s TP (12.55 minutes, IC -17.07, 42.17; p: 0.4). The TP intervention produced a level change in the timeliness of care in Triage I and II subgroups, of 28.34 minutes (IC 95% 16.9, 39.79; p valor 0.00), there was no change in the trend. The classification of Triage I and II was more frequent in the post-intervention period. There was evidence of the increase in reperfusion therapy with tissue plasminogen activator (rTPA) in 4% (95% CI – 0.08, - 0.01; p value 0.01). Mortality increased 4% in the post-intervention period without being statistically significant (0.04, IC 95% - 0.08 – 0; p valor 0.06). There were no significant changes in the same outcomes in the control group.Conclusions: The implementation of the triage policy allowed improving the timeliness of ED care only in patients with ischemic CVA classified as Triage I and II, in an Emergency Department in the city of Medellín, Colombia.

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