scholarly journals LO009: Impact of physician navigators on measures of emergency department efficiency

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S33-S33
Author(s):  
A. Leung ◽  
Z. Gong ◽  
B. Chen ◽  
M. Duic
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Patient Flow ◽  
High Volume ◽  
Physician Satisfaction ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Secondary Outcomes ◽  
Very High

Introduction: The Physician Navigator (PN) is a novel position created to manage patient flow in real-time at a very-high volume emergency department (ED). When paired with an emergency physician, PNs actively track patient wait times, and direct the physician to see and re-assess patients in a particular order to improve measures of emergency department efficiency, and maximize patient flow. Anecdotal evidence has shown that PNs decrease length-of-stay times for non-resuscitative patients in the setting of increased patient volumes, and without additional nursing or physician hours. The objective was to study the operational impact of PN on emergency department patient flow. Methods: A 48-month pre-/post-intervention retrospective chart review at an urban community emergency department from September 2011 to September 2015. The PN program started on March 1, 2013. The main outcome is emergency department length-of-stay (LOS). Secondary outcomes include time to physician-initial-assessment (PIA), left-without-being-seen rates (LWBS), left-against-medical-advice (LAMA), and physician satisfaction rates. Autoregressive integrated moving average models were generated for Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether the impact was sustained over time. Results: Interim results are provided. 399,958 patients attended the ED during the study period. Daily patient volumes increased 11.2% during the post-intervention period. There were no significant increases in the number of physicians shifts/day, and physician hours/day during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.04 hours/PN (p<0.05), and 90th-percentile LOS by 0.14 hours/PN (p<0.05). For secondary outcomes, there was a decrease in overall average PIA by 6.37 minutes/PN (p<0.05), and 90th-percentile PIA by 8.29 minutes/PN (p<0.05). LWBS rates decreased by 40.8% (p<0.05). There were no significant changes in LAMA rates. Conclusion: The implementation of Physician Navigators is associated with significant reductions in LOS, PIA, and LWBS rates for non-resuscitative patients at a very-high volume emergency department.

scholarly journals A Daytime Fast Track Improves Throughput in a Single Physician Coverage Emergency Department

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 648-655 ◽  
Author(s):  
Julie Copeland ◽  
Andrew Gray
Keyword(s):  
Emergency Department ◽  
Fast Track ◽  
Community Hospital ◽  
Wait Time ◽  
Intervention Period ◽  
Post Intervention ◽  
Study Objective ◽  
Post Intervention Period ◽  
Left Without Being Seen ◽  
Physician Coverage

AbstractObjectivesFast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity.MethodsA daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS).ResultsWT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates.ConclusionsImplementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

scholarly journals 770. Multimodal Sepsis Performance Improvement Initiative Improves Early and Appropriate Treatment, Reduces Sepsis-related Readmissions, and Reduces Overall Mortality

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S343-S343
Author(s):  
Seife Yohannes
Keyword(s):  
Septic Shock ◽  
Severe Sepsis ◽  
Length Of Stay ◽  
Performance Improvement ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Sepsis And Septic Shock

Abstract Background CMS has implemented the SEP-1 Core Measure, which mandates that hospitals implement sepsis quality improvement initiatives. At our hospital, a 900-bed tertiary hospital, a sepsis performance improvement initiative was implemented in April 2016. In this study, we analyzed patient outcomes before and after these interventions. Methods We studied coding data in patients with a diagnosis of Sepsis reported to CMS using a third-party performance improvement database between October, 2015 and July, 2017. The interventions included a hospital-wide education campaign about sepsis; a 24–7 electronic warning system (EWS) using SIRS criteria; a rapid response nursing team that monitors the EWS; a 24–7 mid-level provider team; a database to monitor compliance and timely treatment; and education in sepsis documentation and coding. We performed a before and after analysis of patient outcomes. Results A total of 4,102 patients were diagnosed with sepsis during the study period. 861 (21%) were diagnosed during the pre-intervention period and 3,241 (80%) were diagnosed in the post-intervention period. The overall incidence of sepsis, severe sepsis, and septic shock were 59%, 13%, and 28% consecutively. Regression analysis showed age, admission through the ED, and severity of illness as independent risk factors for increased mortality. Adjusted for these risk factors, the incidence of severe sepsis and septic was reduced by 5.3% and 6.9% in the post-intervention period, while the incidence of simple sepsis increased by 12%. In the post-intervention period, compliance with all 6 CMS mandated sepsis bundle interventions improved from 11% to 37% (P = 0.01); hospital length of stay was reduced by 1.8 days (P = 0.05); length of stay above predicted was less by 1.5 days (P = 0.05); re-admission rate was reduced by 1.6% (P = 0.05); and death from any sepsis diagnosis was reduced 4.5% (P = 0.01). Based on an average of 2000 sepsis cases at our hospital, this amounted to 90 lives saved per year. Death from severe sepsis and septic shock both were also reduced by 5% (P = 0.01) and 6.5% (P = 0.01). Conclusion A multi-modal sepsis performance improvement initiative reduced the incidence of severe sepsis and septic shock, reduced hospital length of stay, reduced readmission rates, and reduced all-cause mortality. Disclosures All authors: No reported disclosures.

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

CJEM ◽  
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.

scholarly journals Assessing the Impact of a New Emergency Triage System on Head Injury Mortality: Tikur Anbessa Specialized Hospital Emergency Department in Addis Ababa, Ethiopia

2019 ◽  
Vol 34 (s1) ◽  
pp. s103-s103
Author(s):  
helena Fantaye ◽  
Amanuel Lomencho ◽  
Pol de vos
Keyword(s):  
Emergency Department ◽  
Head Injury ◽  
Addis Ababa ◽  
Intervention Period ◽  
Post Intervention ◽  
Triage System ◽  
Post Intervention Period ◽  
Injury Mortality ◽  
Specialized Hospital ◽  
Tikur Anbessa Specialized Hospital

Introduction:One of the improvements in Ethiopia’s emergency medical system was the introduction of a five-level Emergency Triage System (ETS) in January 2015 that was piloted in selected Addis Ababa hospitals.Aim:To assess the effect of this intervention on the head injury mortality in Tikur Anbessa Specialized Hospital (TASH) Emergency Department (ED).Methods:Data were retrospectively collected from all medical records of head injury patients seen in Adult TASH- ED over two 6 months periods, before and after the new Emergency Triage System implementation: 01/04/2014 – 30/09/2014 versus 01/04/2016 – 30/09/2016. An inclusion criterion was age above 13 for the records that could be retrieved. Exclusion criterion was “patient declared dead on arrival.” Mortality and patterns of head injury were compared pre- and post-intervention. Chi-square was used for the analysis using STATA 14.Results:A total of 522 Head injury patients were analyzed in the ED in both the pre- 258 and post-264 intervention study periods. Among head injury admission in the ED in both study periods, the highest number of patients were Road Traffic Accident/RTA/ victims, males and young age (<30). Mortality rate among head injury patients decreased from a pre-intervention 44 (17.05%) to post-intervention 27 (10.2%) (OR=0.55 9. 5% CI (0.32, 0.95), p=0.02). The median age of death was 45 years in pre- and 40 years in the post-intervention period, with ages ranging from 13 to 85 and 13 to 96 years, respectively. The proportion of deaths from moderate head injury decreased significantly from 14.0% in pre-intervention to 6.3% in the post-intervention period, respectively (p<0.001).Discussion:The Emergency Triage System at TASH-ED has decreased mortality caused by head injury. This could increase life years saved and productivity in a cost-effective and easily achievable way in resource-poor settings.

Analysis of Plastic Surgery Consultations in a High-Volume Paediatric Emergency Department: A Quality Improvement Initiative

2020 ◽  
pp. 229255032096965
Author(s):  
Kathrin Neuhaus ◽  
Emily S. Ho ◽  
Nelson Low ◽  
Christopher R. Forrest
Keyword(s):  
Emergency Department ◽  
Quality Of Care ◽  
High Volume ◽  
Patient Characteristics ◽  
Quality Improvement Initiative ◽  
Education Intervention ◽  
Intervention Period ◽  
Post Intervention ◽  
Ed Overcrowding

Introduction: Consult services influence emergency department (ED) workflow. Prolonged ED length of stay (LOS) correlates with ED overcrowding and as a consequence decreased quality of care and satisfaction of health team professionals. To improve management of paediatric ED patients requiring plastic and reconstructive surgery (PRS) expertise, current processes were analyzed. Methods: Patient characteristics and metrics of PRS consultations in our paediatric ED were collected over a 3-month period. Data analysis was followed by feedback education intervention to ED and PRS staff. Data collection was then resumed and results were compared to the pre-intervention period. Results: One hundred ninety-eight PRS consultations were reviewed, mean patient age was 6.3 years. Most common (52%) diagnoses were burns and hand trauma; 81% of PRS referrals were deemed appropriate; 25% of PRS consults were requested after hour with no differences in patient characteristics compared to regular hours; 60% of consultations involved interventions in the ED. Time between ED registration and PRS consultation request (116.5 minutes), quality of procedural sedation (52% rated inadequate), and overall ED LOS (289.2 minutes) were identified as main areas of concern and addressed during feedback education intervention. Emergency department LOS and quality of sedation did not improve in the post-intervention period. Conclusion: The study provides detailed insights in the characteristics of PRS consultation in the paediatric ED population. Despite high referral appropriateness and education feedback intervention, significant inefficiencies were identified that call for further collaborative efforts to optimize quality of care for paediatric ED patients and improve satisfaction of involved healthcare professionals.

Relationship of hospital volume on outcomes in patients with acute pulmonary embolism: Analysis of a 70,000 patient database

2020 ◽  
pp. 1358863X2097026
Author(s):  
Mark Finkelstein ◽  
Mario A Cedillo ◽  
David C Kestenbaum ◽  
Obaib S Shoaib ◽  
Aaron M Fischman ◽  
...  
Keyword(s):  
New York ◽  
Pulmonary Embolism ◽  
Length Of Stay ◽  
New York State ◽  
Multivariable Analysis ◽  
High Volume ◽  
Categorical Variables ◽  
Patient Database ◽  
Very High ◽  
Total Charges

Positive relationships between volume and outcome have been seen in several surgical and medical conditions, resulting in more centralized and specialized care structures. Currently, there is a scarcity of literature involving the volume–outcome relationship in pulmonary embolism (PE). Using a state-wide dataset that encapsulates all non-federal admissions in New York State, we performed a retrospective cohort study on admitted patients with a diagnosis of PE. A total of 70,443 cases were separated into volume groups stratified by hospital quartile. Continuous and categorical variables were compared between cohorts. Multivariable regression analysis was conducted to assess predictors of 1-year mortality, 30-day all-cause readmission, 30-day PE-related readmission, length of stay, and total charges. Of the 205 facilities that were included, 128 (62%) were labeled low volume, 39 (19%) medium volume, 23 (11%) high volume, and 15 (7%) very high volume. Multivariable analysis showed that very high volume was associated with decreased 30-day PE-related readmission (OR 0.64; 95% CI, 0.55 to 0.73), decreased 30-day all-cause readmission (OR 0.84; 95% CI, 0.79 to 0.89), decreased 1-year mortality (OR 0.85; 95% CI, 0.80 to 0.91), decreased total charges (OR 0.96; 95% CI, 0.94 to 0.98), and decreased length of stay (OR 0.94; 95% CI, 0.92 to 0.96). In summary, facilities with higher volumes of acute PE were found to have less 30-day PE-related readmissions, less all-cause readmissions, shorter length of stay, decreased 1-year mortality, and decreased total charges.

scholarly journals 986. Improvement in Administration of HIV Post-Exposure Prophylaxis in the Emergency Department Following Sexual Assault

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S521-S522
Author(s):  
Jennifer R Silva-Nash ◽  
Stacie Bordelon ◽  
Ryan K Dare ◽  
Sherrie Searcy
Keyword(s):  
Emergency Department ◽  
Sexual Assault ◽  
Hiv Transmission ◽  
Post Exposure Prophylaxis ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Exposure ◽  
Assault Victims ◽  
Exposure Prophylaxis

Abstract Background Nonoccupational post exposure prophylaxis (nPEP) following sexual assault can prevent HIV transmission. A standardized Emergency Department (ED) protocol for evaluation, treatment, and follow up for post assault victims was implemented to improve compliance with CDC nPEP guidelines. Methods A single-center observational study of post sexual assault patients before/after implementation of an ED nPEP protocol was conducted by comparing the appropriateness of prescriptions, labs, and necessary follow up. A standardized order-set based on CDC nPEP guidelines, with involvement of an HIV pharmacist and ID clinic, was implemented during the 2018-2019 academic year. Clinical data from pre-intervention period (07/2016-06/2017) was compared to post-intervention period (07/2018-08/2019) following a 1-year washout period. Results During the study, 147 post-sexual assault patients (59 Pre, 88 Post) were included. One hundred thirty-three (90.4%) were female, 68 (46.6%) were African American and 133 (90.4%) were candidates for nPEP. Median time to presentation following assault was 12.6 hours. nPEP was offered to 40 (67.8%) and 84 (95.5%) patients (P&lt; 0.001) and ultimately prescribed to 29 (49.2%) and 71 (80.7%) patients (P&lt; 0.001) in pre and post periods respectively. Renal function (37.3% vs 88.6%; P&lt; 0.001), pregnancy (39.0% vs 79.6%; P&lt; 0.001), syphilis (3.4% vs 89.8%; P&lt; 0.001), hepatitis B (15.3% vs 95.5%; P&lt; 0.001) and hepatitis C (27.1% vs 94.3%) screening occurred more frequently during the post period. Labratory, nPEP Prescription and Follow up Details for Patients Prescribed nPEP Conclusion The standardization of an nPEP ED protocol for sexual assault victims resulted in increased nPEP administration, appropriateness of prescription, screening for other sexually transmitted infectious and scheduling follow up care. While guideline compliance dramatically improved, further interventions are likely warranted in this vulnerable population. Disclosures Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support)

Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

2021 ◽  
pp. 001857872110557
Author(s):  
Jessica L. Colmerauer ◽  
Kristin E. Linder ◽  
Casey J. Dempsey ◽  
Joseph L. Kuti ◽  
David P. Nicolau ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Antibiotic Use ◽  
Community Acquired Pneumonia ◽  
Intervention Period ◽  
Provider Education ◽  
Broad Spectrum Antibiotic ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Days Of Therapy ◽  
Order Set

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

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