scholarly journals LO06: Effects of emergency department system transformation (EDST) on patient experience of emergency department visits

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S8-S8
Author(s):  
S. Danby ◽  
K. Van Aarsen ◽  
M. Columbus ◽  
A. Dukelow
Keyword(s):  
Emergency Department ◽  
Patient Experience ◽  
Tertiary Care ◽  
Emergency Department Visits ◽  
Assessment Process ◽  
Initial Assessment ◽  
System Transformation ◽  
Structured Interviews ◽  
Kappa Score ◽  
Perfect Agreement

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions partially implemented in two Canadian tertiary care Emergency Departments (ED) between June 2014- July 2016 with the goal to improve patient care by increasing value and reducing waste. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards and a novel initial assessment process. Some interventions have only been partially implemented due to persistent access block. This project was designed to examine the effect of partial EDST implementation on patient experience of emergency department visits. Patient satisfaction has been linked to improved patient outcomes, improved adherence to physician instruction, and improved provider satisfaction. Methods: Semi structured interviews were conducted over three distinct time periods (summer 2015, 2016 and 2017) to encompass progressive levels of EDST implementation. The interviews focused on the patients perceptions in each of 4 stages of their ED visit - Check-in, assessment, reassessment, and disposition. Patients were asked a list of positive (respected, listened to, supported, safe) and negative (in pain, worried, confused, frustrated) emotions frequently experienced and asked if they felt any of these emotions during their ED stay. Open ended questions were also asked about their overall visit. Descriptive statistics were calculated as differences in the proportion of patients feeling each emotion across timeframes. The open-ended question was coded by two reviewers as positive, negative or mixed. A kappa score was calculated to determine reviewer agreement. Results: 987 interviews were completed. In general, the proportion of patients feeling negative emotions remained consistent while positive emotions increased as EDST implementation progressed. For open-ended responses, the percentage of overtly positive experiences increased significantly from 2015 to 2017 (p=0.006), while overtly negative experiences did not significantly change. Reviewers agreed in the coding of the open-ended responses in 97.6% of surveys. The kappa score for reviewer agreement was 0.96 (95%CI 0.94-0.98) indicating almost perfect agreement. Conclusion: Partial implementation of EDST positively impacted patients experience of emergency department visits.

scholarly journals LO53: Emergency department visits for hyperglycemia: through the eyes of the patient

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S26-S26
Author(s):  
J. Yan ◽  
D. Azzam ◽  
S. Liu ◽  
T. Spaic ◽  
M. Columbus ◽  
...  
Keyword(s):  
Emergency Department ◽  
Glycemic Control ◽  
Patient Experience ◽  
Diabetes Care ◽  
Symptom Relief ◽  
Tertiary Care ◽  
Emergency Department Visits ◽  
Comparative Approach ◽  
Post Discharge

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

scholarly journals MP04: Interim analysis of the impact of the Emergency Department Transformation System on ambulance offload delay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S66
Author(s):  
S. Pawa ◽  
K. Van Aarsen ◽  
A. Dukelow ◽  
D. Lizotte ◽  
M. Zheng
Keyword(s):  
Emergency Department ◽  
Negative Impact ◽  
Positive Impact ◽  
Tertiary Care ◽  
Assessment Process ◽  
Hospital Length Of Stay ◽  
Initial Assessment ◽  
Hospital Inpatient ◽  
Chi Square Analysis ◽  
The Impact

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two London, Canada tertiary care Emergency Departments (ED) between April 2014 and July 2016 to improve patient care by increasing value and reducing waste. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards, and a novel initial assessment process. Offload delays are associated with longer hospital length of stay and delayed admission, and may increase morbidity and mortality. Delays also result in fewer circulating ambulances in the community. CIHI sets a benchmark of 30 minutes as an acceptable offload target. It is possible that EDST may have impacted offload times. Methods: Middlesex-London EMS provided offload times. Data was collected from London Health Sciences Centre including daily ED visit volumes, ED occupancy, offload nursing hours, and site variation. A binomial logistic regression analysis was performed to determine the impact of interventions and confounding variables on the proportion of patients meeting CIHI benchmark. A chi-square analysis was done comparing proportion of patients meeting the benchmark in the first 3 months versus the last 3 months to identify overall impact of EDST to date. Results: Increased offload nursing hours had a positive impact (p<0.001) on the proportion of offload times meeting the CIHI benchmark while increased ED visit volume and hospital inpatient volume had a significant negative impact (p<0.001). At both ED sites, the proportion of patients meeting the offload target ranged from 58-83% over the timeframe. There was a significant increase in the proportion of patients meeting the benchmark from the first quarter to the last quarter (69.6% vs 75.0%; 95% CI 3.45% to 7.38%, p=0.000). Specific interventions had varying degrees of impact on offload times. Conclusion: The proportion of patients meeting the benchmark offload time varied over the study timeframe but significantly increased with EDST implementation. Offload times are one of many outcomes we aim to improve with EDST and it remains an ongoing process as new interventions continue to be implemented. Once transformation is complete, future studies will focus on the impact of EDST on all ED flow metrics, and patient and provider satisfaction.

scholarly journals P036: Interim analysis of the impact of the emergency department transformation system on flow metrics

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S69-S69
Author(s):  
A. Dukelow ◽  
K. Van Aarsen ◽  
C. MacDonald ◽  
V. Dagnone
Keyword(s):  
Emergency Department ◽  
Interim Analysis ◽  
Tertiary Care ◽  
Improve Patient Care ◽  
University Hospital ◽  
Assessment Process ◽  
Initial Assessment ◽  
High Acuity ◽  
Systems Transformation ◽  
The Impact

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two Canadian tertiary care Emergency Departments (ED) between June 2014 to July 2016. The goals were to improve patient care by increasing value and reducing waste. Longer times to physician initial assessment (PIA), ED length of stays (LOS) and times to inpatient beds are associated with increased patient morbidity and potentially mortality. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards and a novel initial assessment process ED access block has limited full implementation of EDST. An interim analysis was conducted to assess impact of interventions implemented to date on flow metrics. Methods: Daily ED visit volumes, boarding at 7am, time to PIA and LOS for non-admitted patients were collected from April 2014 -June 2016. Volume and boarding were compared from first to last quarter using an independent samples median test. Linear regression for each variable versus time was conducted to determine unadjusted relationships. PIA, LOS for non-admitted low acuity (Canadian Triage and Acuity Scale (CTAS) 4,5) and non-admitted high acuity (CTAS 1,2,3) patients were subsequently adjusted for volume and/or boarding to control for these variables using a non-parametric correlation. Results: Overall, median ED boarding decreased at University Hospital (UH) (14.0 vs 6.0, p<0.01) and increased at Victoria Hospital (VH) (17.0 vs 21.0, p<0.01) from first to last quarter. Median ED volume increased significantly at UH from first to last quarter (129.0 vs 142.0, p<0.01) but remained essentially unchanged at VH. 90th percentile LOS for non-admitted low acuity patients significantly decreased at UH (adjusted rs=-0.24, p<0.01) but did not significantly change at VH. For high acuity patients 90th percentile LOS significantly decreased at both hospitals (UH: adjusted rs=-0.23, p<0.01; VH: adjusted rs=-0.21, p<0.01). 90th percentile time to PIA improved slightly but significantly in both EDs (UH: adjusted rs=-0.10, p<0.01; VH: adjusted rs=-0.18, p<0.01). Conclusion: Persistent ED boarding impacted the ability to fully implement the EDST model of care. Partial EDST implementation has resulted in improvement in PIA at both LHSC EDs. At UH where ED boarding decreased, LOS metrics improved significantly even after controlling for boarding.

scholarly journals Emergency Department Referral Profile of Traumatic Brain Injury Records at a Tertiary Care Hospital of Pakistan

2021 ◽  
Author(s):  
Maria Khan ◽  
Uzair Yaqoob ◽  
Zair Hassan ◽  
Muhammad Muizz Uddin
Keyword(s):  
Traumatic Brain Injury ◽  
Emergency Department ◽  
Brain Injury ◽  
Road Traffic ◽  
Tertiary Care ◽  
Initial Assessment ◽  
Care Hospital ◽  
Mild Tbi ◽  
Epidemiological Characteristics ◽  
The Impact

Abstract Background: Traumatic Brain Injury (TBI) is the leading cause of morbidity and mortality all over the world and the impact is much worse in Pakistan. The objective here is to describe the epidemiological characteristics of patients with TBI in our country and to determine the immediate outcomes of patients with TBI after the presentation.Method: This was a cross-sectional study conducted at the Lady Reading Hospital, Peshawar, Pakistan. Data were extracted from the medical records from January 1st to December 31st, 2019. Patient age, sex, type of trauma, and immediate outcome of the referral to the Emergency Department were recorded. The severity of TBI was categorized based on Glasgow Coma Scale (GCS) in mild (GCS 13-15), moderate (GCS 9-12), and severe (GCS <8) classes. The Emergency Department referral profile was classified as admissions, disposed, detained and disposed, referred.Results: Out of 5047 patients, 3689 (73.1%) males and 1358 (26.9%) females. The most commonly affected age group was 0-10 years (25.6%) and 21-30 years (20.1%). Road Traffic accident was the predominant cause of injury (38.8%, n=1960) followed by fall (32.7%, n=1649). Most (93.6%, n=4710) of the TBIs were mild. After the full initial assessment and workup, and completing all first-aid management, the immediate outcome was divided into four, most frequent (67.2%, n=3393) of which was “disposed (discharged)”, and 9.3% (n=470) were admitted for further management.Conclusion: Our study represents a relatively commonplace picture of epidemiological data on the burden of TBI in Pakistan. As a large proportion of patients had a mild TBI, and there is a high risk of mild TBI being under-diagnosed, we warrant further investigation of mild TBI in population-based studies.

Patient perception regarding privacy and confidentiality: A study from the emergency department of a tertiary care hospital in Karachi, Pakistan

2021 ◽  
Vol 38 (ICON-2022) ◽  
Author(s):  
Syed Ghazanfar Saleem ◽  
Saima Ali ◽  
Nida Ghouri ◽  
Quratulain Maroof ◽  
Muhammad Imran Jamal ◽  
...  
Keyword(s):  
Emergency Department ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Patient Perception ◽  
Care Hospital ◽  
Structured Interviews ◽  
Privacy Concerns ◽  
Creative Commons ◽  
Privacy And Confidentiality ◽  
And Behavior

Background and Objective: Maintaining privacy and ensuring confidentiality with patients is paramount to developing an effective patient-provider relationship. This is often challenging in over-crowded Emergency Departments (EDs). This survey was designed to explore patients’ perceptions on maintenance of privacy and confidentiality and their subsequent interactions with providers in a busy tertiary care hospital in Karachi. Methods: Trained nursing staff conducted structured interviews with 571 patients who presented to The Indus Hospital (TIH) ED from January to December 2020. All patients were 14 years of age or older, could speak and understand Urdu, and provide informed consent. Patients were asked about their perceptions of privacy and confidentiality in the ED and whether this affected their interactions with providers. Results: Respondents were primarily men (64%) under the age of 45 (62%) presenting for the first time (49%). The majority of patients felt that privacy and confidentiality were maintained, however 10% of patients reported that they had rejected examination due to privacy concerns and 15% of patients reported that they had changed or omitted information provided to a provider due to confidentiality concerns. There was correlation between privacy and confidentiality concerns and patient-provider interactions (p<0.0001). Conclusions: Despite the often over-crowded and busy environment of the ED, patients generally felt that privacy and confidentiality were maintained. Given the correlation between perception and behavior and the importance of an effective patient-provider relationship, particularly in the acute setting when morbidity and mortality is high, initiatives that focus on maintaining privacy and confidentiality should be pursued. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5785 How to cite this:Saleem SG, Ali S, Ghouri N, Maroof Q, Jamal MI, Aziz T, et al. Patient perception regarding privacy and confidentiality: A study from the emergency department of a tertiary care hospital in Karachi, Pakistan. Pak J Med Sci. 2022;38(2):351-355.  doi: https://doi.org/10.12669/pjms.38.ICON-2022.5785 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

scholarly journals P143: A prospective cohort study characterizing 30-day recurrent emergency department visits for hyperglycemia

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S116
Author(s):  
J. Yan ◽  
D. Azzam ◽  
M. Columbus ◽  
K. Van Aarsen
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Diabetes Management ◽  
Care Delivery ◽  
Tertiary Care ◽  
Emergency Department Visits ◽  
Local Health

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.

scholarly journals LO79: The impact of access block on consultation time in the emergency department

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S36-S37
Author(s):  
L. Carroll ◽  
M. Nemnom ◽  
E. Kwok ◽  
V. Thiruganasambandamoorthy
Keyword(s):  
Emergency Department ◽  
Performance Metrics ◽  
Tertiary Care ◽  
Initial Assessment ◽  
Inpatient Service ◽  
Care Hospital ◽  
Important Indicator ◽  
Consultation Request ◽  
The Impact ◽  
Consultation Time

Introduction: Access block (AB) is the most important indicator of Emergency Department (ED) crowding, but the impact of AB on consultation time has not been described. Our objectives were to determine if ED AB affects inpatient service consultation time, and operational and patient outcomes. Methods: We conducted a health records review of all ED patients referred and admitted at a university-affiliated tertiary care hospital over 60-days. A computational algorithm determined hourly ED AB at the time of consultation request, and observational cohorts were determined based on ED AB high (&gt;35% ED bed capacity occupied by admitted patients) or low (&lt;35%). The outcomes included total consultation time (TCT), ED physician initial assessment (PIA) time, ED length of stay (LOS), transfer time to inpatient bed (TTB), hospital LOS, return to ED (RTED) within 30 days, and 30-day mortality. Results: We included 2,871 patients (48% male; M = 63 years, IQR 45–78), and the low AB cohort were higher acuity (N = 1,692; 50.4% CTAS 1–2) than the high AB cohort (N = 1,179; 47.1% CTAS 1–2). Median TCT was not significantly different (low = 209min, high = 212min; p = 0.09), and there was no difference in consults completed within the 3-hour institutional time target (low = 41.1%, high = 40.9%; p = 0.89). Median ED PIA time was not significantly different (low = 66min, high = 68min; p = 0.08), however, patients seen within the funding-associated provincial ED PIA time target was significantly less during high AB (high = 82.2%, low = 89.2%; p &lt; 0.001). Median ED LOS was significantly longer during high AB (high = 12.1hr, low = 11.1hr; p = 0.009), but median hospital LOS was not different (high = 109.5hr, low = 112.4hr; p = 0.44). Median TTB was significantly longer during high AB (high = 8.0hr, low = 5.9hr; p = 0.0004). There was no difference in RTED visits (high = 12.4%, low = 10.6%; p = 0.15) or 30-day mortality (high = 8.4%, low = 9.2%; p = 0.51). Conclusion: In conclusion, consultation time is not affected by AB. However, boarding admitted patients in the ED impairs our ability to meet funding-associated performance metrics. Reducing boarding time should be an ED and hospital-wide priority, as it negatively impacts funding and delays patient care.

scholarly journals P121: Understanding health equity: a pilot project to collect socio-demographic information on emergency department patients at registration

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S119
Author(s):  
S. Vaillancourt ◽  
M. McGowan ◽  
C. Semprun ◽  
P. Hannam ◽  
G. Bandiera ◽  
...  
Keyword(s):  
Emergency Department ◽  
Data Collection ◽  
Large Scale ◽  
Capture Rate ◽  
Tertiary Care ◽  
Participation Rate ◽  
Pilot Project ◽  
Patient Data ◽  
Structured Interviews ◽  
Number Of Patients

Introduction: There is strong evidence that socio-economic factors such as income, housing and ethnicity are linked to health outcome disparities for emergency department (ED) patients. However, lack of real-time patient data has limited our ability to identify, understand and address health disparities. During a 14-week period, we assessed the feasibility and acceptability of the systematic collection of patient-level equity data in a busy tertiary care urban ED. Methods: We assessed feasibility by directly observing impact on registration time, percentage of patients on which data was collected, and ambulance patient data collection. We also assessed acceptability to patients, registration staff and clinicians through structured interviews of patients systematically sampled, focus group and surveys of registration staff and survey of clinicians. Results: Over the course of the study, equity data was collected on 2017 patients. Capture rate peaked in week 7 with 51% of eligible patients offered the equity questions and 30% answering. Average patient registration time increased from 215 seconds to 345 seconds (60%). Data collection with ambulance patients did not appear feasible. Patients (n=30) reported being comfortable with most questions except income (47% comfortable). 93% believed it could improve health services. However, a small number of patients voiced concern that the data could result in discrimination. Registration staff required sustained support and engagement, but some continued to feel uncomfortable with offering the questionnaire to some patients. Conclusion: Large scale collection of equity data is feasible but requires additional resources and sustained staff and patient support. Patient participation rate is likely to remain relatively low and is likely to underestimate disadvantaged groups. Data collection at multiple points within an institution may improve capture rate.

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