P095: Preparing emergency patients and providers study: Clinician and patient satisfaction with communication tool

Introduction: Effective communication to develop a shared understanding of patient/caregiver (P/C) expectations is critical during emergency department (ED) encounters. However, there is limited research examining the use of communication tools of P/C expectations to improve communication in the ED. The objective of this study was to examine satisfaction with a patient expectations questionnaire, known as the PrEPP tool, and its impact on communication and management of patients in the ED. Methods: The PrEPP tool collected P/C expectations over 3 phases of the study. In phase1, the PrEPP tool was distributed to all P/Cs (CTAS score of 2 to 5) in four EDs in Nova Scotia. In phase 2 the PrEPP tool was refined to a 5-item questionnaire. In phase 3 the PrEPP tool was re-implemented over a six-month period. Follow-up surveys were distributed to P/Cs via email (phase 1, 3) and HCPs on iPads in the ED (phase 3) to determine the impact of the tool on communication and management of patients. Entries were compiled on a REDCap database and descriptive statistics were used to analyze responses related to satisfaction.The PrEPP tool collected P/C expectations over 3 phases of the study. In phase1, the PrEPP tool was distributed to all P/Cs (CTAS score of 2 to 5) in four EDs in Nova Scotia. In phase 2 the PrEPP tool was refined to a 5-item questionnaire. In phase 3 the PrEPP tool was re-implemented over a six-month period. Follow-up surveys were distributed to P/Cs via email (phase 1, 3) and HCPs on iPads in the ED (phase 3) to determine the impact of the tool on communication and management of patients. Entries were compiled on a REDCap database and descriptive statistics were used to analyze responses related to satisfaction. Results: In Phase 1, 11418 PrEPP tools and 147 surveys (29% response rate) were collected from January-June 2016. The majority of P/Cs found the PrEPP questionnaire easy to complete (95.9%) and felt HCPs met their expectations (87.1%). In Phase 3, 951 P/C (31.1% response rate) and 128 HCP surveys were collected. Of P/C respondents 45.9% felt PrEPP helped to communicate expectations, while 49.7% said that they would like to use it on future ED visits. The majority of P/C respondents (75.4%) indicated their expectations were met during their visit to the ED. Of those whose expectations were not met, 69% felt their expectations were not discussed. The majority of HCP respondents (90.4%) indicated they used the PrEPP tool at least sometimes. Also, 78.4% said it influenced patient communication and 42% indicated the tool influenced management of patients at least sometimes. Conclusion: Obtaining expectations early in the patient encounter may provide opportunities for improved communication in the ED. P/Cs found the PrEPP tool easy to use to communicate their expectations and HCPs felt it influenced communication and management of patients in the ED. Further qualitative thematic analysis is needed to explore how the PrEPP tool impacted ED visits.

Download Full-text

MP09: Canadian Community Utilization of Stroke Prevention Pilot Study-Emergency Department (C-CUSP ED)

CJEM ◽

10.1017/cem.2017.175 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S68 ◽

Cited By ~ 1

Author(s):

R. Parkash ◽

K. Magee ◽

M. McMullen ◽

M.B. Clory ◽

M. D’Astous ◽

...

Keyword(s):

Stroke Prevention ◽

Phase 1 ◽

Retrospective Chart Review ◽

Phase 2 ◽

Phase 3 ◽

Three Phase ◽

Rigorous Study ◽

The Mean ◽

Prior Risk

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods: This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primary outcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results: A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71±15, 67±12, 67±13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA2DS2-VASc score was 2.6±1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA2DS2-VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p<0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p<0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion: Use of a simple OAC-prescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated.

Download Full-text

137. Impact of Antimicrobial Stewardship Interventions on Post-Elective Caesarean Antibiotic Prophylaxis and Surgical Site Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.339 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S182-S182

Author(s):

Xue Fen Valerie Seah ◽

Yue Ling Rina Ong ◽

Wei Ming Cedric Poh ◽

Shahul Hameed Mohamed Siraj ◽

Kai-Qian Kam ◽

...

Keyword(s):

Risk Factors ◽

Antibiotic Prophylaxis ◽

Patient Outcomes ◽

Phase 1 ◽

Surgical Site Infections ◽

Phase 2 ◽

Oral Antibiotics ◽

Post Intervention ◽

Phase 3 ◽

The Impact

Abstract Background Antimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. Post-operative antibiotics are generally not necessary, especially those without surgical site infections risk factors (e.g. obesity). Few studies have described the impact of ASP interventions on patient outcomes especially in unique populations such as obstetrics. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use and patient outcomes including SSI rates. Methods This pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was actively discouraged in those without SSI risk factors. This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 7 months (phase 2). Phase 3 (next 6 months) constituted speaking to the operating consultant. The primary outcome was post-operative oral antibiotics prescription rates. Secondary outcomes included rates of 30-day post-operative SSI. Results A total of 1751 women was reviewed. Appropriateness of pre-operative antibiotic prophylaxis was 98% in our institution. There were 244 women pre-intervention, 274 in post-intervention phase 1, 658 in phase 2 and 575 in phase 3. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), which reduced significantly post-intervention to 54% (148) in phase 1, 50% (331) in phase 2 and 39% (226) in phase 3 (p< 0.001). There was no significant difference in patients who developed post-operative SSI pre-post intervention (0.8%, 2 of 242 vs. 1.9%, 28 of 1479, p=0.420) and among who received post-operative oral antibiotics compared to those without (1.9%, 17 of 905 vs. 1.5%, 13 of 846, p=0.582). Conclusion ASP interventions can reduce post-eLSCS antibiotic prophylaxis rates without adversely impacting patient safety. Disclosures All Authors: No reported disclosures

Download Full-text

GEM Centre: Completion report for Phase 2 funding, 2017–2020

10.37517/978-1-74286-621-5 ◽

2021 ◽

Author(s):

Keyword(s):

Global Education ◽

Phase 1 ◽

Lessons Learned ◽

Foreign Affairs ◽

Phase 2 ◽

Phase 3 ◽

Monitoring Centre ◽

Australian Council ◽

The Impact ◽

Further Development

In 2014, the Australian Council for Educational Research (ACER) and the Australian Government’s Department of Foreign Affairs and Trade (DFAT) established a partnership under the Global Education Monitoring Centre. Since then, there have been two funding periods: Phase 1 from 2014–2017 and Phase 2 from 2017–2020. Phase 3 will cover 2020–2023. This report documents the completion of Phase 2 funding and describes the shared priorities of DFAT and ACER through the GEM Centre, followed by the objectives and key outcomes of the work program during this period. The outcomes and lessons learned, together with findings from the GEM Centre mid-term review (MTR) in 2019,1 are reflected against the impact and sustainability of the ACER–DFAT partnership. The MTR validated the overall success of the GEM Centre and identified areas for further development, specifically to improve the effectiveness of the partnership. This report concludes with a brief outlook on how these developments will be addressed under Phase 3 of the GEM Centre.

Download Full-text

P094: Meeting patient expectations in the emergency department: preliminary findings from the preparing emergency patients and providers study

CJEM ◽

10.1017/cem.2017.296 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S110

Author(s):

J. Nunn ◽

C. Cassidy ◽

D. Chiasson ◽

S. MacPhee ◽

J. Curran

Keyword(s):

Emergency Department ◽

Response Rate ◽

Phase 1 ◽

Patient Expectations ◽

Satisfaction With Care ◽

Medical Encounter ◽

X Ray ◽

Phase Study ◽

The Impact

Introduction: Effective communication to develop a shared understanding of patient expectations is critical in establishing a positive medical encounter in the emergency department (ED). However, there is limited research examining patient/caregiver expectations in the ED, and their impact on the beliefs, attitudes and behaviours during and after an ED visit. The objective of this study is to examine patient/caregiver expectations and satisfaction with care in the ED using a patient expectation questionnaire and a follow up survey. Methods: As a part of a larger 3-phase study on patient/caregiver expectations in adult and pediatric EDs, a 7-item, paper-based questionnaire was distributed to all patients and/or caregivers who presented to one of four EDs in Nova Scotia with a Canadian Triage and Acuity Scale (CTAS) score of 2 to 5. A follow-up survey was distributed to all willing participants via email to determine their satisfaction with care received in ED. Descriptive statistics were used to analyze responses. Results: Phase 1 was conducted from January to September 2016. In total, 24,788 expectation questionnaires were distributed to ED patients/caregivers, 11,571 were collected (47% response rate), and 509 patients were contacted for a follow-up survey. Preliminary analysis of 4,533 questionnaires shows the majority of patients (67.1%) made the decision by themselves to present to the ED, while others were advised by a family/friend (22%). Respondents were most worried about an injury (17.8%) followed by illness (15.6%) and expected to talk to a physician (69.9%) and receive an x-ray (39.3%). The majority of physicians (53.3%) reported the expectation tool helped in caring for the patient and 87.5% felt they met patient expectations. There were 147 patient/caregiver responses to a follow-up survey (29% response rate) and 87.1% of responders reported that ED clinicians met their expectations. Conclusion: Patient/caregivers have a variety of concerns, questions, and expectations when presenting to the ED. Obtaining expectations early in the patient encounter may provide opportunities for improved communication between clinicians and patients while enhancing satisfaction with care received. Further analysis is needed to determine the impact of the expectation questionnaire on productivity in the ED.

Download Full-text

Pharmaceutical interventions in medications prescribed for administration via enteral tubes in a teaching hospital

Revista Latino-Americana de Enfermagem ◽

10.1590/1518-8345.0619.2696 ◽

2016 ◽

Vol 24 (0) ◽

Author(s):

Carolina Justus Buhrer Ferreira Neto ◽

Caroline Koga Plodek ◽

Franciny Kossemba Soares ◽

Rayza Assis de Andrade ◽

Fernanda Teleginski ◽

...

Keyword(s):

Teaching Hospital ◽

Inpatient Treatment ◽

Phase 1 ◽

Phase 2 ◽

Phase 3 ◽

Standard Procedures ◽

Unit Dose ◽

Microsoft Office ◽

The Impact ◽

Pharmaceutical Interventions

Abstract Objective: to analyze the impact of guidelines regarding errors in medications prescribed for administration through enteral tubes. Method: quantitative study, in three phases, undertaken in internal medicine, neurology and an intensive care unit in a general teaching hospital. In Phase 1, the following was undertaken: a protocol for dilution and unit-dose repackaging and administration for 294 medications via enteral tubes; a decision flowchart; operational-standard procedures for dilution and unit-dose repackaging of oral pharmaceutical forms and for administration of medications through enteral tubes. In phase 2, errors in 872 medications prescribed through enteral tubes, in 293 prescriptions for patients receiving inpatient treatment between March and June, were investigated. This was followed by training of the teams in relation to the guidelines established. In Phase 3, pharmaceutical errors and interventions in 945 medications prescribed through enteral tubes, in 292 prescriptions of patients receiving inpatient treatment between August and September, were investigated prospectively. The data collected, in a structured questionnaire, were compiled in the Microsoft Office Excel(r) program, and frequencies were calculated. Results: 786 errors were observed, 63.9% (502) in Phase 2, and 36.1% (284) in Phase 3. In Phase 3, a reduction was ascertained in the frequency of prescription of medications delivered via enteral tubes, medications which were contraindicated, and those for which information was not available. Conclusion: guidelines and pharmaceutical interventions were determined in the prevention of errors involving medications delivered through enteral tubes.

Download Full-text

Impact of a Delirium Screening Tool and Multifaceted Education on Nurses’ Knowledge of Delirium and Ability to Evaluate It Correctly

American Journal of Critical Care ◽

10.4037/ajcc2012605 ◽

2012 ◽

Vol 21 (1) ◽

pp. e1-e11 ◽

Cited By ~ 59

Author(s):

Gail Gesin ◽

Brittany B. Russell ◽

Andrew P. Lin ◽

H. James Norton ◽

Susan L. Evans ◽

...

Keyword(s):

Intensive Care ◽

Education Program ◽

Screening Tool ◽

Phase 1 ◽

Surgical Trauma ◽

Phase 2 ◽

Phase 3 ◽

Didactic Lecture ◽

The Impact ◽

Nurses Knowledge

BackgroundThe impact of using a validated delirium screening tool and different levels of education on surgical-trauma intensive care unit (STICU) nurses’ knowledge about delirium is unclear.ObjectivesTo measure the impact of using the Intensive Care Delirium Screening Checklist (ICDSC), with or without a multi-faceted education program, on STICU nurses’ knowledge and perceptions of delirium and their ability to evaluate it correctly.MethodsThe knowledge and perceptions of subject nurses about delirium, and agreement between the independent assessments of delirium by the subject nurse and by a validated judge (who always used the ICDSC), were compared across 3 phases. Phase 1: No delirium screening tool and no education. Phase 2: ICDSC and minimal education (ie, ICDSC validation study only). Phase 3: ICDSC and multifaceted education (ie, pharmacist-led didactic lecture, Web-based module, and nurse-led bedside training).ResultsNurses’ knowledge (mean [SD] score out of 10 points) was similar (P = .08) in phase 1 (6.1 [1.4]) and phase 2 (6.5 [1.4]) but was greater (P = .001) in phase 3 (8.2 [1.4]). Agreement between nurses and the validated judge in the assessment of delirium increased from phase 1 (κ = 0.40) to phase 2 (κ = 0.62) to phase 3 (κ = 0.74). Nurses perceived use of the ICDSC as improving their ability to recognize delirium.ConclusionsUse of a multifaceted education program improves both nurses’ knowledge about delirium and their perceptions about its recognition. Implementation of the ICDSC improves the ability of STICU nurses to evaluate delirium correctly.

Download Full-text

Eight-Year Experience of Antimicrobial Stewardship Program and the Trend of Carbapenem Use at a Tertiary Acute-Care Hospital in Japan—The Impact of Postprescription Review and Feedback

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz389 ◽

2019 ◽

Vol 6 (10) ◽

Cited By ~ 4

Author(s):

Tsubasa Akazawa ◽

Yoshiki Kusama ◽

Haruhisa Fukuda ◽

Kayoko Hayakawa ◽

Satoshi Kutsuna ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Phase 1 ◽

Cost Savings ◽

Care Hospital ◽

Antimicrobial Stewardship Program ◽

Phase 2 ◽

Phase 3 ◽

Car Use ◽

Stewardship Program ◽

The Impact

Abstract Objective We implemented a stepwise antimicrobial stewardship program (ASP). This study evaluated the effect of each intervention and the overall economic impact on carbapenem (CAR) use. Method Carbapenem days of therapy (CAR-DOT) were calculated to assess the effect of each intervention, and antipseudomonal DOT were calculated to assess changes in use of broad-spectrum antibiotics. We carried out segmented regression analysis of studies with interrupted time series for 3 periods: Phase 1 (infectious disease [ID] consultation service only), Phase 2 (adding monitoring and e-mail feedback), and Phase 3 (adding postprescription review and feedback [PPRF] led by ID specialist doctors and pharmacists). We also estimated cost savings over the study period due to decreased CAR use. Results The median monthly CAR-DOT, per month per 100 patient-days, during Phase 1, Phase 2, and Phase 3 was 5.46, 3.69, and 2.78, respectively. The CAR-DOT decreased significantly immediately after the start of Phase 2, but a major decrease was not observed during this period. Although the immediate change was not apparent after Phase 3 started, CAR-DOT decreased significantly over this period. Furthermore, the monthly DOT of 3 alternative antipseudomonal agents also decreased significantly over the study period, but the incidence of antimicrobial resistance did not decrease. Cost savings over the study period, due to decreased CAR use, was estimated to be US $150 000. Conclusions Adding PPRF on the conventional ASP may accelerate antimicrobial stewardship. Our CAR stewardship program has had positive results, and implementation is ongoing.

Download Full-text

Examining the impact of a community-based exercise intervention on cardiorespiratory fitness, cardiovascular health, strength, flexibility and physical activity among adults living with HIV: A three-phased intervention study

PLoS ONE ◽

10.1371/journal.pone.0257639 ◽

2021 ◽

Vol 16 (9) ◽

pp. e0257639

Author(s):

Kelly K. O’Brien ◽

Aileen M. Davis ◽

Soo Chan Carusone ◽

Lisa Avery ◽

Ada Tang ◽

...

Keyword(s):

Physical Activity ◽

Blood Pressure ◽

Cardiovascular Health ◽

Intervention Study ◽

Phase 1 ◽

Community Based ◽

Phase 3 ◽

Living With Hiv ◽

The Impact

Purpose Our aim was to examine the impact of a community-based exercise (CBE) intervention on cardiorespiratory fitness, cardiovascular health, strength, flexibility, and physical activity outcomes among adults living with HIV. Methods We conducted a longitudinal intervention study with community-dwelling adults living with HIV in Toronto, Canada. We measured cardiopulmonary fitness (V̇O2peak (primary outcome), heart rate, blood pressure), strength (grip strength, vertical jump, back extension, push-ups, curl ups), flexibility (sit and reach test), and self-reported physical activity bimonthly across three phases. Phase 1 included baseline monitoring (8 months); Phase 2 included the CBE Intervention (6 months): participants were asked to exercise (aerobic, strength, balance and flexibility training) for 90 minutes, 3 times/week, with weekly supervised coaching at a community-based fitness centre; and Phase 3 included follow-up (8 months) where participants were expected to continue with thrice weekly exercise independently. We used segmented regression (adjusted for baseline age and sex) to assess the change in trend (slope) among phases. Our main estimates of effect were the estimated change in slope, relative to baseline values, over the 6 month CBE intervention. Results Of the 108 participants who initiated Phase 1, 80 (74%) started and 67/80 (84%) completed the intervention and 52/67 (77%) completed the study. Most participants were males (87%), with median age of 51 years (interquartile range (IQR): 45, 59). Participants reported a median of 4 concurrent health conditions in addition to HIV (IQR: 2,7). Participants attended a median of 18/25 (72%) weekly supervised sessions. Change in V̇O2peak attributed to the six-month Phase 2 CBE intervention was 0.56 ml/kg/min (95% Confidence Interval (CI): -1.27, 2.39). Significant effects of the intervention were observed for systolic blood pressure (-5.18 mmHg; 95% CI: -9.66, -0.71), push-ups (2.30 additional push-ups; 95% CI: 0.69, 3.91), curl ups (2.89 additional curl ups; 95% CI: 0.61, 5.17), and sit and reach test (1.74 cm; 95% CI: 0.21, 3.28). More participants engaged in self-reported strength (p<0.001) and flexibility (p = 0.02) physical activity at the end of intervention. During Phase 3 follow-up, there was a significant reduction in trend of benefits observed during the intervention phase for systolic blood pressure (1.52 mmHg/month; 95% CI: 0.67, 2.37) and sit and reach test (-0.42 cm/month; 95% CI: -0.68, -0.16). Conclusion Adults living with HIV who engaged in this six-month CBE intervention demonstrated inconclusive results in relation to V̇O2peak, and potential improvements in other outcomes of cardiovascular health, strength, flexibility and self-reported physical activity. Future research should consider features tailored to promote uptake and sustained engagement in independent exercise among adults living with HIV. ClinicalTrials.gov Identifier NCT02794415. https://clinicaltrials.gov/ct2/show/record/NCT02794415.

Download Full-text

A Small Nudge can make a Difference: Impact of Passive Feedback on Prescription Behavior

International Journal of Research Foundation of Hospital and Health Care Administration ◽

10.5005/jp-journals-10035-1057 ◽

2016 ◽

Vol 4 (1) ◽

pp. 31-34

Author(s):

DK Sharma

Keyword(s):

Error Rate ◽

Phase 1 ◽

Audit And Feedback ◽

Phase 2 ◽

Phase 3 ◽

Prescription Errors ◽

The Impact ◽

Prescription Behavior

ABSTRACT It is generally believed that big changes can be brought about by big interventions. Sometimes, small interventions also can show spectacular results. This case describes the impact of simple intervention, audit and feedback on change in the behavior of clinicians. In this case, the impact of simple intervention in the form of passive feedback has been documented. All the prescriptions received in pharmacy during the period of study were scrutinized for specific prescription errors. An overall error rate of 0.12% was observed in phase 1 of the study, which was reduced to 0.04% during phase 2 of the study after implementation of the intervention, which further dropped to zero during phase 3. It was concluded that a simple audit and feedback nudged the recipients of the feedback to modify their behavior. How to cite this article Tadia VK, Ahlawat R, Arya SK, Sharma DK. A Small Nudge can make a Difference: Impact of Passive Feedback on Prescription Behavior. Int J Res Foundation Hosp Health Adm 2016;4(1):31-34.

Download Full-text

Centralized Ambulance Destination Determination: A Retrospective Data Analysis to Determine Impact on EMS System Distribution, Surge Events, and Diversion Status

Western Journal of Emergency Medicine ◽

10.5811/westjem.2021.8.53198 ◽

2021 ◽

Vol 22 (6) ◽

pp. 1311-1316

Author(s):

Gurvijay Bains ◽

Amelia Breyre ◽

Ryan Seymour ◽

Juan Carlos Montoy ◽

John Brown ◽

...

Keyword(s):

Phase 1 ◽

Geographical Area ◽

Pilot Project ◽

Baseline Period ◽

System Level ◽

Phase 2 ◽

Phase 3 ◽

Retrospective Data Analysis ◽

Level Loading ◽

The Impact

Introduction: Emergency medical services (EMS) systems can become impacted by sudden surges that can occur throughout the day, as well as by natural disasters and the current pandemic. Because of this, emergency department crowding and ambulance “bunching,” or surges in ambulance-transported patients at receiving hospitals, can have a detrimental effect on patient care and financial implications for an EMS system. The Centralized Ambulance Destination Determination (CAD-D) project was initially created as a pilot project to look at the impact of an active, online base hospital physician and paramedic supervisor to direct patient destination and distribution, as a way to improve ambulance distribution, decrease surges at hospitals, and decrease diversion status. Methods: The project was initiated March 17, 2020, with a six-week baseline period; it had three additional study phases where the CAD-D was recommended (Phase 1), mandatory (Phase 2), and modified (Phase 3), respectively. We used coefficients of variation (CV) statistical analysis to measure the relative variability between datasets (eg, CAD-D phases), with a lower variation showing better and more even distribution across the different hospitals. We used analysis of co-variability for the CV to determine whether level loading was improved systemwide across the three phases against the baseline period. The primary outcomes of this study were the following: to determine the impact of ambulance distribution across a geographical area by using the CV; to determine whether there was a decrease in surge rates at the busiest hospital in this area; and the effects on diversion. Results: We calculated the CV of all ratios and used them as a measure of EMS patient distribution among hospitals. Mean CV was lower in Phase 2 as compared to baseline (1.56 vs 0.80 P < 0.05), and to baseline and Phase 3 (1.56 vs. 0.93, P <0.05). A lower CV indicates better distribution across more hospitals, instead of the EMS transports bunching at a few hospitals. Furthermore, the proportion of surge events was shown to be lower between baseline and Phase 1 (1.43 vs 0.77, P <0.05), baseline and Phase 2 (1.43 vs. 0.33, P < 0.05), and baseline and Phase 3 (1.43 vs 0.42, P < 0.05). Diversion was shown to increase over the system as a whole, despite decreased diversion rates at the busiest hospital in the system. Conclusion: In this retrospective study, we found that ambulance distribution increased across the system with the implementation of CAD-D, leading to better level loading. The surge rates decreased at some of the most impacted hospitals, while the rates of hospitals going on diversion paradoxically increased overall. Specifically, the results of this study showed that there was an improvement when comparing the CAD-D implementation vs the baseline period for both the ambulance distribution across the system (level loading/CV), and for surge events at three of the busiest hospitals in the system.

Download Full-text