scholarly journals Diagnostic test utilization in the emergency department for alert headache patients with possible subarachnoid hemorrhage

CJEM ◽  
2002 ◽  
Vol 4 (05) ◽  
pp. 333-337 ◽  
Author(s):  
Jeffrey J. Perry ◽  
Ian Stiell ◽  
George Wells ◽  
Alena Spacek
Keyword(s):  
Emergency Department ◽  
Subarachnoid Hemorrhage ◽  
Length Of Stay ◽  
Tertiary Care ◽  
Diagnostic Testing ◽  
Clinical Decision ◽  
Lengths Of Stay ◽  
Level Of Consciousness ◽  
The Mean ◽  
Acute Headache

ABSTRACT: Objectives: This study evaluated the incidence of subarachnoid hemorrhage (SAH) and the use of computed tomography (CT) and lumbar puncture (LP) in a cohort of emergency department (ED) patients with acute headache. Methods: Health records from a tertiary care ED were used to identify all patients over 15 years of age who presented with headache over a 10-month period. Patients were excluded if they had been referred with confirmed SAH or if they had recurrent headache, head trauma, decreased level of consciousness or new neurologic deficits. Outcome measures included ED diagnosis, use of CT or LP, and ED length of stay. Analysis included descriptive statistics, 95% confidence intervals (CIs) and analysis of variance for length of stay. Results: The mean age of the 891 patients was 41.9 years. Ten (1.1%) of the patients had SAH, 313 (35.1%) underwent CT, and 85 (9.5%) underwent LP. Only 9 (2.9%) of the CT scans and 2 (2.4%) of the LPs were positive for SAH. Of the 296 patients with normal CT results, 232 (78.4%) did not undergo subsequent LP. The mean length of stay was 4.0 hours (95% CI, 3.8–4.1) if no diagnostic testing was performed, 5.0 hours (95% CI, 4.7–5.4) if CT was performed and 7.1 hours (95% CI, 6.3–7.9) if LP was performed (p = 0.001). Conclusions: Diagnostic testing was associated with substantially prolonged lengths of stay. CT and LP had low diagnostic yields, which suggests the need for a clinical decision rule to rule out SAH in ED patients with acute headache.

scholarly journals P139: The impact of a pancreatitis admission algorithm on emergency department length of stay in a tertiary care academic hospital

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S114-S115
Author(s):  
A. Albina ◽  
F. Kegel ◽  
F. Dankoff ◽  
G. Clark
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Tertiary Care ◽  
Physician Satisfaction ◽  
Academic Hospital ◽  
Before And After ◽  
Potential Applicability ◽  
The Mean ◽  
Algorithm Implementation ◽  
The Impact

Background: Emergency department (ED) overcrowding is associated with a broad spectrum of poor medical outcomes, including medical errors, mortality, higher rates of leaving without being seen, and reduced patient and physician satisfaction. The largest contributor to overcrowding is access block – the inability of admitted patients to access in-patient beds from the ED. One component to addressing access block involves streamlining the decision process to rapidly determine which hospital service will admit the patient. Aim Statement: As of Sep 2011, admission algorithms at our institution were supported and formalised. The pancreatitis algorithm clarified whether general surgery or internal medicine would admit ED patients with pancreatitis. We hypothesize that this prior uncertainty delayed the admission decision and prolonged ED length of stay (LOS) for patients with pancreatitis. Our project evaluates whether implementing a pancreatitis admission algorithm at our institution reduced ED time to disposition (TTD) and LOS. Measures & Design: A retrospective review was conducted in a tertiary care academic hospital in Montreal for all adult ED patients diagnosed with pancreatitis from Apr 2010 to Mar 2014. The data was used to plot separate run charts for ED TTD and LOS. Serial measurements of each outcome were used to monitor change and evaluate for special cause variation. The mean ED LOS and TTD before and after algorithm implementation were also compared using the Student's t test. Evaluation/Results: Over four years, a total of 365 ED patients were diagnosed with pancreatitis and 287 (79%) were admitted. The mean ED LOS for patients with pancreatitis decreased following the implementation of an admission algorithm (1616 vs. 1418 mins, p = 0.05). The mean ED TTD was also reduced (1171 vs. 899 mins, p = 0.0006). A non-random signal of change was suggested by a shift above the median prior to algorithm implementation and one below the median following. Discussion/Impact: This project demonstrates that in a busy tertiary care academic hospital, an admission algorithm helped reduce ED TTD and LOS for patients with pancreatitis. This proves especially valuable when considering the potential applicability of such algorithms to other disease processes, such as gastrointestinal bleeding and congestive heart failure, among others. Future studies demonstrating this external applicability, and the impact of such decision algorithms on physician decision fatigue and within non-academic institutions, proves warranted.

scholarly journals Emergency Stay Duration of Patients in Emergency Department of A Tertiary Care Hospital in Nepal: A Descriptive Cross-sectional Study

2020 ◽  
Vol 58 (222) ◽  
Author(s):  
Prashant Simkhada ◽  
Shradha Acharya ◽  
Roshan Lama ◽  
Sujata Dahal ◽  
Nita Lohola ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Cross Sectional Study ◽  
Care Hospital ◽  
Sectional Study ◽  
Cross Sectional ◽  
Duration Of Stay ◽  
The Mean

Introduction: Emergency department of a hospital is responsible for providing medical and surgical care to patients arriving at the hospital in need of immediate care. Emergency department is not staffed or equipped to provide prolonged care. Duration of stay in the Emergency department directly affects the quality of patient care. Longer length of stay is associated with Emergency department overcrowding, decline in patient care, increased mortality and decreased patients satisfaction. The main aim of this study is to find the mean stay duration of patients in the emergency department of a tertiary care hospital in Nepal.Methods: This is a descriptive cross-sectional study which was conducted in a tertiary care teaching hospital from Jan 15,2019 to Jan 30, 2019. Ethical clearance was obtained from Kathmandu Medical College- Instutional Review Committee. The calculated sample size was 587. Consecutive sampling technique was used. The data thus obtained was entered in SPSS version 20 and necessary calculations were done. Results: The mean emergency stay duration was obtained to be 3.18 hours at 95% confidence interval (C.I  and standard deviation was 2.51 hours. Female had longer mean duration of stay (3.25 hours) compared to male (3.11 hours). The maximum length of stay was 15.3 hours. Most of the patients attending the emergency department were discharged right through the emergency department 398 ( 67.8%). Mean duration of stay was longest (5.06 hours) for the referral group. Conclusions: The mean stay duration in Emergency Department of tertiary care hospital in Nepal is getting shorter compared to similar study done previously.

scholarly journals Analysis of factors influencing length of stay in the emergency department

CJEM ◽  
2003 ◽  
Vol 5 (03) ◽  
pp. 155-161 ◽  
Author(s):  
Philip Yoon ◽  
Ivan Steiner ◽  
Gilles Reinhardt
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Patient Care ◽  
Linear Regression Analysis ◽  
Tertiary Care ◽  
Future Research ◽  
Consultation Rate ◽  
Lengths Of Stay ◽  
The Impact ◽  
Triage Level

ABSTRACTObjectives:Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Time studies that assess key ED processes will help clarify the causes of patient care delays and prolonged LOS. The objectives of this study were to identify and quantify the principal ED patient care time intervals, and to measure the impact of important service processes (laboratory testing, imaging and consultation) on LOS for patients in different triage levels.Methods:In this retrospective review, conducted at a large urban tertiary care teaching hospital and trauma centre, investigators reviewed the records of 1047 consecutive patients treated during a continuous 7-day period in January 1999. Key data were recorded, including patient characteristics, ED process times, tests performed, consultations and overall ED LOS. Of the 1047 patient records, 153 (14.6%) were excluded from detailed analysis because of incomplete documentation. Process times were determined and stratified by triage level, using theCanadian Emergency Department Triage and Acuity Scale(CTAS). Multiple linear regression analysis was performed to determine which factors were most strongly associated with prolonged LOS.Results:Patients in intermediate triage Levels III and IV generally had the longest waiting times to nurse and physician assessment, and the longest ED lengths of stay. CTAS triage levels predicted laboratory and imaging utilization as well as consultation rate. The use of diagnostic imaging and laboratory tests was associated with longer LOS, varying with the specific tests ordered. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service consulted.Conclusions:Triage level, investigations and consultations are important independent variables that influence ED LOS. Future research is necessary to determine how these and other factors can be incorporated into a model for predicting LOS. Improved information systems will facilitate similar ED time studies to assess key processes, lengths of stay and clinical efficiency.

scholarly journals P096: Prospective pilot implementation of a clinical decision aid for acute aortic syndrome

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S98
Author(s):  
R. Ohle ◽  
N. Fortino ◽  
O. Montpellier ◽  
M. Ludgate ◽  
S. McIsaac ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Length Of Stay ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Acute Aortic Syndrome ◽  
Pilot Implementation ◽  
Test Probability ◽  
D Dimer

Introduction: The RAPID RIP clinical decision aid was developed to identify patients at high-risk for acute aortic syndrome (AAS) who require investigations. It stratifies patients into low (no further testing) intermediate (D-dimer if no alternative diagnosis) and High risk (Computed tomography (CT) aorta). Our objectives were to assess its impact on: a) Documentation of high risk features/pre test probability for AAS b) D-dimers ordered c) CT ordered and d) Emergency department length of stay. Methods: We conducted a prospective pilot before/after study at a single tertiary-care emergency department between August and September 2018. Consecutive alert adults with chest, abdominal, flank, back pain or stroke like symptoms were included. Patients with pain >14 days or secondary to trauma were excluded. Results: We enrolled 1,340 patients, 656 before and 684 after implementation, including 0 AAS. Documentation of pre test probability assessment increased (0% to 3%, p < 0.009) after implementation. The proportion who had D-dimer performed increased (5.8% to 9.2% (p < 0.2), while the number of CT to rule out AAS remained stable (0.59% versus 0.58%; p = 0.60). The mean length of ED stay was stable (2.31+/−2.0 to 2.28+/−1.5 hours; p = 0.45) and slightly decreased in those with pre test probability documented (2.1+/−1.4 p < 0.09). The specificity of the decision aid for CT was 100%( 95%CI 71.5- 100%). If it were applied to all patients with high-risk clinical features of AAS the specificity would be 92.6% (95%CI 90.1-94.6%). Conclusion: Implementation of the RAPID RIP increased documentation of important high-risk features for AAS. The RAPID RIP strategy increased use of D-dimer without increasing the number of CT and had a trend towards decreased length of stay.

Evaluation of Analgesic and Sedative Effects of Ketamine Infusion against Intravenous Morphine in Relieving Fracture Pain of Long or Short Bones of Upper and Lower Limbs

2021 ◽  
Vol 15 (6) ◽  
pp. 1807-1811
Author(s):  
Meysam Moezi ◽  
Hassan Motamed ◽  
Mohammad Ali Fahimi ◽  
Azam Khalighi
Keyword(s):  
Emergency Department ◽  
Lower Limbs ◽  
Ketamine Infusion ◽  
Disturbed Sleep ◽  
Limb Trauma ◽  
Level Of Consciousness ◽  
Sedative Effects ◽  
Intravenous Morphine ◽  
Minimum Age ◽  
The Mean

Introduction and Purpose: The importance of pain control in patients with limb trauma in the emergency department and its complications is the main issue in post-emergency care and plays an important role in accelerating the improvement of patients' general status. Therefore, the present study aimed to evaluate the analgesic and sedative effects of ketamine infusion against intravenous morphine in relieving fracture pain of long or short bones in the upper and lower limbs. Materials and Methods: We examined the effect of ketamine and morphine as ketamine infusion at a dose of 0.4 mg/kg/IV/10min and intravenous morphine at a dose of 0.1 mg/kg/IV in patients aged 18-65 years with limb trauma who visited the hospital emergency department. We also compared the duration of analgesia, the amount of pain relief according to the Visual Analogue Scale (VAS) in each of the drugs and complications of the above methods, including apnea, bradycardia, tachycardia, decreased level of consciousness, nausea, vomiting, hypertension and hypotension, seizures, and disturbed sleep, and mentioned the preferred method. Results: In the study, we studied 120 patients, 60 of whom received ketamine and 60 received morphine. The mean age of patients was 13.02±13.67 years with a minimum age of 19 years and a maximum age of 70 years, and 89(74.2%) patients were male. There was not any difference between ketamine and morphine in the factors at different times. Conclusion: The results indicated that the potency of low-dose ketamine in relieving pain in patients was very similar to morphine. Keywords: Bone fracture; Ketamine; Morphine.

Analysis of the Effects of Applying Federal Diagnosis-Related Grouping (DRG) Guidelines to a Population of High-Risk Newborn Infants

PEDIATRICS ◽  
1985 ◽  
Vol 76 (1) ◽  
pp. 104-109
Author(s):  
Ronald L. Poland ◽  
Robert O. Bollinger ◽  
Mary P. Bedard ◽  
Sanford N. Cohen
Keyword(s):  
High Risk ◽  
Length Of Stay ◽  
Geometric Mean ◽  
Tertiary Care ◽  
Newborn Infants ◽  
Frequency Distributions ◽  
Federal Register ◽  
Children's Hospital ◽  
Lengths Of Stay ◽  
Children’S Hospital

Length of stay data collected for high-risk newborn infants admitted to a tertiary care children's hospital neonatal unit over a 6-year period were compared with mean and outlier lengths of stay published in the Federal Register as part of a proposed system for prospective payment of hospital cost by diagnosis-related groupings (DRGs). We found that the classification system for newborns markedly underestimated the number of days required for the treatment of these infants. The use of the geometric mean instead of the arithmetic mean as the measure of central tendency was a significant contributor to the discrepancy, especially in those sub-groups with bimodal frequency distributions of lengths of stay. Another contributor to the discrepancy was the lack of inborn patients in the children's hospital cohort. The system of prospective payments, as outlined, does not take into account several factors that have a strong influence on length of stay such as birth weight (which requires more than three divisions to serve as an effective predictor), surgery, outborn status, and ventilation. Implementation of the system described in the Federal Register would severely discourage tertiary care referral hospitals from providing neonatal intensive care.

Impact of Antibiotic-Resistant Pathogens Colonizing the Respiratory Secretions of Patients in an Extended-Care Area of the Emergency Department

2003 ◽  
Vol 24 (5) ◽  
pp. 351-355 ◽  
Author(s):  
Sônia R. P. E. Dantas ◽  
M. Luiza Moretti-Branchini
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Univariate Analysis ◽  
Antibiotic Resistant ◽  
Prolonged Stay ◽  
Nasogastric Intubation ◽  
Extended Care ◽  
The Mean

AbstractObjective:To determine the incidence of acquired infection, and the incidence, risk factors, and molecular typing of multidrug-resistant bacterial organisms (MROs) colonizing respiratory secretions or the oropharynx of patients in an extended-care area of the emergency department (ED) in a tertiary-care university hospital.Methods:A case-control study was conducted regarding risk factors for colonization with MROs in ED patients from July 1996 to August 1998. The most prevalent MRO strains were determined using plasmid and genomic analysis with PFGE.Results:MROs colonized 59 (25.4%) of 232 ED patients and 173 controls. The mean ED length of stay for the 59 cases was 13.9 days versus 9.8 days for the 173 controls. The mean length of stay prior to the first isolation of MROs was 9.9 days. MRO species included Acinetobacter baumannii, Staphylococcus aureus, and Pseudomonas aeruginosa. The rate of hospital-acquired infection was 32.7 per 1,000 ED patient-days. The case fatality rate was significantly higher for cases. Univariate analysis identified mechanical ventilation, nebulization, nasogastric intubation, urinary catheterization, antibiotic therapy, and number of antibiotics as risk factors for MRO colonization. Multivariate regression analysis found that mechanical ventilation and nasogastric intubation independently predicted MRO colonization. Endemic clones were identified by PFGE in ED patients and were also found in patients in other parts of the hospital.Conclusions:Prolonged stay in the ED posed a risk for colonization with MROs and for contracting nosocomial infections, both of which were associated with increased mortality. Patients colonized with antibiotic-resistant A. baumannii may serve as a reservoir for spread in this hospital.

scholarly journals P108: Characterizing use of next-day ultrasound from the emergency department

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S103
Author(s):  
C. Roberts ◽  
T. Oyedokun ◽  
B. Cload ◽  
L. Witt
Keyword(s):  
Emergency Department ◽  
Patient Care ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Improve Patient Care ◽  
Additional Stress ◽  
Start Date ◽  
The Mean ◽  
Tertiary Care Hospitals ◽  
Improve Patient

Introduction: Formal ultrasound imaging, with use of ultrasound technicians and radiologists, provides a valuable diagnostic component to patient care in the Emergency Department (ED). Outside of regular weekday hours, ordering formal ultrasounds can produce logistical difficulties. EDs have developed protocols for next-day ultrasounds, where the patient returns the following day for imaging and reassessment by an ED physician. This creates additional stress on ED resources – personnel, bed space, finances – that are already strained. There is a dearth of literature regarding the use of next-day ultrasounds or guidelines to direct efficient use. This study sought to accumulate data on the use of ED next-day ultrasounds and patient oriented clinical outcomes. Methods: This study was a retrospective chart review of 150 patients, 75 from each of two different tertiary care hospitals in Saskatoon, Saskatchewan. After a predetermined start date, convenience samples were collected of all patients who had undergone a next-day ultrasound ordered from the ED until the quota was satisfied. Patients were identified by an electronic medical record search for specific triage note phrases indicating use of next-day ultrasounds. Different demographic, clinical, and administrative parameters were collected and analyzed. Results: Of the 150 patients, the mean age was 35.9 years and 75.3% were female. Median length of stay for the first visit was 4.1 hours, and 2.2 hours for the return visit. Most common ultrasound scans performed were abdomen and pelvis/gyne (34.7%), complete abdomen (30.0%), duplex extremity venous (10.0%). Most common indications on the ultrasound requisition were nonspecific abdominal pain (18.7%), vaginal bleeding with or without pregnancy (17.3%), and hepatobiliary pathology (15.3%). Ultrasounds results reported a relevant finding 56% of the time, and 34% were completely normal. After the next-day ultrasound 5.3% of patients had a CT scan, 10.7% had specialist consultation, 8.2% were admitted, and 7.3% underwent surgery. Conclusion: Information was gathered to close gaps in knowledge about the use of next-day ultrasounds from the ED. A large proportion of patients are discharged home without further interventions. Additional research and the development of next-day ultrasound guidelines or outpatient pathways may improve patient care and ED resource utilization.

scholarly journals Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

QJM ◽  
2020 ◽  
Author(s):  
K Jusmanova ◽  
C Rice ◽  
R Bourke ◽  
A Lavan ◽  
C G McMahon ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Admission Rate ◽  
Readmission Rates ◽  
Specialist Service ◽  
Admission Rates ◽  
Potential Benefits ◽  
Bed Days ◽  
The Mean ◽  
The Impact

Summary Background Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission. Aim To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness. Design Pre- and post-cohort study. Methods Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS). Results There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4–24.0] days compared to 18.2 (95% CI 14.6–21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030). Conclusion This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

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