The effect of context on performance of an acute medical unit: experience from an Australian tertiary hospital

2012 ◽  
Vol 36 (3) ◽  
pp. 320 ◽  
Author(s):  
Belinda Suthers ◽  
Robert Pickles ◽  
Michael Boyle ◽  
Kichu Nair ◽  
Justyn Cook ◽  
...  
Keyword(s):  
Emergency Department ◽  
Nursing Home ◽  
Length Of Stay ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Local Context ◽  
Health Staff ◽  
Medical Unit ◽  
Acute Medical Unit ◽  
Transfers Of Care

Objective. To ascertain the improvements in length of stay and discharge rates following the opening of an acute medical unit (AMU). Methods. Retrospective cohort study of all patients admitted under general medicine from June–November 2008. Main outcome measures were length of stay in hospital and in the emergency department (ED). Results. The length of time spent in the emergency department for those admitted to the AMU was significantly shorter than those admitted directly to a medical ward (6.83 h v. 9.40 h, P < 0.0001). A trend towards shorter hospital length of stay continued after the AMU opened compared with the same period in the previous year (5.15 days (2.49, 11.57 CI) v. 5.66 days (2.76, 11.52 CI)). However, the number of ward transfers for a patient and the need to wait for a nursing home bed or public rehabilitation affected length of stay much more than the AMU. Conclusion. An AMU was successful in decreasing ED length of stay and contributed to decreasing hospital length of stay. However, we suggest that local context is crucially important in tailoring an AMU to obtain maximal benefit, and that AMUs are not a ‘one size fits all’ solution. What is known about the topic? Acute Medical Units were pioneered in the UK and have been shown to decrease length of stay with no increase in adverse events. As a result, they have been enthusiastically adopted in Australia. However, most studies have been single point ‘before/after’ designs looking at all medical patients, and there has been little consideration of the context in which AMUs operate and how this might affect their performance. What does this paper add? We consider length of stay trends over many years and separate single organ disease from multi-system disease patients, in order to ensure that gains are not simply a result of selective entry of healthier patients into AMUs. We also show that the effect of an AMU is small compared with other systemic issues, such as waiting for nursing home placement and the number of transfers of care. What are the implications for practitioners? Although there may be gains in terms of length of stay in the emergency department, those considering the establishment of an AMU need to consider other factors that may mitigate the improvements in hospital length of stay, such as the roadblocks to discharge, the organisation of allied health staff, and the number of transfers of care.

scholarly journals Association of Emergency Department Waiting Times With Patient Experience in Admitted and Discharged Patients

2021 ◽  
Vol 8 ◽  
pp. 237437352110114
Author(s):  
Andrew Nyce ◽  
Snehal Gandhi ◽  
Brian Freeze ◽  
Joshua Bosire ◽  
Terry Ricca ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Patient Experience ◽  
Waiting Times ◽  
Hospital Length ◽  
Short Length ◽  
Hospital Length Of Stay ◽  
Patient’S Experience ◽  
Discharged Patients ◽  
The Impact

Prolonged waiting times are associated with worse patient experience in patients discharged from the emergency department (ED). However, it is unclear which component of the waiting times is most impactful to the patient experience and the impact on hospitalized patients. We performed a retrospective analysis of ED patients between July 2018 and March 30, 2020. In all, 3278 patients were included: 1477 patients were discharged from the ED, and 1680 were admitted. Discharged patients had a longer door-to-first provider and door-to-doctor time, but a shorter doctor-to-disposition, disposition-to-departure, and total ED time when compared to admitted patients. Some, but not all, components of waiting times were significantly higher in patients with suboptimal experience (<100th percentile). Prolonged door-to-doctor time was significantly associated with worse patient experience in discharged patients and in patients with hospital length of stay ≤4 days. Prolonged ED waiting times were significantly associated with worse patient experience in patients who were discharged from the ED and in inpatients with short length of stay. Door-to-doctor time seems to have the highest impact on the patient’s experience of these 2 groups.

scholarly journals Predictive factors for prolonged hospitalisation in acute pyelonephritis patients admitted to the emergency medicine ward

2021 ◽  
pp. 102490792110009
Author(s):  
Howard Tat Chun Chan ◽  
Ling Yan Leung ◽  
Alex Kwok Keung Law ◽  
Chi Hung Cheng ◽  
Colin A Graham
Keyword(s):  
Emergency Department ◽  
Emergency Medicine ◽  
Length Of Stay ◽  
Acute Pyelonephritis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Prolonged Length ◽  
Reactive Protein ◽  
Prolonged Hospital ◽  
Emergency Medicine Ward

Background: Acute pyelonephritis is a bacterial infection of the upper urinary tract. Patients can be admitted to a variety of wards for treatment. However, at the Prince of Wales Hospital in Hong Kong, they are managed initially in the emergency medicine ward. The aim of the study is to identify the risk factors that are associated with a prolonged hospital length of stay. Methods: This was a retrospective cohort study conducted in Prince of Wales Hospital. The study recruited patients who were admitted to the emergency medicine ward between 1 January 2014 and 31 December 2017. These patients presented with clinical features of pyelonephritis, received antibiotic treatment and had a discharge diagnosis of pyelonephritis. The length of stay was measured and any length of stay over 72 h was considered to be prolonged. Results: There were 271 patients admitted to the emergency medicine ward, and 118 (44%) had a prolonged hospital length of stay. Univariate and multivariate analyses showed that the only statistically significant predictor of prolonged length of stay was a raised C-reactive protein (odds ratio 1.01; 95% confidence 1.01–1.02; p < 0.0001). Out of 271 patients, 261 received antibiotics in the emergency department. All 10 patients (8.5%) who did not receive antibiotics in emergency department had a prolonged length of stay (p = 0.0002). Conclusion: In this series of acute pyelonephritis treated in the emergency medicine ward, raised C-reactive protein levels were predictive for prolonged length of stay. Patients who did not receive antibiotics in the emergency department prior to emergency medicine ward admission had prolonged length of stay.

Disagreement between emergency department admission diagnosis and hospital discharge diagnosis: mortality and morbidity

Diagnosis ◽  
2016 ◽  
Vol 3 (1) ◽  
pp. 23-30 ◽  
Author(s):  
James Eames ◽  
Arie Eisenman ◽  
Richard J. Schuster
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Medical Center ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Admission Diagnosis ◽  
Mortality And Morbidity ◽  
Emergency Department Admission ◽  
Icu Length Of Stay ◽  
Discordant Group

AbstractPrevious studies have shown that changes in diagnoses from admission to discharge are associated with poorer outcomes. The aim of this study was to investigate how diagnostic discordance affects patient outcomes.: The first three digits of ICD-9-CM codes at admission and discharge were compared for concordance. The study involved 6281 patients admitted to the Western Galilee Medical Center, Naharyia, Israel from the emergency department (ED) between 01 November 2012 and 21 January 2013. Concordant and discordant diagnoses were compared in terms of, length of stay, number of transfers, intensive care unit (ICU) admission, readmission, and mortality.: Discordant diagnoses was associated with increases in patient mortality rate (5.1% vs. 1.5%; RR 3.35, 95% CI 2.43, 4.62; p<0.001), the number of ICU admissions (6.7% vs. 2.7%; RR 2.58, 95% CI 2.07, 3.32; p<0.001), hospital length of stay (3.8 vs. 2.5 days; difference 1.3 days, 95% CI 1.2, 1.4; p<0.001), ICU length of stay (5.2 vs. 3.8 days; difference 1.4 days, 95% CI 1.0, 1.9; p<0.001), and 30 days readmission (14.11% vs. 12.38%; RR 1.14, 95% CI 1.00, 1.30; p=0.0418). ED length of stay was also greater for the discordant group (3.0 vs. 2.9 h; difference 8.8 min; 95% CI 0.1, 0.2; p<0.001): These findings indicate discordant admission and discharge diagnoses are associated with increases in morbidity and mortality. Further research should identify modifiable causes of discordance.

scholarly journals Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

BMJ Open ◽  
2018 ◽  
Vol 8 (3) ◽  
pp. e018190 ◽  
Author(s):  
Marcel Émond ◽  
Valérie Boucher ◽  
Pierre-Hugues Carmichael ◽  
Philippe Voyer ◽  
Mathieu Pelletier ◽  
...  
Keyword(s):  
Older Adults ◽  
Emergency Department ◽  
Cohort Study ◽  
Length Of Stay ◽  
Hospital Length ◽  
Cognitive Status ◽  
Hospital Ward ◽  
Hospital Length Of Stay ◽  
Multicentre Cohort Study ◽  
Multicentre Cohort

ObjectiveWe aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.DesignThis is a prospective observational multicentre cohort study (March–July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.SettingThe study took place in four Canadian EDs.Participants338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.Main outcome(s) and measure(s)The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.ResultsMean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5–47.9) hours and hospital LOS was 146.6 (75.2–267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient.ConclusionsAn incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

scholarly journals Implementation of a Physician Incentivized QI Strategy to Address Time to Parenteral Analgesia in Patients with Voe in the Pediatric Emergency Department

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2989-2989
Author(s):  
Romy Shane ◽  
Sanjay J. Shah ◽  
Blake Bulloch ◽  
Anita Bharath
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Post Intervention ◽  
Opioid Administration ◽  
Ed Visits ◽  
Mean Time ◽  
Timely Administration ◽  
Order Set

Abstract Introduction Vaso-occlusive episodes (VOE) are the most common cause of pediatric Emergency Department (ED) visits and hospitalizations in Sickle Cell Disease (SCD). The National Heart Lung and Blood Institute published an Expert Panel Report regarding the management of SCD and VOE. Their consensus statement recommends initiating analgesic therapy within 30 minutes of triage or within 60 minutes of registration in the Emergency Department. Previous studies have demonstrated that earlier maximum opioid has been associated with shorter length of hospitalization and improved time to ED disposition decision. Despite the overwhelming evidence for timely administration of parenteral analgesic, significant delays still exist in delivery of pain medication in the pediatric SCD population. Barriers to timely administration include rapid triage of SCD patients, provider ordering of pain medication, and peripheral intravenous access. Therefore, a standardized approach to pain management may improve ED management of SCD crises. In order to address timely administration of opiates to SCD patients with VOE episodes in our pediatric ED a SCD pain order set was developed. This order set implemented the use of intranasal (IN) fentanyl as a first line analgesic for SCD patients who presents to the ED with VOE. The purpose of this study was addressing barriers to decrease time to parenteral opioid administration in the pediatric ED. Methods This Quality Improvement (QI) measure was performed at a free-standing, urban pediatric ED. Patients were included if they had a diagnosis of SCD and presented with a pain score &gt;5 and without fever. A PDSA cycle was utilized for designing and evaluating the proposed changes. This cycle consisted of three intervention phases: (1) electronic medical record (EMR) order set development in October 2019, (2) provider incentive for order set use in January 2020, and (3) nursing/patient & family education in April 2020. Baseline data was collected pre-intervention from April-September 2019. The outcomes measures were mean time to 1 st analgesic, mean time from triage to disposition, Hospital Length of Stay, and overall admission rates. Our balancing measure included 48 hour ED re-visits after discharge. Results There were 67 ED visits from April-September 2019 (pre-intervention) and 104 ED visits in the post-intervention data from October-June 2020. There was no significant difference in age or initial pain score in the pre- and post- intervention groups. Improvements were seen in: mean time to first analgesic (58 to 26 minutes), time to disposition (271 to 213 minutes). Hospital length of stay was found to increase with the introduction of IN fentanyl: pre-intervention (120 hours), phase 1 (148 hours), phase 2 (152 hours), phase 3 (218 hours). However, the overall admission rate decreased (55% to 44%). The number of 48-hour ED re-visits remained stable. Conclusion By using QI methods to address key barriers in the pediatric ED, we demonstrated that timely administration of parenteral analgesic can be achieved for SCD patients with VOE. Utilizing the EMR order set allowed for more stream-lined care, both by physicians and nursing staff, resulting in more rapid ordering of medication therefore decreasing time to ED disposition. Additional interventions such as provider incentivization to meet the goal of parenteral opioids within 30 minutes of patient arrival led to further improvement. One of the greatest barriers to our QI intervention was hesitancy both by patients and their caregivers regarding the efficacy of IN fentanyl in decreasing pain compared to IV opioid. Further education was needed both for families and medical staff regarding the efficacy of IN fentanyl as a first line analgesic. It is unclear why overall hospital length of stay was not shown to be decreased with these interventions but this can be offset by an overall decrease in hospital admissions seen with our interventions. This data may be limited by the SARS-CoV-2 pandemic and how psychosocial stressors can impact patients with chronic medical conditions. Length of stay is also confounded by other factors during the hospitalization and acquisition of other diagnoses such as acute chest. Future research is needed to determine if the demonstrated trend of admission rates and hospital length of stay can be replicated in other pediatric EDs and whether earlier opioid administration affects the outcome of VOEs beyond the ED. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals Hospital outreach service: Helping to prevent nursing home placement

1998 ◽  
Vol 21 (4) ◽  
pp. 192 ◽  
Author(s):  
Phillip Bairstow ◽  
Sarah Ashe ◽  
Mary Bairstow
Keyword(s):  
Nursing Home ◽  
Length Of Stay ◽  
Health Service ◽  
Hospital Length ◽  
Nursing Home Placement ◽  
Hospital Length Of Stay ◽  
Advantages And Disadvantages ◽  
Outreach Service ◽  
Home Placement

An outreach service from a post-acute metropolitan teaching hospital delivered anintensive, multidisciplinary and coordinated allied health service, and achieved bothearly hospital discharge and the prevention or delay of nursing home placement. Thisarticle reports on three types of cases which illustrate how the service assisted wardteams, families and patients to determine whether nursing home placement wasessential. For a group of 20 cases, the total reduction in hospital length of stay was556 days, and home accommodation as an alternative to nursing homeaccommodation was achieved for a total of 7505 days. The article outlines a matrixof advantages and disadvantages, both tangible and intangible, of home versusnursing home accommodation. It is suggested that a full costing of this matrix wouldinform debate on the comparative merits of long-term home and nursing homeaccommodation.

scholarly journals Time between Symptom Onset, Hospitalisation and Recovery or Death: a Statistical Analysis of Different Time-Delay Distributions in Belgian COVID-19 Patients

2020 ◽  
Author(s):  
Christel Faes ◽  
Steven Abrams ◽  
Dominique Van Beckhoven ◽  
Geert Meyfroidt ◽  
Erika Vlieghe ◽  
...  
Keyword(s):  
Nursing Home ◽  
Length Of Stay ◽  
Symptom Onset ◽  
Age Groups ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Age Group ◽  
Median Length ◽  
Nursing Home Patients ◽  
Interval Censored

Background There are different patterns in the COVID-19 outbreak in the general population and amongst nursing home patients. Different age-groups are also impacted differently. However, it remains unclear whether the time from symptom onset to diagnosis and hospitalization or the length of stay in the hospital is different for different age groups, gender, residence place or whether it is time dependent. Methods Sciensano, the Belgian Scientific Institute of Public Health, collected information on hospitalized patients with COVID-19 hospital admissions from 114 participating hospitals in Belgium. Between March 14, 2020 and June 12, 2020, a total of 14,618 COVID-19 patients were registered. The time of symptom onset, time of COVID-19 diagnosis, time of hospitalization, time of recovery or death, and length of stay in intensive care are recorded. The distributions of these different event times for different age groups are estimated accounting for interval censoring and right truncation in the observed data. Results The truncated and interval-censored Weibull regression model is the best model for the time between symptom onset and diagnosis/hospitalization best, whereas the length of stay in hospital is best described by a truncated and interval-censored lognormal regression model. Conclusions The time between symptom onset and hospitalization and between symptom onset and diagnosis are very similar, with median length between symptom onset and hospitalization ranging between 3 and 10.4 days, depending on the age of the patient and whether or not the patient lives in a nursing home. Patients coming from a nursing home facility have a slightly prolonged time between symptom onset and hospitalization (i.e., 2 days). The longest delay time is observed in the age group 20-60 years old. The time from symptom onset to diagnosis follows the same trend, but on average is one day longer as compared to the time to hospitalization. The median length of stay in hospital varies between 3 and 10.4 days, with the length of stay increasing with age. However, a difference is observed between patients that recover and patients that die. While the hospital length of stay for patients that recover increases with age, we observe the longest time between hospitalization and death in the age group 20-60. And, while the hospital length of stay for patients that recover is shorter for patients living in a nursing home, the time from hospitalization to death is longer for these patients. But, over the course of the first wave, the length of stay has decreased, with a decrease in median length of stay of around 2 days.

Sign in / Sign up

Export Citation Format

Share Document