583 Impacting the Length of Stay of Burn Patients in the Emergency Department

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S133-S133
Author(s):  
Nicole M Kopari
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Process Improvement ◽  
Life Support ◽  
Early Interventions ◽  
Burn Patients ◽  
Burn Unit ◽  
Early Transfer ◽  
Activation Criteria ◽  
Rapid Transfer

Abstract Introduction Burn patients represent a challenging patient population and require early interventions. Advance Burn Life Support classes have been developed to guide first responders with assessing and treating burn patients in the pre-hospital setting. In the emergency department (ED) patients may experience hypothermia, delayed resuscitation, inadequate pain control, and delayed wound cares. Methods ED length of stay (LOS) was retrospectively reviewed for burn patient who met trauma activation criteria from 2013–2018. Patients were categorized based on ED disposition to burn stepdown, burn unit intensive care (BICU), or directly to the burn operating room (OR). Patients who died in the ED or were discharged home were excluded. In 2019, guidelines for burn activations, responses, and consults were developed to mirror the activation criteria for a Level 1 trauma institution. ED nurses and physicians were educated on burn assessment, wound care, and the new triage guidelines with emphasis on the importance of early transfer out of the ED. Results Prior to the change in burn activation guidelines, rapid transfer of burn patients out of the ED had not been emphasized. Of the 144 patients examined, ED LOS was 5.4 hours for those going to burn stepdown, 4.3 hours for BICU, and 3.7 hours for those who went directly to the burn OR. Several barriers to early transfer out of the ED were identified including lack of bed availability, lack of cleaning staff on nights and weekends, difficult lateral transfers of non-burn patients out of the Burn Unit, and a lack of education on the importance of early interventions by nursing staff. Since the implementation of the guidelines, there has been an improvement in LOS for BICU patients, but the goal of less than one hour in the ED has not yet been achieved. Conclusions Unacceptable ED LOS for burn patients were identified, triage guidelines were developed, and education was provided to staff. Guidelines and education, in conjunction with emphasizing the importance of having available beds in the Burn Unit, have led to a decrease in ED length of stay. Ongoing education and process improvement are key for rapid transfer of burn patients out of the ED. Applicability of Research to Practice Burn Centers can improve patient accounts by identifying areas that put burn patients at risk. Implementation of protocols can lead to process improvement and lead to better patient outcomes.

627 Strategies for Reducing Emergency Department Lengths of Stay for Admitted Pediatric Burn Patients

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S169-S169
Author(s):  
Lisa M Shostrand ◽  
Brett C Hartman ◽  
Belinda Frazee ◽  
Dawn Daniels ◽  
Madeline Zieger
Keyword(s):  
Emergency Department ◽  
Gap Analysis ◽  
Burn Patients ◽  
Improvement Project ◽  
Burn Trauma ◽  
Charge Nurse ◽  
Lengths Of Stay ◽  
Burn Unit ◽  
Set Up ◽  
Trauma Activation

Abstract Introduction Various strategies to reduce emergency department (ED) lengths of stay (LOS) for admitted pediatric burn patients may be employed as a quality improvement project. Decreasing ED LOS may promote patient outcomes and reduce morbidity. Initial discussions were brought forth during trauma and burn multidisciplinary peer review rounds in March 2019 and have persisted to present day. Methods Several strategies, such as preparation of the burn unit staff within one hour of patient arrival in ED, notification to the burn unit by the burn attending of an incoming pediatric burn patient, allowing the PICU charge nurses or advisors to assist with room set up and admissions, and creating a checklist to assist PICU nurses and advisors in helping prepare for anticipating inpatient admissions. These strategies were designed and enforced in March/April 2019. In addition to these action plans, trauma activation alerts were added in December 2019 to the burn charge nurse phone for pediatric burn trauma one and trauma alerts for more expedient notifications. Finally, communication efforts between ED and burn leadership teams were conducted in June 2020 to help with additional mitigating of ED LOS, such as discussing the appropriateness of specialty consults while in the ED. Results Initial ED LOS was reduced from 209 minutes in March 1019 to 150 minutes in June 2019. Increased trends were noted in early 2020, with a peak at 244 minutes in July 2020. Additional interventions, such as trauma activation alerts and ED/Burn team communications, did not provide sustainable long-term reductions. Conclusions Recent strategies to reduce overall ED LOS trends have been beneficial, but not consistent, in sustaining downward trends. Action to perform a gap analysis to discover persistent barriers and to introduce additional structure, such as a burn trauma one algorithm, may provide stability to this metric.

26 Clogged Feeding Tubes: Why Does It Matter?

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S22-S23
Author(s):  
Sarah Zavala ◽  
Ashley Wang ◽  
Cheryl W Zhang ◽  
Jennifer M Larson ◽  
Yuk Ming Liu
Keyword(s):  
Risk Factors ◽  
Length Of Stay ◽  
Nutritional Support ◽  
Total Body Surface Area ◽  
Tube Feeding ◽  
Feeding Tube ◽  
Admission Diagnosis ◽  
Burn Patients ◽  
Feeding Tubes ◽  
Burn Unit

Abstract Introduction Many patients treated on a burn unit require tube feeding as their primary caloric source or as supplemental feeding due to their injuries. Burn patients specifically require higher caloric intake due to the hypermetabolic state of burn injuries. Inadequate nutritional support contributes to longer ICU stays and higher mortality. Clogged feeding tubes reduce nutrition provided due to temporary discontinuation of feeding. The objective of this study was to identify risk factors for the incidence of tube clogging. Methods This was a single-center retrospective chart review of all patients admitted to an American Burn Association-verified Burn Unit between August 2017 and October 2019 who received tube feeds during their admission. Data collected included baseline demographics, clinical outcomes, and details about tube feed formulations, number of clogs, and details leading up to the clog. Baseline demographics were compared using descriptive statistics. Nominal data was compared using Chi-square test. Continuous data was analyzed using student’s t-test or Mann-Whitney U test. Results A total of 170 patients were included; admission diagnoses included burn (97), soft tissue infections (29), SJS/TEN (11), and others (33). At least one clogged feeding tube was experienced by 51 patients and some experienced up to seven separate clogs. SJS/TEN patients were less likely to experience a clog (9.2 vs 0%, p = 0.035) and frostbite patients were more likely to experience a clog (0 vs 5.9%, p = 0.026). Burn mechanism did not affect incidence of tube feed clog, but patients with larger total body surface area (TBSA) burned were more likely to have a clog (15.55 vs 25.03%, p = 0.004). It was a median of 12 days until the first clog occurred (IQR 7.8–17.3). Two tube feed formulas demonstrated an increased likelihood of clog: a renal formulation (16.8 vs 33.3%, p = 0.017) and a polymeric concentrated product (5.0 vs 17.6%, p = 0.008). Both products have a high viscosity. Patients who experienced a clog had a longer length of stay (21.5 vs 44.0 days, p = 0.001). Conclusions This study identified several risk factors associated with higher incidence of clogged feeding tube in the burn unit including tube feed formulation and viscosity, admission diagnosis, and larger TBSA in burn patients. This study also confirms that clogged feeding tubes, and the resultant insufficient nutritional support, may contribute to an increased length of stay.

scholarly journals Evaluation of an Emergency Department Lean Process Improvement Program to reduce length of stay

2014 ◽  
Vol 14 (Suppl 2) ◽  
pp. P110 ◽  
Author(s):  
Marian Vermeulen ◽  
Therese Stukel ◽  
Astrid Guttmann ◽  
Brian Rowe ◽  
Merrick Zwarenstein ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Process Improvement ◽  
Improvement Program

scholarly journals Evaluation of an Emergency Department Lean Process Improvement Program to Reduce Length of Stay

2014 ◽  
Vol 64 (5) ◽  
pp. 427-438 ◽  
Author(s):  
Marian J. Vermeulen ◽  
Therese A. Stukel ◽  
Astrid Guttmann ◽  
Brian H. Rowe ◽  
Merrick Zwarenstein ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Process Improvement ◽  
Improvement Program

scholarly journals Demographic Characteristic Of Burn Mortality And Its Relation To Tangential Excision At Burn Unit Of Cipto Mangunkusumo National General Hospital

2019 ◽  
Vol 5 (1) ◽  
pp. 194-202
Author(s):  
Aditya Wardhana ◽  
Dhita Kurniasari
Keyword(s):  
Length Of Stay ◽  
Burn Injury ◽  
Delay Group ◽  
Burn Patients ◽  
Mortality And Morbidity ◽  
Online Databases ◽  
Burn Unit ◽  
Wound Excision ◽  
Pros And Cons ◽  
Culture Positive

Background: Burn injury is considered as major problem because of high mortality and morbidity. One of the several managements to decrease the mortality rate is wound excision. This study aimed to describe the characteristics of burn mortality in our burn unit and its association with timing of tangential excision. Method: We collect data of burn patients who died in 2016 at Burn Unit of Cipto Mangunkusumo Hospital. We investigate the association of mortality and timing of tangential excision. The data were compared with other studies from online databases. Result: Thirty-four burn patients died at RSCM Burn Unit from January - December 2016. 13 patients underwent early tangential excision, the rest had delayed or no tangential excision. Only length of stay (LOS) has statistically significant result. The early tangential excision group has significantly longer median LOS (p=0.003) compared to delayed tangential excision. From five relevant studies, three studies had higher mortality in early tangential excision group compared to delay group but fewer complications and shorter LOS. Two studies reported a significant reduction in mortality in early tangential excision group while culture positive wounds were more frequent in the delay group. Conclusion: Mortality in our patients in early tangential excision group is fewer than the delayed one. The early tangential excision group has longer length of stay compared to delay tangential excision. Although there are pros and cons from the literature review, we suggest that early tangential excision should be done in burn patients.

scholarly journals National Trends in Emergency Department Care Processes for Acute Myocardial Infarction in the United States, 2005 to 2015

2020 ◽  
Vol 9 (20) ◽  
Author(s):  
Akshay Pendyal ◽  
Craig Rothenberg ◽  
Jean E. Scofi ◽  
Harlan M. Krumholz ◽  
Basmah Safdar ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Length Of Stay ◽  
Real World ◽  
The United States ◽  
Emergency Department Care ◽  
Care Processes ◽  
Ed Visits

Background Despite investments to improve quality of emergency care for patients with acute myocardial infarction (AMI), few studies have described national, real‐world trends in AMI care in the emergency department (ED). We aimed to describe trends in the epidemiology and quality of AMI care in US EDs over a recent 11‐year period, from 2005 to 2015. Methods and Results We conducted an observational study of ED visits for AMI using the National Hospital Ambulatory Medical Care Survey, a nationally representative probability sample of US EDs. AMI visits were classified as ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI. Outcomes included annual incidence of AMI, median ED length of stay, ED disposition type, and ED administration of evidence‐based medications. Annual ED visits for AMI decreased from 1 493 145 in 2005 to 581 924 in 2015. Estimated yearly incidence of ED visits for STEMI decreased from 1 402 768 to 315 813. The proportion of STEMI sent for immediate, same‐hospital catheterization increased from 12% to 37%. Among patients with STEMI sent directly for catheterization, median ED length of stay decreased from 62 to 37 minutes. ED administration of antithrombotic and nonaspirin antiplatelet agents rose for STEMI (23%–31% and 10%–27%, respectively). Conclusions National, real‐world trends in the epidemiology of AMI in the ED parallel those of clinical registries, with decreases in AMI incidence and STEMI proportion. ED care processes for STEMI mirror evolving guidelines that favor high‐intensity antiplatelet therapy, early invasive strategies, and regionalization of care.

Effect of Undertriage on the Outcomes of Cancer Patients with Febrile Neutropenia, Sepsis, and Septic Shock

2021 ◽  
pp. 105477382199968
Author(s):  
Anas Alsharawneh
Keyword(s):  
Emergency Department ◽  
Septic Shock ◽  
Length Of Stay ◽  
Febrile Neutropenia ◽  
Cancer Patients ◽  
Emergency Setting ◽  
Extended Length ◽  
Life Threatening ◽  
Sepsis And Septic Shock ◽  
Timely Treatment

Sepsis and neutropenia are considered the primary life-threatening complications of cancer treatment and are the leading cause of hospitalization and death. The objective was to study whether patients with neutropenia, sepsis, and septic shock were identified appropriately at triage and receive timely treatment within the emergency setting. Also, we investigated the effect of undertriage on key treatment outcomes. We conducted a retrospective analysis of all accessible records of admitted adult cancer patients with febrile neutropenia, sepsis, and septic shock. Our results identified that the majority of patients were inappropriately triaged to less urgent triage categories. Patients’ undertriage significantly prolonged multiple emergency timeliness indicators and extended length of stay within the emergency department and hospital. These effects suggest that triage implementation must be objective, consistent, and accurate because of the several influences of the assigned triage scoring on treatment and health outcomes.

11 Vitamin D Deficiency on Admission and the Association with Length of Stay in Patients with Thermal Injury: A Multi-center Analysis

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S13-S14
Author(s):  
Sarah Zavala ◽  
Kate Pape ◽  
Todd A Walroth ◽  
Melissa A Reger ◽  
Katelyn Garner ◽  
...  
Keyword(s):  
Vitamin D ◽  
Length Of Stay ◽  
Vitamin D Deficiency ◽  
Burn Injury ◽  
Total Body Surface Area ◽  
Inhalation Injury ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Comfort Care ◽  
The Impact

Abstract Introduction In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). Methods This was a multi-center retrospective study of adult patients at 7 burn centers admitted between January 1, 2016 and July 25, 2019 who had a 25-hydroxyvitamin D (25OHD) concentration drawn within the first 7 days of injury. Patients were excluded if admitted for a non-burn injury, total body surface area (TBSA) burn less than 5%, pregnant, incarcerated, or made comfort care or expired within 48 hours of admission. The primary endpoint was to compare hospital LOS between burn patients with vitamin D deficiency (defined as 25OHD < 20 ng/mL) and sufficiency (25OHD ≥ 20 ng/mL). Secondary endpoints include in-hospital mortality, ventilator-free days of the first 28, renal replacement therapy (RRT), length of ICU stay, and days requiring vasopressors. Additional data collected included demographics, Charlson Comorbidity Index, injury characteristics, form of vitamin D received (ergocalciferol or cholecalciferol) and dosing during admission, timing of vitamin D initiation, and form of nutrition provided. Dichotomous variables were compared via Chi-square test. Continuous data were compared via student t-test or Mann-Whitney U test. Univariable linear regression was utilized to identify variables associated with LOS (p < 0.05) to analyze further. Cox Proportional Hazard Model was utilized to analyze association with LOS, while censoring for death, and controlling for TBSA, age, presence of inhalation injury, and potential for a center effect. Results Of 1,147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, p < 0.001), acute kidney injury (AKI) requiring RRT (7.3 vs 1.7%, p = 0.009), more days requiring vasopressors (mean 1.24 vs 0.58 days, p = 0.008), and fewer ventilator free days of the first 28 days (mean 22.9 vs 25.1, p < 0.001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, the best fit model included only deficiency and days until vitamin D initiation. Conclusions Patients with thermal injuries and vitamin D deficiency on admission have increased length of stay and worsened clinical outcomes as compared to patients with sufficient vitamin D concentrations.

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.

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