COVID-19 Pandemic Once Again Exposes the Weakest Link in Laboratory Services: Specimen Delivery

Abstract Objective Reorganization of the emergency department (ED) during the COVID-19 pandemic implied closure of the ED-dedicated laboratory and manual transport of all specimens to the dislocated central laboratory. The impact of such reorganization on laboratory turnaround time (TAT) was examined. Methods The TAT from blood sampling to specimen reception (TAT1), from specimen reception to test reporting (TAT2), and from sampling to test reporting (TAT3) were compared between the pandemic peak month in 2020 and the same month in 2019. We evaluated whether TAT2 fulfills the recommended 60-minute criteria. Results A statistically significant difference was observed for all comparisons (P <.001), with TAT1 prominently contributing to TAT3 prolongation (from 48 minutes to 108 minutes) and exceeding the recommended 60-minute criteria. The TAT2 was extended from 33 minutes to 49 minutes. Conclusion An ED reorganization compromised the usual laboratory services for patients in the ED, with manual specimen delivery being the main cause for TAT prolongation.

Download Full-text

P035: Impact of EMS direct referral to community care on emergency department utilization

CJEM ◽

10.1017/cem.2019.226 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S75

Author(s):

A. Dukelow ◽

M. Lewell ◽

J. Loosley ◽

S. Pancino ◽

K. Van Aarsen

Keyword(s):

Emergency Department ◽

Home Care ◽

Community Care ◽

Home Care Services ◽

Emergency Department Visits ◽

Emergency Department Utilization ◽

Care Services ◽

Significant Difference ◽

Ed Visits ◽

The Impact

Introduction: The Community Referral by Emergency Medical Services (CREMS) program was implemented in January 2015 in Southwestern Ontario. The program allows Paramedics interacting with a patient to directly refer those in need of home care support to their local Community Care Access Centre (CCAC) for needs assessment. If indicated, subsequent referrals are made to specific services (e.g. nursing, physiotherapy and geriatrics) by CCAC. Ideally, CREMS connects patients with appropriate, timely care, supporting individual needs. Previous literature has indicated CREMS results in an increase of home care services provided to patients. Methods: The primary objective of this project is to evaluate the impact of the CREMS program on Emergency Department utilization. Data for all CCAC referrals from London-Middlesex EMS was collected for a thirteen month period (February 2015-February 2016). For all patients receiving a new or increased service from CCAC the number of Emergency Department visits 2 years before referral and 2 years after referral were calculated. A related samples Wilcoxon Signed Rank Test was performed to examine the difference in ED visits pre and post referral to CCAC. Results: There were 213 individuals who received a new or increased service during the study timeframe. Median [IQR] patient age was 77 [70-85.5]. 113/213 (53%) of patients were female. The majority of patients 135/213 (63.4%) were a new referral to CCAC. The median [IQR] number of hospital visits before referral was 3 [1-5] and after referral was 2 [0-4]. There was no significant difference in the overall number of ED visits before versus after referral (955 vs 756 visits, p = 0.051). Conclusion: Community based care can improve patient experience and health outcomes. Paramedics are in a unique position to assess patients in their home to determine who might benefit from home care services. CREMS referrals for this patient group showed a trend towards decreased ED visits after referral but the trend was not statistically significant.

Download Full-text

Evaluation of an Initial Specimen Diversion Device (ISDD) on Rates of Blood Culture Contamination in the Emergency Department

Kansas Journal of Medicine ◽

10.17161/kjm.vol1413804 ◽

2021 ◽

Vol 14 ◽

pp. 73-76

Author(s):

Blake Buzard ◽

Patrick Evans ◽

Todd Schroeder

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Blood Culture ◽

Blood Cultures ◽

Contamination Rate ◽

Total Hospital Cost ◽

Initial Specimen ◽

Significant Difference ◽

Secondary Outcomes ◽

The Impact

Introduction: Blood cultures are the gold standard for identifying bloodstream infections. The Clinical and Laboratory Standards Institute recommends a blood culture contamination rate of <3%. Contamination can lead to misdiagnosis, increased length of stay and hospital costs, unnecessary testing and antibiotic use. These reasons led to the development of initial specimen diversion devices (ISDD). The purpose of this study is to evaluate the impact of an initial specimen diversion device on rates of blood culture contamination in the emergency department. Methods: This was a retrospective, multi-site study including patients who had blood cultures drawn in an emergency department. February 2018 to April 2018, when an ISDD was not utilized, was compared with June 2019 to August 2019, a period where an ISDD was being used. The primary outcome was total blood culture contamination. Secondary outcomes were total hospital cost, hospital and intensive care unit length of stay, vancomycin days of use, vancomycin serum concentrations obtained, and repeat blood cultures obtained. Results: A statistically significant difference was found in blood culture contamination rates in the Pre-ISDD group vs the ISDD group (7.47% vs 2.59%, p<0.001). None of the secondary endpoints showed a statistically significant difference. Conclusions: Implementation of an ISDD reduces blood culture contamination in a statistically significant manner. However, we were unable to capture any statistically significant differences in the secondary outcomes.

Download Full-text

Transcapillary escape rate of 125I-albumin in relation to timing of blood sampling: the need for standardization.

10.21203/rs.3.rs-99396/v2 ◽

2021 ◽

Author(s):

Youssef Chahid ◽

Nienke Rorije ◽

Soufian el Boujoufi ◽

Ron Mathôt ◽

Liffert Vogt ◽

...

Keyword(s):

Kinetic Modeling ◽

Exponential Model ◽

Blood Sampling ◽

Escape Rate ◽

Maximum Serum ◽

Sampling Schemes ◽

Transcapillary Escape Rate ◽

Significant Difference ◽

Reference Scheme ◽

The Impact

Abstract Background Increased vascular permeability is an early sign of vascular damage and can be measured with the transcapillary escape rate of albumin (TERalb). Although TERalb has a multi-exponential kinetic model, most published TERalb data are based on mono-exponential kinetic models with variation in blood sampling schemes. Aim of this posthoc study was to evaluate the influence of variation in blood sampling schemes and the impact of mono- or bi-exponential analyses on the calculation of TERalb. Study participants were part of a cross-over intervention study protocol, investigating effects of sodium loading on blood pressure, endothelial surface layer and microcirculation. Multiple blood samples were drawn between 3 and 60 minutes after injection of radioactive iodide labeled human serum albumin (rHSA). Results In total 27 male participants with 54 measurements were included. For all participants the maximum serum radioactivity was reached within 20 minutes, while 85% of the participants had their maximum serum activity within 10 min. The TERalb calculated with the subsequently chosen T20 – 60 min reference scheme (6.19 ± 0.49%/h) was significantly lower compared to the TERalb of the T3 – 60 min, T5 – 60 min, and Tmax – 60 min schemes. There was no significant difference between the T20 – 60 min reference scheme and the T10 – 60 min and T15 – 60 min schemes. Bi-exponential kinetic modeling did not result in significant different observations compared to the mono-exponential kinetic analysis.Conclusions As there is variation in the timing of the maximum serum radioactivity of rHSA, blood sampling schemes starting before 10 minutes after administration of rHSA will result in a significant overestimation of TERalb. In addition, variation in kinetic modeling did not result in significant changes in TERalb. Therefore, we emphasize the need to standardize TERalb and for practical and logistical reasons advocate the use of a mono-exponential model with blood sampling starting 20 minutes after rHSA administration.

Download Full-text

Evaluation of Early Versus Late Postdischarge Medication Reconciliation on Readmission Rates and Emergency Department Visits

Journal of Pharmacy Practice ◽

10.1177/0897190017710525 ◽

2017 ◽

Vol 31 (3) ◽

pp. 279-283 ◽

Cited By ~ 1

Author(s):

Tina Joseph ◽

Rebecca A. Barros ◽

Elise Kim ◽

Bupendra Shah

Keyword(s):

Emergency Department ◽

Clinical Pharmacist ◽

Medication Reconciliation ◽

Emergency Department Visits ◽

Optimal Timing ◽

Significant Difference ◽

The Impact ◽

Late Group ◽

Hospital Use

Background: The current literature speculates ideal postdischarge follow-up focusing on transitions from hospital to home can range anywhere between 48 hours and 2 weeks. However, there is a lack of evidence regarding the optimal timing of follow-up visit to prevent readmissions. Objective: The purpose of this study is to evaluate the impact of early (<48 hours) versus late (48 hours-14 days) postdischarge medication reconciliation on readmissions and emergency department (ED) use. Methods: In this retrospective study, data for patients who had a clinic visit with a primary care provider (PCP), clinical pharmacist, or both for postdischarge medication reconciliation were reviewed. Primary outcome included hospital use rate at 30 days. Secondary outcomes included hospital use rate at 90 days and hospital use rate with a postdischarge PCP follow-up visit, clinical pharmacist, or both at 30 days. Results: One hundred sixty patients were included in the analysis: 31 early group patients and 129 late group patients. There was no significant difference on hospital use at 30 days in patients who received early or late groups (32.3% vs 21.8%, P = .947). There was also no significant difference on hospital use at 90 days in patients in early versus late group (51.6% vs 50.3%, P = .842). The type of provider (PCP vs pharmacists) conducting postdischarge medication reconciliation did not show significance on hospital use at 30 days (19.9% vs 21.4%, P = .731). Conclusion: Results from this study suggest patients can be seen up to 14 days postdischarge for medication reconciliation with no significant difference on hospital use.

Download Full-text

Electronic health record (EHR) training program identifies a new tool to quantify the EHR time burden and improves providers’ perceived control over their workload in the EHR

JAMIA Open ◽

10.1093/jamiaopen/ooz003 ◽

2019 ◽

Vol 2 (2) ◽

pp. 222-230 ◽

Cited By ~ 6

Author(s):

Yumi T DiAngi ◽

Lindsay A Stevens ◽

Bonnie Halpern – Felsher ◽

Natalie M Pageler ◽

Tzielan C Lee

Keyword(s):

Electronic Health Record ◽

Training Program ◽

Perceived Control ◽

Turnaround Time ◽

Health Record ◽

Holistic View ◽

Provider Satisfaction ◽

Significant Difference ◽

Electronic Health ◽

The Impact

AbstractObjectiveTo understand if providers who had additional electronic health record (EHR) training improved their satisfaction, decreased personal EHR-use time, and decreased turnaround time on tasks.Materials and MethodsThis pre-post study with no controls evaluated the impact of a supplemental EHR training program on a group of academic and community practice clinicians that previously had go-live group EHR training and 20 months experience using this EHR on self-reported data, calculated EHR time, and vendor-reported metrics.ResultsProviders self-reported significant improvements in their knowledge of efficiency tools in the EHR after training and doubled (significant) their preference list entries (mean pre = 38.1 [65.88], post = 63.5 [90.47], P < .01). Of the 7 EHR satisfaction variables, only 1 self-reported variable significantly improved after training: Control over my workload in the EHR (mean pre = 2.7 [0.96], post = 3.0 [1.04], P < .01). There was no significant decrease in their calculated EHR usage outside of clinic (mean pre = 0.39 [0.77] to post = 0.37 [0.48], P = .73). No significant difference was seen in turnaround time for patient calls (mean pre = 2.3 [2.06] days, post = 1.9 [1.76] days, P = .08) and results (mean before = 4.0 [2.79] days, after = 3.2 [2.33] days, P = .03).DiscussionMultiple sources of data provide a holistic view of the provider experience in the EHR. This study suggests that individualized EHR training can improve the knowledge of EHR tools and satisfaction with their perceived control of EHR workload, however this did not translate into less Clinician Logged-In Outside Clinic (CLOC) time, a calculated metric, nor quicker turnaround on in box tasks. CLOC time emerged as a potential less-costly surrogate metric for provider satisfaction in EHR work than surveying clinicians. Further study is required to understand the cost-benefit of various interventions to decrease CLOC time.ConclusionsThis supplemental EHR training session, 20 months post go-live, where most participants elected to receive 2 or fewer sessions did significantly improve provider satisfaction with perceived control over their workload in the EHR, but it was not effective in decreasing EHR-use time outside of clinic. CLOC time, a calculated metric, could be a practical trackable surrogate for provider satisfaction (inverse correlation) with after-hours time spent in the EHR. Further study into interventions that decrease CLOC time and improve turnaround time to respond to inbox tasks are suggested next steps.

Download Full-text

Impact of Delayed Admission to the Intensive Care Unit from the Emergency Department upon Sepsis Outcomes and Sepsis Protocol Compliance

Critical Care Research and Practice ◽

10.1155/2017/9616545 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Michael Agustin ◽

Lori Lyn Price ◽

Augustine Andoh-Duku ◽

Peter LaCamera

Keyword(s):

Emergency Department ◽

Hospital Mortality ◽

Statistical Significance ◽

Tertiary Care ◽

Included Study ◽

Chi Square ◽

Significant Difference ◽

Protocol Compliance ◽

Sepsis And Septic Shock ◽

The Impact

Rationale. The impact of emergency department length of stay (EDLOS) upon sepsis outcomes needs clarification. We sought to better understand the relationship between EDLOS and both outcomes and protocol compliance in sepsis. Methods. We performed a retrospective observational study of septic patients admitted to the ICU from the ED between January 2012 and December 2015 in a single tertiary care teaching hospital. 287 patients with severe sepsis and septic shock were included. Study population was divided into patients with EDLOS < 6 hrs (early admission) versus ≥6 hours (delayed admission). We assessed the impact of EDLOS on hospital mortality, compliance with sepsis protocol, and resuscitation. Statistical significance was determined by chi-square test. Results. Of the 287 septic ED patients, 137 (47%) were admitted to the ICU in <6 hours. There was no significant in-hospital mortality difference between early and delayed admissions (p=0.68). Both groups have similar compliance with the 3-hour protocol (p=0.77). There was no significant difference in achieving optimal resuscitation within 12 hours (p=0.35). Conclusion. We found that clinical outcomes were not significantly different between early and delayed ICU admissions. Additionally, EDLOS did not impact compliance with the sepsis protocol with the exception of repeat lactate draw.

Download Full-text

Does Nursery-Based Intensified Anticipatory Guidance Reduce Emergency Department Use for Nonurgent Conditions in the First Month of Life? A Randomized Controlled Trial

International Journal of Pediatrics ◽

10.1155/2016/8356582 ◽

2016 ◽

Vol 2016 ◽

pp. 1-6

Author(s):

Kelly Kamimura-Nishimura ◽

Vikram Chaudhary ◽

Folake Olaosebikan ◽

Maryam Azizi ◽

Sneha Galiveeti ◽

...

Keyword(s):

Emergency Department ◽

Controlled Trial ◽

Intervention Group ◽

Newborn Care ◽

Secondary Outcome ◽

Control Group ◽

Anticipatory Guidance ◽

Guidance Program ◽

Significant Difference ◽

The Impact

Objective.We aimed to evaluate the impact of an intensified anticipatory guidance program in the nursery on Emergency Department (ED) use for nonurgent conditions (NUCs) in the neonatal period.Methods. Parturient mothers of healthy newborns were randomized to an intervention group or control group. Baseline and 1-month follow-up knowledge surveys regarding newborn care were conducted. The primary outcome was the proportion of neonates who used the ED for a NUC. Secondary outcome was change in caregivers’ knowledge on NUC.Results. Of a total of 594 mothers, 323 (54%) agreed to participate and were randomized to intervention (n=170) or control (n=153) group. Most were Hispanic (68%), single (61%), primiparous (39%), and without high school diploma (44%). 35 (21%) neonates in the intervention group and 41 (27%) in the control group were brought at least once for a NUC to the ED (p=0.12). There was no statistically significant difference in within subject change on knowledge scores between the two study arms.Conclusions. Neonatal ED visits for NUCs occur frequently. This nursery-based intensified anticipatory guidance program had no statistically significant impact on neonatal ED use for NUC, nor on neonatal care-relevant knowledge among parturient mothers. Alternative modalities and timing of parental educational intervention may need to be considered. This trial is registered with Clinical Trials NumberNCT01859065(Clinicaltrials.gov).

Download Full-text

112 Impact of the COVID-19 pandemic on emergency department visits at a university medical centre

Paediatrics & Child Health ◽

10.1093/pch/pxab061.092 ◽

2021 ◽

Vol 26 (Supplement_1) ◽

pp. e81-e82

Author(s):

Viviane Mallette ◽

Claude Cyr

Keyword(s):

Emergency Department ◽

Emergency Room ◽

Emergency Department Visits ◽

Medical Centre ◽

Pediatric Care ◽

Emergency Room Visits ◽

Traumatic Injuries ◽

Health Measures ◽

Significant Difference ◽

The Impact

Abstract Primary Subject area Emergency Medicine - Paediatric Background The new coronavirus, SARS-Cov-2, responsible for a global pandemic, led to the declaration of a health emergency and the implementation of large-scale public health measures by governments in 2020. Those measures, combined with the overlapping symptoms of COVID-19 disease and common viral infections in children, have led hospitals to prepare for possible changes in volume of emergency room visits by children. Objectives This study aims to determine the effect of the pandemic and governmental restrictions on the use of the emergency department by pediatric patients at a university medical centre, as well as to assess the impact on the severity of initial presentations. Design/Methods A single-centre study was conducted at a university hospital among children aged 0 to 17 who visited the emergency room. We used interrupted time series analysis to compare the average of pre-COVID-19 data (from January 1 2017, to December 31 2019) with data from the first wave of the COVID-19 pandemic (from January 1 to September 2020). Emergency room visits, initial triage codes, and admission and pediatric consultation rates were analyzed to assess whether there was a significant difference between periods. Results An important increase in total daily visits (+11.18, 95% CI [6.23-16.14]) was first observed with the emergence of COVID-19 cases in Canada. Then, during the strict confinement, which corresponds to an active period of COVID-19, we detected a significant drop in daily visits (-25.64, 95% CI [-30.4 to -20.66]), which continued while progressively loosening restrictions. The proportion of admissions and pediatric consultations rose slightly only throughout the time of intensive health measures (respectively +4.07% and +3.32%), but no changes in the severity of the triage codes at the emergency department were observed for all periods. Traumatic injuries also saw a significant decrease (p=0.018) when comparing data by groups of diagnosis. Conclusion These results show a significantly lower number of children’s visits to the emergency room of a university medical centre, and a transient increase in pediatric care with little impact on the immediate severity of the initial presentations during strict government health measures in the first wave of COVID-19. These measures also had a beneficial effect in reducing the number of traumatic injuries.

Download Full-text

Opioid prescribing trends in a Veterans Affairs emergency department and dental clinic before and after implementation of opioid-prescribing guidelines

Mental Health Clinician ◽

10.9740/mhc.2020.09.270 ◽

2020 ◽

Vol 10 (5) ◽

pp. 270-274

Author(s):

Rebecca Lavasani ◽

Michelle Chung ◽

Allison Beatty ◽

Phillip Lawrence ◽

Elizabeth Unni

Keyword(s):

Emergency Department ◽

Salt Lake ◽

Salt Lake City ◽

Veterans Affairs ◽

Opioid Overdose ◽

Dental Clinic ◽

Opioid Prescribing ◽

Prescribing Trends ◽

Significant Difference ◽

The Impact

Abstract Introduction Opioid overdose is highly prevalent among veterans. The Opioid Safety Initiative (OSI) and Centers for Disease Control and Prevention (CDC) issued prescribing guidelines for managing chronic pain. The purpose of this study was to investigate the impact of the 2013 OSI and 2016 CDC guidelines on opioid-prescribing trends in the emergency department and dental clinic within the Veterans Affairs Salt Lake City Health Care System. Methods In this retrospective, cohort study, opioid prescriptions were queried from January 1, 2013, through March 31, 2017, and separated into 3 groups: pre-OSI, post-OSI, and post-CDC. The primary outcome was to determine a decrease in opioid prescribing. Secondary outcomes included changes in concurrent benzodiazepine and naloxone prescriptions and prescriber status. Analysis of variance was used to determine a difference between study periods. Results There were 7339 opioid prescriptions identified. A statistically significant difference was found between the 3 groups in average number of opioids prescribed, morphine milligram equivalents per prescription, days' supplied, and medication quantity per prescription (P < .01). There was no significant difference between the 3 groups regarding morphine milligram equivalents per day (P = .24). Benzodiazepine prescribing remained the same. Concurrent naloxone prescriptions increased. Discussion The results demonstrate that days' supply, quantity, and morphine milligram equivalent per day in the post-CDC group were consistent with guideline recommendations. Concurrent naloxone prescribing increased throughout all time periods. Implementation of guidelines impacted opioid-prescribing trends, ultimately lessening potential for misuse and abuse. However, there is still need for improvement with reducing concurrent benzodiazepine prescriptions.

Download Full-text

Transcapillary Escape Rate of 125I-albumin in Relation to Timing of Blood Sampling: The Need for Standardization.

10.21203/rs.3.rs-99396/v1 ◽

2020 ◽

Author(s):

Youssef Chahid ◽

Nienke Rorije ◽

Soufian el Boujoufi ◽

Ron Mathot ◽

Liffert Vogt ◽

...

Keyword(s):

Kinetic Modeling ◽

Exponential Model ◽

Blood Sampling ◽

Escape Rate ◽

Maximum Serum ◽

Sampling Schemes ◽

Transcapillary Escape Rate ◽

Significant Difference ◽

Reference Scheme ◽

The Impact

Abstract BackgroundIncreased vascular permeability is an early sign of vascular damage and can be measured with the transcapillary escape rate of albumin (TERalb). Although TERalb has a multi-exponential kinetic model, most published TERalb data are based on mono-exponential kinetic models with variation in blood sampling schemes. Aim of this study was to evaluate the influence of variation in blood sampling schemes and the impact of mono- or bi-exponential analyses on the calculation of TERalb. Study subjects were part of a cross-over intervention study protocol, investigating effects of sodium loading on blood pressure, endothelial surface layer and microcirculation. Multiple blood samples were drawn between 3 and 60 minutes after injection of radioactive iodide labeled human serum albumin (rHSA). ResultsIn total 27 male subjects were included. For all subjects the maximum serum radioactivity was reached within 20 minutes, while 86% of the subjects had their maximum serum activity within 10 min. The TERalb calculated with the subsequently chosen T20 – 60 min reference scheme (5.97 ± 0.39%/h) was significantly lower compared to the TERalb of the T3 – 60 min, T5 – 60 min, T10 – 60 min, and Tmax – 60 min schemes. There was no significant difference between the T20 – 60 min reference scheme and the T15 – 60 min scheme. Bi-exponential kinetic modeling did not result in significant different observations compared to the mono-exponential kinetic analysis.ConclusionsAs there is variation in the timing of the maximum serum radioactivity of rHSA, blood sampling schemes starting before 15-20 minutes after administration of rHSA will result in a significant overestimation of TERalb. In addition, variation in kinetic modeling did not result in significant changes in TERalb. Therefore, we emphasize the need to standardize TERalb and for practical and logistical reasons advocate the use of a mono-exponential model with blood sampling starting 20 minutes after rHSA administration.

Download Full-text