Frequent users of emergency departments and patient flow in Alberta and Ontario, Canada: an administrative data study

Abstract Background This paper describes and compares patient flow characteristics of adult high system users (HSUs) and control groups in Alberta and Ontario emergency departments (EDs), Canada. Methods Annual cohorts of HSUs were created by identifying patients who made up the top 10% of ED users (by count of ED presentations) in the National Ambulatory Care Reporting System during 2011–2016. Random samples of patients not in the HSU groups were selected as controls. Presentation (e.g., acuity) and ED times (e.g., time to physician initial assessment [PIA], length of stay) data were extracted and described. The length of stay for 2015/2016 data was decomposed into stages and Cox models compared time between stages. Results There were 20,343,230 and 18,222,969 ED presentations made by 7,032,655 and 1,923,462 individuals in the control and HSU groups, respectively. The Ontario groups had higher acuity than the Alberta groups: about 20% in the Ontario groups were from the emergent level whereas Alberta had 11–15%. Time to PIA was similar across provinces and groups (medians of 60 min to 67 min). Lengths of stay were longest for Ontario HSUs (median = 3 h) and shortest for Alberta HSUs (median = 2.2 h). HSUs had shorter times to PIA (hazard ratio [HR] = 1.03; 95% confidence interval [CI] 1.02,1.03), longer times from PIA to decision (HR = 0.84; 95%CI 0.84,0.84), and longer times from decision to leaving the ED (HR = 0.91; 95%CI 0.91,0.91). Conclusions Ontario HSUs had higher acuity and longer ED lengths of stay than the other groups. In both provinces, HSU had shorter times to PIA and longer times after assessment.

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LO25: Characteristics of frequent users of emergency departments in Alberta and Ontario, Canada: an administrative data study

CJEM ◽

10.1017/cem.2020.81 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S16-S16

Author(s):

R. Rosychuk ◽

A. Chen ◽

S. Fielding ◽

X. Hu ◽

P. McLane ◽

...

Keyword(s):

Emergency Departments ◽

Regression Models ◽

Income Quintile ◽

Control Groups ◽

Frequent Users ◽

Logistic Regression Models ◽

Random Samples ◽

High System ◽

Disproportionate Number ◽

And Control

Introduction: Frequent users to emergency departments (EDs) are a diverse group of patients with a disproportionate number of ED presentations. This study aimed to compare sociodemographic and clinical characteristics of adult high system users (HSUs) and control groups in two provinces. Methods: Cohorts of HSUs were created for Alberta and Ontario by identifying the patients with the top 10% of ED presentations in the National Ambulatory Care Reporting System during April 2015 to March 2016. Random samples of patients not in the HSU groups were selected in each province as controls (4:1 ratio). Sociodemographic and presentation data (e.g., Canadian Triage and Acuity Scale [CTAS], disposition) were extracted and compared using separate logistic regression models. Results: In Alberta, 101,250 HSU patients made 686,918 ED presentations (median [med] = 5 interquartile range [IQR] 4,7 presentations per patient), compared with 401,923 controls who made 560,765 ED presentations (med = 1 IQR 1,2 per patient). HSUs were more likely to be female (odds ratio (OR) = 1.20 95% confidence interval (CI) 1.18,1.22), older (OR = 1.03 per 5y 95%CI 1.03,1.03), live closer to hospital (OR = 1.02 per 100km 95%CI 1.00,1.03), and be from the lowest income quintile (OR = 1.39 95%CI 1.37,1.42) than controls. In Ontario, 478,424 HSUs made 2,222,487 ED presentations (med = 4 IQR 3,5 per patient) and 1,714,037 controls made 2,114,070 ED presentations (med = 1 IQR 1,1 per patient). Ontario HSUs were also more likely to be female (OR = 1.13 95%CI 1.12,1.14), older (OR = 1.03 per 5y 95%CI 1.03,1.03), and from the lowest income quintile (OR = 1.41 95%CI 1.40,1.42) than controls, but were less likely to live closer to hospital (OR = 0.93 per 100km 95%CI 0.92, 0.93). Higher acuity was seen in Ontario (CTAS 1/2 vs. others OR = 1.05 95%CI 1.04,1.06) but not for Alberta (CTAS 1/2 vs others OR = 0.75, 95%CI 0.74,0.76). Discharges were less likely in the HSUs compared to controls (Alberta OR = 0.89 95%CI 0.88,0,90; Ontario OR = 0.65 95%CI 0.65,0.66). HSUs were more likely to leave without being seen (Alberta OR = 1.10 95%CI 1.07,1.13; Ontario OR = 1.37 95%CI 1.35,1.40) and against medical advice (Alberta OR = 1.47 95%CI 1.41,1.53; Ontario OR = 1.67 95%CI 1.63,1.71). Conclusion: HSUs were more likely to be female, older, and poorer than controls. Ontario HSUs had higher acuity than the other groups. Disposition differed for HSUs and controls. Further study is required to identify ways to safely reduce ED utilization by HSUs.

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The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments

CJEM ◽

10.1017/s1481803500011659 ◽

2009 ◽

Vol 11 (05) ◽

pp. 455-461 ◽

Cited By ~ 19

Author(s):

James Ducharme ◽

Robert J. Alder ◽

Cindy Pelletier ◽

Don Murray ◽

Joshua Tepper

Keyword(s):

Health Care ◽

Nurse Practitioners ◽

Emergency Departments ◽

Patient Flow ◽

Physician Assistants ◽

Wait Times ◽

Care Providers ◽

Lengths Of Stay ◽

Left Without Being Seen ◽

The Impact

ABSTRACT Objective: We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs). Methods: We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status. Results: Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3–2.1, p < 0.05) and 2.1 (95% CI 1.6–2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%–39.0%, p < 0.01) and 48.8% (95% CI 35.0%–62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%–63%, p < 0.01) and 71% (95% CI 53%–96%, p < 0.05), respectively. Conclusion: The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

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Type of facility influences lengths of stay of children presenting to high volume emergency departments

BMC Pediatrics ◽

10.1186/s12887-020-02400-6 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Rhonda J. Rosychuk ◽

Brian H. Rowe

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Emergency Departments ◽

High Volume ◽

Population Based ◽

Initial Assessment ◽

Teaching Hospitals ◽

Emergency Department Crowding ◽

Academic Teaching ◽

The Impact

Abstract Background Emergency department crowding may impact patient and provider outcomes. We describe emergency department crowding metrics based on presentations by children to different categories of high volume emergency departments in Alberta, Canada. Methods This population-based retrospective study extracted all presentations made by children (age < 18 years) during April 2010 to March 2015 to 15 high volume emergency departments: five regional, eight urban, and two academic/teaching. Time to physician initial assessment, and length of stay for discharges and admissions were calculated based on the start of presentation and emergency department facility. Multiple metrics, including the medians for hourly, facility-specific time to physician initial assessment and length of stay were obtained. Results About half (51.2%) of the 1,124,119 presentations were made to the two academic/teaching emergency departments. Males presented more than females (53.6% vs 46.4%) and the median age was 5 years. Pediatric presentations to the three categories of emergency departments had mostly similar characteristics; however, urban and academic/teaching emergency departments had more severe triage scores and academic/teaching emergency departments had higher admissions. Across all emergency departments, the medians of the metrics for time to physician initial assessment, length of stay for discharges and for admission were 1h11min, 2h21min, and 6h29min, respectively. Generally, regional hospitals had shorter times than urban and academic/teaching hospitals. Conclusions Pediatric presentations to high volume emergency departments in this province suggest similar delays to see providers; however, length of stay for discharges and admissions were shorter in regional emergency departments. Crowding is more common in urban and especially academic emergency departments and the impact of crowding on patient outcomes requires further study.

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Changing inpatient diabetes care in a district general hospital

British Journal of Diabetes ◽

10.15277/bjd.2019.212 ◽

2019 ◽

Vol 19 (1) ◽

pp. 49-52

Author(s):

Marie Wallner ◽

Basharat Andrabi ◽

David Russell-Jones ◽

Roselle Herring

Keyword(s):

Length Of Stay ◽

General Hospital ◽

Patient Flow ◽

District General Hospital ◽

Model Of Care ◽

Lengths Of Stay ◽

Inpatient Diabetes ◽

Time Period ◽

Service Redesign ◽

Evidence Based Care

Introduction: People with diabetes in hospital have longer lengths of stay and are at higher risk of experiencing avoidable harm. This has a significant impact on patient flow and capacity in any hospital Trust.Aims and Methods: A Trust-wide peripatetic inpatient diabetes service redesign was performed to deliver reduced medication errors, improved patient flow, reduced length of stay and reduced inpatient risk. The service redesign was delivered without new recurring expenditure on senior staff. The model of care was multidisciplinary and introduced consensus and evidence-based care with clear governance processes.Results: Following introduction of the new service on 7 December 2017 to 1 June 2018, a reduction in length of stay in both medicine and surgical divisions was seen with 2,168 ‘saved’ inpatient bed days compared with the same time period in the preceding year, which represented a significant cost saving for the Trust and improvement in patient flow. This was associated with a reduction in the number of diabetes-related Datix reports and serious untoward incidents.Conclusions: This is the first major diabetes service redesign in a small district general hospital. The introduction of a dedicated inpatient diabetes service has led to Trust-wide improvements in patient care and patient flow without additional cost to the Trust.

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Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry)

Internal and Emergency Medicine ◽

10.1007/s11739-021-02919-1 ◽

2022 ◽

Author(s):

Ronny Otto ◽

Sabine Blaschke ◽

Wiebke Schirrmeister ◽

Susanne Drynda ◽

Felix Walcher ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Emergency Departments ◽

Patient Flow ◽

Management Strategies ◽

Organizational Factors ◽

Related Factors ◽

Adult Age ◽

Emergency Department Data ◽

Data Registry

AbstractSeveral indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany. This study analyzed the fixed and influenceable determinants of LOS by evaluating data from the German Emergency Department Data Registry (AKTIN registry). We performed a retrospective evaluation of all adult (age ≥ 18 years) ED patients enrolled in the AKTIN registry for the year 2019. Primary outcome was LOS for the whole cohort; secondary outcomes included LOS stratified by (1) patient-related, (2) organizational-related and (3) structure-related factors. Overall, 304,606 patients from 12 EDs were included. Average LOS for all patients was 3 h 28 min (95% CI 3 h 27 min–3 h 29 min). Regardless of other variables, patients admitted to hospital stayed 64 min longer than non-admitted patients. LOS increased with patients’ age, was shorter for walk-in patients compared to medical referral, and longer for non-trauma presenting complaints. Relevant differences were also found for acuity level, day of the week, and emergency care levels. We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status). These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.

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Initial assessment in emergency departments by chief complaint and respiratory rate

Journal of General and Family Medicine ◽

10.1002/jgf2.423 ◽

2021 ◽

Author(s):

Shoko Soeno ◽

Konan Hara ◽

Ryo Fujimori ◽

Katsuhiko Hashimoto ◽

Toru Shirakawa ◽

...

Keyword(s):

Respiratory Rate ◽

Emergency Departments ◽

Chief Complaint ◽

Initial Assessment

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Impact of Medicare’s Bundled Payments Initiative on Patient Selection, Payments, and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.119.006171 ◽

2020 ◽

Vol 13 (9) ◽

Author(s):

Christian McNeely ◽

E. John Orav ◽

Jie Zheng ◽

Karen E. Joynt Maddox

Keyword(s):

Length Of Stay ◽

Patient Selection ◽

Artery Bypass ◽

Coronary Intervention ◽

Intervention Period ◽

Difference In Differences ◽

Emergency Department Use ◽

Bundled Payments ◽

Percutaneous Coronary ◽

And Control

Background: The Center for Medicare and Medicaid Innovation launched the Bundled Payments for Care Initiative (BPCI) in 2013. Its effect on payments and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown. Methods and Results: We used Medicare inpatient files to identify index admissions for PCI and CABG from 2013 through 2016 at BPCI hospitals and matched control hospitals and difference in differences models to compare the 2 groups. Our primary outcome was the change in standardized Medicare-allowed payments per 90-day episode. Secondary outcomes included changes in patient selection, discharge to postacute care, length of stay, emergency department use, readmissions, and mortality. Forty-two hospitals joined BPCI for PCI and 46 for CABG. There were no differential changes in patient selection between BPCI and control hospitals. Baseline Medicare payments per episode for PCI were $20 164 at BPCI hospitals and $19 955 at control hospitals. For PCI, payments increased at both BPCI and control hospitals during the intervention period, such that there was no significant difference in differences (BPCI hospitals +$673, P =0.048; control hospitals +$551, P =0.022; difference in differences $122, P =0.768). For CABG, payments at both BPCI and control hospitals decreased during the intervention period (BPCI baseline, $36 925, change −$2918, P <0.001; control baseline, $36 877, change −$2618, P <0.001; difference in differences, $300; P =0.730). For both PCI and CABG, BPCI participation was not associated with changes in mortality, readmissions, or length of stay. Among BPCI hospitals, emergency department use differentially increased for patients undergoing PCI and decreased for patients undergoing CABG. Conclusions: Participation in episode-based payment for PCI and CABG was not associated with changes in patient selection, payments, length of stay, or clinical outcomes.

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144 The Use of a Multidisciplinary Team Discharge “Huddle” to Improve Patient Flow and Planning

Age and Ageing ◽

10.1093/ageing/afz102.30 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii1-iii16

Author(s):

Mary Randles ◽

Sylvia Hickey ◽

Susanne Cotter ◽

Carmel Walsh ◽

Kieran O'Connor ◽

...

Keyword(s):

Length Of Stay ◽

Patient Care ◽

Multidisciplinary Team ◽

Older Persons ◽

Patient Flow ◽

Geriatric Medicine ◽

City Centre ◽

Nurse Specialist ◽

Complex Care ◽

Clinical Nurse

Abstract Background Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or ‘HUDDLE’ was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital. Methods The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services .We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications. Results There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days). Conclusion Rather than using a negative view of older adults as potential ‘bed blockers’, the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient’s hospital journey.

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