Diagnostic anticipation to reduce emergency department length of stay: a cohort study in Ferrara University Hospital, Italy

Abstract Background : Emergency Department (ED) crowding reduces staff satisfaction and healthcare quality and safety, which in turn increase costs. Despite a number of proposed solutions, ED length of stay (LOS) - a main cause of overcrowding - remains a major issue worldwide. This cohort study was aimed at evaluating the effectiveness on ED LOS of a procedure called “diagnostic anticipation”, which consisted in anticipating the ordering of blood tests by nurses, at triage, following a diagnostic algorithm approved by physicians. Methods : In the second half of 2019, the ED of the University Hospital of Ferrara, Italy, adopted the diagnostic anticipation protocol on alternate weeks for all patients with chest pain, abdominal pain, and non-traumatic bleeding. Using ED electronic data, LOS independent predictors were evaluated through multiple regression. Results : During the weeks when diagnostic anticipation was adopted, as compared to control weeks, the mean LOS was shorter by 18.2 minutes for chest pain, but longer by 15.7 minutes for abdominal pain, and 33.3 for non-traumatic bleeding. At multivariate analysis, adjusting for age, gender, triage priority and ED crowding, the difference in visit time was significant for chest pain only (p<0.001). Conclusions : The effectiveness of the anticipation of blood testing by nurses varied by patients' condition, being significant for chest pain only. Further research is needed before the implementation, estimating the potential proportion of inappropriate blood tests and ED crowding status

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Emergency department attendances during the COVID-19 pandemic: a retrospective analysis of attendances following Irish governmental pandemic measures

Emergency Medicine Journal ◽

10.1136/emermed-2020-209992 ◽

2021 ◽

pp. emermed-2020-209992

Author(s):

Ryan Taylor Sless ◽

Nathaniel Edward Hayward ◽

Paul MacDaragh Ryan ◽

Conor Deasy ◽

Kantikiran Dasari

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Chest Pain ◽

Perceived Risk ◽

Tertiary Hospital ◽

University Hospital ◽

Medical Attention ◽

Public Confidence ◽

Government Regulations ◽

Time Period

BackgroundCOVID-19 has resulted in the death of over 1 million people to date. Following government-implemented regulations, there has been concern over the apparent decline in emergency department (ED) attendances and the resultant health legacy. Therefore, we aimed to characterise the attendances to an Irish tertiary hospital ED following the implementation of these regulations during the COVID-19 pandemic.MethodsThis retrospective observational study investigated all attendances to the Cork University Hospital ED from 15 February to 11 April in 2020 and 2017–2019. Attendances were stratified into four periods: Before COVID (BC) (15 February to 5 March), After COVID (AC) (6 March to 12 March), Educational Closure (EC) (13 March to 27 March) and Stay Home (SH) (28 March to 11 April), as per government regulations. Triage presentations of abdominal pain, shortness of breath, chest pain, headache and trauma were examined. Data were analysed by independent t-tests and χ2 analysis.ResultsThere were 8261 attendances to the ED in the 2020 time period compared with a mean of 10 389 attendances during the corresponding periods in 2017–2019. There was a significant decrease in daily attendances in 2020 compared with 2017–2019 in the AC (142 vs 188, p=0.02), EC (122 vs 184, p<0.001) and SH (121 vs 181, p<0.001) periods, including significant decreases in abdominal pain (AC: 9 vs 22, EC: 10 vs 19, SH: 11 vs 18, p<0.001), chest pain (AC: 9 vs 15, EC: 8 vs 15, SH: 9 vs 15, p<0.01), headache (AC: 5 vs 11, EC: 4 vs 9, SH: 4 vs 9, p<0.01) and trauma (AC: 3 vs 5, EC: 2 vs 6, SH: 3 vs 5, p<0.01).ConclusionOur findings suggest that the combination of government-imposed restrictions and perceived risk of attending an ED during a pandemic may contribute to reduced attendances. Public confidence in EDs is necessary to reduce collateral damage caused by failure to seek medical attention during a pandemic; adequate infrastructure to allow social distancing and isolation capacity in EDs is a necessity.

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Diagnostic anticipation to reduce emergency department length of stay: a retrospective cohort study in Ferrara University hospital, Italy

BMC Health Services Research ◽

10.1186/s12913-020-05472-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Andrea Strada ◽

Niccolò Bolognesi ◽

Lamberto Manzoli ◽

Giorgia Valpiani ◽

Chiara Morotti ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Length Of Stay ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

University Hospital

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Demografi og triage af børn med akutte mavesmerter

Dansk Tidsskrift for Akutmedicin ◽

10.7146/akut.v2i4.110483 ◽

2019 ◽

Vol 2 (4) ◽

pp. 56-61

Author(s):

Thomas Purup ◽

Jette Møller Ahrensberg ◽

Lone Nikolajsen

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Abdominal Pain ◽

Retrospective Cohort ◽

Severe Pain ◽

Flank Pain ◽

University Hospital ◽

Specific Diagnosis ◽

Life Threatening ◽

Vital Parameters

Formålet med dette studie var primært at beskrive populationen af børn med mavesmerter i de danske akutmodtagelser. Det sekundære formål var at undersøge, om det danske triagesystem viser en tendens til at kunne detektere, hvem der har potentielt livstruende sygdomme (PLS – appendicitis anvendt som indikator), eller omvendt udelukke, hvem der ikke har. Data for alle børn med ”mave- og flankesmerter” i skadestuen på Aarhus Universitetshospital (AUH) i 2017 er inkluderet i dette retroperspektive kohorte-studie. Børnene kategoriseres efter en række karakteristika (alder, køn mv.), og der er vist grafer over triagefordelingen for hver gruppe. 276 børn er inkluderet. Medianalderen var 12 år, med 46% drenge og 54% piger. De fleste havde stærke smerter (239 patienter; 87%) og 90 børn (33%) havde påvirkede vital-parametre. 148 børn (66%) fik en uspecifik diagnose, mens 94 børn (34%) fik en specifik. Appendicitis blev fundet i alle triagekategorier. Data viser en tendens til, at en lav triagescore ikke udelukker PLS (som appendicitis). Det kan sammenfattes, at børn med mavesmerter præsenterer sig meget forskelligt, og at vitalparametrene ved ankomst ikke altid afspejler alvorligheden af den tilstand, som barnet indlægges med. ENGLISH The main aim of this study was to describe characteristics of children presenting with abdominal pain in a Danish Emergency Department (ED). The secondary aim was to assess if the present triage system in the Danish EDs is indicative of children with potentially life-threatening diseases (PLTD – appendicitis used as indicator). Data of all children with “abdominal and flank pain” in the ED at Aarhus University Hospital (AUH) during 2017 were included in this retrospective cohort study. Patients were classified according to several characteristics (e.g. age, gender) and graphs of triage distribution were shown and compared. A total of 276 children were included. Median age was 12 years, with 46% boys and 54% girls. Most patients had severe pain (239 patients, 87%) and 90 patients (33%) had affected vital parameters. A total of 148 patients (66%) got an unspecific diagnosis at discharge, while 94 patients (34%) got a specific diagnosis. Appendicitis was found in all triage categories. Data show a tendency towards low triage not excluding PLTD (such as appendicitis). Also, data suggest that children with abdominal pain show a great variation in symptoms, and vital parameters at admission does not always reflect the severity of the child’s condition.

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Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients – A Retrospective Cohort Study

PLoS ONE ◽

10.1371/journal.pone.0135066 ◽

2015 ◽

Vol 10 (8) ◽

pp. e0135066 ◽

Cited By ~ 17

Author(s):

Steffie H. A. Brouns ◽

Patricia M. Stassen ◽

Suze L. E. Lambooij ◽

Jeanne Dieleman ◽

Irene T. P. Vanderfeesten ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Length Of Stay ◽

Elderly Patients ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Organisational Factors

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Association of patient-to-emergency department staff ratio with the incidence of cardiac arrest: A retrospective cohort study

10.22514/sv.2021.029 ◽

2021 ◽

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Cohort Study ◽

Length Of Stay ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Medical Center ◽

Occupancy Rate ◽

Number Of Patients ◽

Ed Overcrowding

Background: Emergency department (ED) overcrowding and overuse are global healthcare problems. Despite that substantial pieces of literature have explored quality parameters to monitor the patients’ safety and quality of care in the ED, to the best of our knowledge, no reasonable patient-to-ED staff ratios were established. Objectives: This study aimed to find the association between unexpected emergency department cardiac arrest (EDCA) and the patient-to-ED staff ratio. Methods: A retrospective cohort study was conducted in a medical center in Taiwan. Non-trauma patients (age > 18) who visited the ED from January 1, 2016 to November 30, 2018 were included. The total number of patients in ED, number of patients waiting for boarding, length of stay over 48 hours, and physician/nurse number in ED were collected and analyzed. The primary outcome was the association of each parameter with the incidence of EDCA. Results: A total of 508 patients were included. The total number of patients in ED ( > 361, RR: 1.54; 95% CI {1.239-1.917}), ED occupancy rate (> 280, RR: 1.54; 95% CI {1.245-1.898}), ED bed occupancy rate (> 184, RR: 1.63; 95% CI {1.308-2.034}), number of patients waiting for boarding (> 134, RR: 1.45; 95% CI {1.164-1.805}), number of patients in ED with length of stay over 48 hours (> 36, RR: 1.27; 95% CI {1.029-1.558}) and patient-to-nurse ratio (> 8.5, adjusted RR: 1.33; 95% CI {1.054-1.672}) had significant associations with higher incidence of EDCA. However, the patient-to-physician ratio was not associated with EDCA incidence. Discussions: Regarding loading parameters, the patient-to-nurse ratio is more representative than the patient-to-physician ratio as regards association with higher EDCA incidence. Conclusions: A higher patient-to-nurse ratio (> 8.5) was associated with an increment in the incidence of EDCA. Our findings provide a basis for setting different thresholds for different ED settings to adjust ED staff and develop individually tailored approaches corresponding to the level of ED overcrowding.

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Association between the level of municipality healthcare services and outcome among acutely older patients in the emergency department: a Danish population-based cohort study

BMJ Open ◽

10.1136/bmjopen-2018-026881 ◽

2019 ◽

Vol 9 (4) ◽

pp. e026881 ◽

Cited By ~ 1

Author(s):

Anette Tanderup ◽

Jesper Ryg ◽

Jens-Ulrik Rosholm ◽

Annmarie Touborg Lassen

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Home Care ◽

Residential Care ◽

Strong Predictor ◽

Healthcare Services ◽

Population Based ◽

University Hospital ◽

Secondary Outcome ◽

Medical Patients

ObjectivesThis study aims to describe the association between use of municipality healthcare services before an emergency department (ED) contact and mortality, hospital reattendance and institutionalisation.DesignPopulation-based prospective cohort study.SettingED of a large university hospital.ParticipantsAll medical patients ≥65 years of age from a single municipality with a first attendance to the ED during a 1-year period (November 2013 to November 2014).Primary and secondary outcome measuresPatients were categorised as independent of home care, dependent of home care or in residential care depending on municipality healthcare before ED contact. Patients were followed 360 days after discharge. Outcomes were postdischarge mortality, hospital reattendance and institutionalisation.ResultsA total of 3775 patients were included (55% women), aged (median (IQR) 78 years (71–85)). At baseline, 48.9% were independent, 34.9% received home care and 16.2% were in residential care. Receiving home care or being in residential care was a strong predictor of mortality, hospital reattendance and institutionalisation. Among patients who were independent, 64.3% continued being independent up to 360 days after discharge. Even among patients ≥85 years, 35.4% lived independently in their own house 1 year after ED contact.ConclusionPrehospital information on municipality healthcare is closely related to patient outcome in older ED patients. It might have the potential to be used in risk stratification and planning of needs of older acute medical patients attending the ED.

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Relationship between Fever and Length of Stay, Antibiotic Use, and Need for Operative Intervention in Emergency Department Patients with Acute Abdominal Pain

Academic Emergency Medicine ◽

10.1197/j.aem.2005.03.043 ◽

2005 ◽

Vol 12 (Supplement 1) ◽

pp. 19-19

Author(s):

A. M. Mills

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Length Of Stay ◽

Acute Abdominal Pain ◽

Antibiotic Use ◽

Operative Intervention ◽

Emergency Department Patients

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

BMJ Open ◽

10.1136/bmjopen-2017-018190 ◽

2018 ◽

Vol 8 (3) ◽

pp. e018190 ◽

Cited By ~ 18

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.

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