The association between the transfer of emergency department admitted patients to inpatient hallways and outcomes of oncology patients

Objective: A protocol was implemented to ease Emergency Department (ED) crowding by moving suitable admitted patients into inpatient hallway beds (HALL) or off-service beds (OFF) when beds on an admitting service’s designated ward (ON) were not available. This study assessed the impact of hallway and off-service oncology admissions on ED patient flow, quality of care and patient satisfaction.Methods: Retrospective and prospective data were collected on patients admitted to the medical oncology service from Jan 1 to Dec 31, 2011. Data on clinician assessments and time performance measures were collected. Satisfaction surveys were prospectively administered to all patients. Results: Two hundred and ninty-seven patients (117 HALL, 90 OFF, 90 ON) were included in this study. There were no significant differences between groups for frequency of physician assessments, physical exam maneuvers at initial physician visit, time to complete vital signs or time to medication administration. The median (IQR) time spent admitted in the ED prior to departure from the ED was significantly longer for HALL patients (5.53 hrs [1.59-13.03 hrs]) compared to OFF patients (2.00 hrs [0.37-3.69 hrs]) and ON patients (2.18 hrs [0.15-5.57 hrs]) (p < .01). Similarly, the median (IQR) total ED length of stay was significantly longer for HALL patients (13.82 hrs [7.43-20.72 hrs]) compared to OFF patients (7.18 hrs [5.72-11.42 hrs]) and ON patients (9.34 hrs [5.43-14.06 hrs]) (p < .01). HALL patients gave significantly lower overall satisfaction scores with mean (SD) satisfaction scores for HALL, OFF and ON patients being 3.58 (1.20), 4.23 (0.58) and 4.29 (0.69) respectively (p < .01). Among HALL patients, 58% were not comfortable being transferred into the hallway and 4% discharged themselves against medical advice. Conclusions: The protocol for transferring ED admitted patients to inpatient hallway beds did not reduce ED length of stay for oncology patients. The timeliness and frequency of clinical assessments were not compromised; however, patient satisfaction was decreased.

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THE EFFECT OF A BOARDING RESTRICTION PROTOCOL ON EMERGENCY DEPARTMENT CROWDING

10.1101/2021.05.01.21255822 ◽

2021 ◽

Author(s):

Ji Hwan Lee ◽

Ji Hoon Kim ◽

Incheol Park ◽

Hyun Sim Lee ◽

Joon Min Park ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Primary Outcome ◽

Treatment Time ◽

Patient Flow ◽

Hospital Beds ◽

Before And After ◽

Day Of The Week ◽

Ed Crowding ◽

Post Period

ABSTRACT Background Access block due to a lack of hospital beds causes emergency department (ED) crowding. We initiated the boarding restriction protocol that limits ED length of stay (LOS) for patients awaiting hospitalization to 24 hours from arrival. This study aimed to determine the effect of the protocol on ED crowding. Method This was a pre-post comparative study to compare ED crowding before and after protocol implementation. The primary outcome was the red stage fraction with more than 71 occupying patients in the ED (severe crowding level). LOS in the ED, treatment time and boarding time were compared. Additionally, the pattern of boarding patients staying in the ED according to the day of the week was confirmed. Results Analysis of the number of occupying patients in the ED, measured at 10-minute intervals, indicated a decrease from 65.0 (51.0-79.0) to 55.0 (43.0-65.0) in the pre- and post-periods, respectively (p<0.0001). The red stage fraction decreased from 38.9% to 15.1% of the pre- and post-periods, respectively (p<0.0001). The proportion beyond the goal of this protocol of 24 hours decreased from 7.6% to 4.0% (p<0.0001). The ED LOS of all patients was similar: 238.2 (134.0-465.2) and 238.3 (136.9-451.2) minutes in the pre- and post-periods, respectively. In admitted patients, ED LOS decreased from 770.7 (421.4-1587.1) to 630.2 (398.0-1156.8) minutes (p<0.0001); treatment time increased from 319.6 (198.5-482.8) to 344.7 (213.4-519.5) minutes (p<0.0001); and boarding time decreased from 298.9 (109.5-1149.0) to 204.1 (98.7-545.7) minutes (p<0.0001). In the pre-period, boarding patients accumulated in the ED on weekdays, with the accumulation resolved on Fridays; this pattern was alleviated in the post-period. Conclusions The protocol effectively resolved excessive ED crowding by alleviating the accumulation of boarding patients in the ED on weekdays. Additional studies should be conducted on changes this protocol brings to patient flow hospital-wide.

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Impact of an emergency department electronic sepsis surveillance system on patient mortality and length of stay

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocx072 ◽

2017 ◽

Vol 25 (5) ◽

pp. 523-529 ◽

Cited By ~ 15

Author(s):

Jonathan S Austrian ◽

Catherine T Jamin ◽

Glenn R Doty ◽

Saul Blecker

Keyword(s):

Emergency Department ◽

Time Series ◽

Length Of Stay ◽

Vital Signs ◽

Interrupted Time Series ◽

Alert System ◽

Process Measures ◽

Emergency Department Patients ◽

Series Study

Abstract Objective The purpose of this study was to determine whether an electronic health record–based sepsis alert system could improve quality of care and clinical outcomes for patients with sepsis. Materials and Methods We performed a patient-level interrupted time series study of emergency department patients with severe sepsis or septic shock between January 2013 and April 2015. The intervention, introduced in February 2014, was a system of interruptive sepsis alerts triggered by abnormal vital signs or laboratory results. Primary outcomes were length of stay (LOS) and in-hospital mortality; other outcomes included time to first lactate and blood cultures prior to antibiotics. We also assessed sensitivity, positive predictive value (PPV), and clinician response to the alerts. Results Mean LOS for patients with sepsis decreased from 10.1 to 8.6 days (P < .001) following alert introduction. In adjusted time series analysis, the intervention was associated with a decreased LOS of 16% (95% CI, 5%-25%; P = .007, with significance of α = 0.006) and no change thereafter (0%; 95% CI, −2%, 2%). The sepsis alert system had no effect on mortality or other clinical or process measures. The intervention had a sensitivity of 80.4% and a PPV of 14.6%. Discussion Alerting based on simple laboratory and vital sign criteria was insufficient to improve sepsis outcomes. Alert fatigue due to the low PPV is likely the primary contributor to these results. Conclusion A more sophisticated algorithm for sepsis identification is needed to improve outcomes.

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Has the implementation of time-based-targets for emergency department length-of-stay influenced the quality of care for patients? A systematic review of qualitative literature

10.1101/2021.01.03.21249171 ◽

2021 ◽

Author(s):

Katie Walker ◽

Bridget Honan ◽

Daniel Haustead ◽

David Mountain ◽

Vinay Gangathimmaiah ◽

...

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Quality Of Care ◽

Length Of Stay ◽

Cochrane Library ◽

Research Approach ◽

Successful Implementation ◽

The Impact ◽

Qualitative Literature

abstractBackgroundTime-based-targets for emergency department length-of-stay were introduced in England in 2000; followed by Canada, Ireland, New Zealand, and Australia after emergency department crowding was associated with poor quality of care and increased mortality.ObjectivesThe aim of the systematic review was to evaluate qualitative literature to investigate how implementing time-based-targets for emergency department length-of-stay has influenced the quality of care of patients.MethodsSystematic review of qualitative studies that described knowledge, attitudes to or experiences regarding a time-based-target for emergency department length-of-stay. Searches were conducted in Cochrane library, Medline, Embase, CInAHL, Emerald, ABI/Inform, and Informit. Individual studies were evaluated using the Critical Appraisal Skills Programme tool. Individual study findings underwent thematic analysis. Confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research approach.ResultsThe review included thirteen studies from four countries, incorporating 617 interviews. Themes identified were: quality of care, access block and overcrowding, patient experience, staff morale and workload, intrahospital and interdepartmental relationships, clinical education and training, gaming, and enablers and barriers to achieving targets. The confidence in findings is moderate or high for most themes. More patient and junior doctor perspectives are needed.ConclusionsEmergency time-based-targets have impacted on the quality of emergency patient care. The impact can be both positive and negative and successful implementation depends on whole hospital resourcing and engagement with targets.FundingThe Australasian College for Emergency Medicine provided administrative support for the study, no funding was received.RegistrationPROSPERO CRD42019107755 (prospective)

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The association between the transfer of emergency department boarders to inpatient hallways or off-service beds and the quality of oncology care.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.113 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 113-113

Author(s):

Simron Singh ◽

Maureen E. Trudeau ◽

Kevin Robert Imrie ◽

Ben De Mendonca ◽

John Fralick ◽

...

Keyword(s):

Emergency Department ◽

Patient Care ◽

Vital Signs ◽

Antibiotic Administration ◽

Care Hospital ◽

High Quality Medical Care ◽

Administration Time ◽

Ed Crowding ◽

The Impact ◽

Mean Time

113 Background: Emergency department (ED) crowding is an important issue in the delivery of high-quality medical care. At our quaternary care hospital a policy was implemented to ease ED crowding by moving suitable admitted patients into inpatient hallway beds or off-service beds. This study assesses the impact of off service and hallway bed admissions on patient care and satisfaction. Methods: Retrospective and prospective data were collected from Jan 1 to Dec 31, 2011, on admissions to the oncology service via the ED. Patient care data was collected as follows: chest/abdominal exams performed at first MD visit, number of MD visits within 48 hours, time to antibiotic administration, time to complete vitals, and mean time spent in the ED. Satisfaction surveys were also given to all patients. Results: One hundred and eighteen patients were admitted to a hallway bed (HALL). A random sample of 90 patients were used for comparison in the on service (ON) and off service (OFF) groups. Among HALL patients, 4% percent discharged themselves against medical advice (0% of OFF and ON patients). MD visits within 48 hours were the same among all groups (mean=6). Forty-two percent of hallway patients had a chest/abdominal exam during the first MD visit (32% and 33% for OFF and ON patients, respectively). Time to first completion of vitals was 1:05 (hh:mm) for HALL patients (1:21 and 00:34 for OFF and ON patients, respectively). Time to antibiotic administration was 15:34 for hallway patients (23:59 and 12:35 for OFF and ON patients, respectively). More HALL patients expressed dissatisfaction with their hospital stay (16.7%) compared to OFF (0%) and ON patients (0%). Mean time for admitted patients in the ED awaiting their HALL bed was 9:14, considerably longer than for OFF patients (3:08) and ON patients (4:19). Conclusions: Admission of oncology patients in hallway or in off-service beds did not appear to compromise the timeliness or frequency of medical assessments. However, delays in nursing care (completion of vital signs and drug administration) were noted and patient satisfaction was decreased. Moreover, the policy did not meet its intent to reduce patient time spent in the ED.

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P064: Effect of increased availability of pre-authorized radiological test ordering on CT scan utilization in the emergency department

CJEM ◽

10.1017/cem.2016.240 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S100-S100

Author(s):

K. Huszarik ◽

K. Wood ◽

M. Columbus ◽

A. Dukelow

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Ct Scan ◽

Patient Flow ◽

Tertiary Care ◽

Ct Scans ◽

Significant Difference ◽

Implementation Period ◽

Flow Through ◽

The Impact

Introduction: Computed tomography (CT) scan utilization has increased dramatically over the past 25 years. This has sparked concern for potential overuse leading to unnecessary radiation exposure for patients and increased health care costs, without any improvement in health outcomes. In order to improve workflow through the Emergency Department (ED) at our institution, an existing pre-authorization policy during weekday business hours allows emergency physicians to order CT scans directly without the need for approval from a radiologist. This policy was recently expanded on September 28, 2015 to allow pre-authorized CT scan orders during weekday evening hours. The objective of our study is to evaluate the impact of increased availability of pre-authorized CT scan ordering on CT scan utilization and patient flow through the ED at two tertiary care hospitals in London, Ontario. Methods: This is a retrospective review comparing monthly CT scan utilization rates in the pre-implementation period from September 28, 2014 to February 28, 2015, to rates in the post-implementation period from September 28, 2015 to February 28, 2016. Length of stay parameters including time from physician initial assessment to CT scan order, completion, report and patient discharge will also be compared between the groups. Results: Results will be presented at CAEP 2016. No significant difference is expected in the monthly number of CT scans ordered per registered ED visits between the pre- and post-implementation groups. We also anticipate a significantly shorter average length of stay for patients receiving a CT scan in the post-implementation group. Conclusion: We expect there will be no significant increase in CT scan utilization with increased availability of pre-authorized CT scan ordering in our EDs. We also anticipated decreased patient length of stay leading to improved patient flow through the ED. Findings may offer support for organizations to safely implement or increase availability of pre-authorized CT scan orders to help improve patient flow and decrease costs in the ED.

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The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department

Open Access Emergency Medicine ◽

10.2147/oaem.s228291 ◽

2020 ◽

Vol Volume 12 ◽

pp. 13-18

Author(s):

Asher L Mandel ◽

Thomas Bove ◽

Amisha D Parekh ◽

Paris Datillo ◽

Joseph Bove Jr ◽

...

Keyword(s):

Emergency Department ◽

Patient Flow ◽

The Impact ◽

Urban Emergency Department

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

Journal of the American Heart Association ◽

10.1161/jaha.120.017208 ◽

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.

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

Journal of Patient Experience ◽

10.1177/23743735211011404 ◽

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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Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow

Canadian Association of Radiologists Journal ◽

10.1177/08465371211023861 ◽

2021 ◽

pp. 084653712110238

Author(s):

Francesco Macri ◽

Bonnie T. Niu ◽

Shannon Erdelyi ◽

John R. Mayo ◽

Faisal Khosa ◽

...

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Patient Flow ◽

Interrupted Time Series ◽

Trauma Patients ◽

Linear Regression Models ◽

High Acuity ◽

Time Series Approach ◽

Comparison Series ◽

The Impact

Purpose: Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. Methods: Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. Results: During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. Conclusions: At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

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