Prolonged Emergency Department Stay at Referring Facilities: A Poor Trauma Performance Improvement Tool

Background Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities. Methods A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS <12 hours. Paired data analyses utilizing prehospital (PH) and RF variables, vital signs (VS), Glasgow Coma Score–Motor component (GCS-M), RF LOS, mortality, trauma center hospital LOS (HLOS), and intensive care unit (ICU) LOS were performed. Results 13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M. Discussion Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.

Results of Classification of Korean Triage And Acute Scale of Patients Visiting The Emergency Department

BackgroundNot much is known about the results of the severity classification according to the time of visit to the emergency department and the appropriateness of using a public ambulance when visiting the emergency department.MethodsThis descriptive research study retrospectively reviewed and analyzed the medical records of patients who visited the emergency department of the B general hospital in Seoul from January to December 2019.ResultsA total of 54,297 patients were included in the analysis. Of the total, 34,629 (63.8%) patients visited directly while 14,065 (25.9%) visited through public ambulances, and 10,328 (73.4%) of patients using public ambulances were discharged home. The numbers of daytime and nighttime patients were 24,891 (45.8%) and 29,406 (54.2%), respectively. The mean length of emergency department stay (LoS) of patients classified as emergency was 326 minutes, while that of non-emergency patients was 159 minutes. In addition, the mean LoS of patients classified as Korean triage and acuity scale levels 1 and 2 was 427 min and 430 min, respectively, which was longer than the total of 236 minutes.ConclusionWe confirmed that patients who visited the emergency department using public ambulances accounted for about 25% of all emergency department visits, and of which 70% were discharged home. In addition, patients with high severity showed a longer mean LoS, and daytime showed higher severity and more patients than nighttime.

Effect of Problem-based Learning on Agreement of Severity Classification Results of Triage Nurses in the Emergency Department

BackgroundProblem-based learning is a learner-led learning method that helps improve critical thinking, problem solving skills, and knowledge. It is necessary to confirm whether it can help to agree the severity classification results among nurses through problem-based learning.MethodsThis study had a single-group time series design to investigate the effect of problem-based learning led by triage nurses on the agreement of Korean Triage and Acuity Scale classification results for patients who visited the emergency department. We extracted 300 patients each in May and August 2018 before problem-based learning began and 300 patients each in May and August 2019 after problem-based learning. ResultsAfter problem-based learning, the length of emergency department stay decreased about 30 minutes, although the decrease was not statistically significant (p=.172). However, self-efficacy for the classification of emergency patients in triage nurses and weighted kappa coefficients were improved (p<.001).ConclusionIn this study, problem-based learning led by triage nurses improved the inter-rater agreement of Korean Triage and Acuity Scale classification results and self-efficacy of triage nurses. Therefore, problem-based learning led by triage nurses can contribute to patient safety in the emergency department by enhancing the expertise of triage nurses and increasing the accuracy of triage classification.

Novel Score for Stratifying Risk of Critical Care Needs in Intracerebral Hemorrhage Patients: Critical Care Needs in ICH

Objective:To develop a risk prediction score identifying intracerebral hemorrhage (ICH) patients at low risk for critical care.Methods:We retrospectively analyzed data of 451 ICH patients between 2010-2018. The sample was randomly divided in a development and a validation cohort. Logistic regression was used to develop a risk score by weighting independent predictors of ICU needs based on strength of association. The risk score was tested in the validation cohort, and externally validated in a dataset from another institution.Results:The rate of ICU interventions was 80.3%. Systolic blood pressure (SBP), Glasgow Coma Scale (GCS), intraventricular hemorrhage (IVH), and ICH volume were independent predictors of critical care, resulting in the following point assignments for the INtensive care TRiaging IN Spontaneous IntraCerebral hemorrhage (INTRINSIC) score: SBP 160-190 mm Hg (1 point), SBP >190 mm Hg (3 points); GCS 8-13 (1 point), GCS <8 (3 points); ICH volume 16-40 cm3 (1 point), ICH volume >40 cm3 (2 points); and presence of IVH (1 point), with values ranging between 0-9. Among patients with a score of 0 and no ICU needs during their emergency department stay, 93.6% remained without critical care needs. In an external validation cohort of ICH patients, the INTRINSIC score achieved an AUC of 0.823 (95% CI 0.782-0.863). A score <2 predicted absence of critical care needs with 48.5% sensitivity and 88.5% specificity, and a score <3 predicted absence of critical care needs with 61.7% sensitivity and 83.0% specificity.Conclusion:The INTRINSIC score identifies ICH patients at low risk for critical care interventions.Classification of Evidence:This study provides Class II evidence that the INTRINSIC score identifies ICH patients at low risk for critical care interventions.

RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction

Background: Although the value of fast diagnostic protocols in suspected acute coronary syndrome has been validated, there is insufficient real world evidence including patients with lower pre-test probability, atypical symptoms and confounding comorbidities. The feasibility, efficacy and safety of European Society of Cardiology (ESC) 0/1 and 0/3-hour algorithms using high-sensitivity troponin T were evaluated in a consecutive cohort with suspected acute coronary syndrome. Methods: During 12 months, 2525 eligible patients were enrolled. In a pre-implementation period of 6 months, the prevalence of protocols, disposition, lengths of emergency department stay and treatments were registered. Implementation of the 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols and 30-day mortality after direct discharge from the emergency department. Results: Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. After rule-out (1588 patients), 1309 patients (76.1%) were discharged directly from the emergency department, with an all-cause mortality of 0.08% at 30 days (one death due to lung cancer). Median lengths of stay were 2.9 (1.9–3.8) and 3.2 (2.7–4.4) hours using a single high-sensitivity troponin T below the limit of detection (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7–6.5) hours using the ESC 0/3-hour rule-out protocol ( P<0.001). Discharge rates increased from 53.9% to 62.8% ( P<0.001), without excessive use of diagnostic resources within 30 days. Conclusion: Implementation of the ESC 0/1-hour algorithm is feasible and safe, is associated with shorter emergency department stay than the ESC 0/3-hour protocol, and an increase in discharge rates. Trial registration: ClinicalTrials.gov , Unique identifier: NCT03111862.

Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes

ObjectivesTo clarify diagnostic accuracy and consequences of misdiagnosis in the admission evaluation of stroke-code patients in a neurologic emergency department with less than 20-minute door-to-thrombolysis times.MethodsAccuracy of admission diagnostics was studied in an observational cohort of 1,015 stroke-code patients arriving by ambulance as candidates for recanalization therapy between May 2013 and November 2015. Immediate admission evaluation was performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily utilizing CT-based imaging.ResultsThe rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (ischemic stroke/TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics. Of the 150 (14.8%) misdiagnosed patients, 135 (90.0%) had no acute findings on initial imaging and 100 (67.6%) presented with NIH Stroke Scale score 0 to 2. Misdiagnosis altered medical management in 70 cases, including administration of unnecessary treatments (thrombolysis n = 13, other n = 24), omission of thrombolysis (n = 5), delays to specific treatments of stroke mimics (n = 13, median 56 [31–93] hours), and delays to antiplatelet medication (n = 14, median 1 [1–2] day). Misdiagnosis extended emergency department stay (median 6.6 [4.7–10.4] vs 5.8 [3.7–9.2] hours; p = 0.001) and led to unnecessary stroke unit stay (n = 10). Detailed review revealed 8 cases (0.8%) in which misdiagnosis was possible or likely to have worsened outcomes, but no death occurred as a result of misdiagnosis.ConclusionsOur findings support the safety of highly optimized door-to-needle times, built on thorough training in a large-volume, centralized stroke service with long-standing experience. Augmented imaging and front-loaded specialist engagement are warranted to further improve rapid stroke diagnostics.

Subjective sleep quality and its etiology in the emergency department

ObjectivePatient sleep quality has a significant impact on recovery. However, most hospital units do not provide an optimal environment for sleep and there are currently no data available on how well patients sleep during their emergency department stay. The main objective of this study was to assess the subjective quality of nighttime sleep and factors that affect sleep in the emergency department (ED).MethodsA prospective sample of patients aged 18 years and older who presented to the ED from July 2015 to October 2015 was investigated. All participants were on stretcher and slept at least one night in the ED. Participants were asked to complete a sleep questionnaire adapted to the ED environment on sleep quality and its potentially modifying factors.ResultsA total of 235 patients participated in the study (mean age: 64±20 years, 51% women). Compared to the week at home prior to admission, subjective sleep quality was lower in the ED (p<0.001): almost half the participants took more than 30 minutes to fall asleep, and they reported waking up 3.5 times per night on average. Lower subjective sleep quality in the ED was associated with higher stress, noise, and pain, as well as with stretcher comfort and lower home sleep quality the week prior to admission.ConclusionsSubjective sleep quality in the emergency department is not optimal, and is influenced by stress, noise, pain, and stretcher comfort, all potentially modifiable factors.

P021: A ‘Pawsitive’ addition to the ER patient experience: A pilot evaluation of the St. John Ambulance therapy dog program in a Canadian hospital

Introduction: Animal-assisted interventions (AAI) have been applied in numerous clinical settings to help reduce pain, stress, and anxiety. This qualitative study sets out to evaluate the St. John Ambulance Therapy Dog program in the emergency department of the Royal University Hospital. Methods: An observer identified patients interested in visiting with a Therapy Dog during their emergency department stay and obtained consent. Participants were asked to indicate on a pictographic scale their physical and mental states before and after the visit. The Therapy Dog team, consisting of a dog and handler, visited the patient for 5-10 minutes. During this time an observer took notes. Participants were asked at the conclusion of the visit to answer questions regarding their overall experience with the Therapy Dog team. Results: 117 patients participated in this study. Pre- and post AAI pictographic faces [c1] scale results showed an average improvement of 1.2. Before AAI, patients most commonly reported feeling pain, anxiety, tiredness, sadness, boredom, weakness, and a desire to go home. Immediately after the AAI, they most commonly reported feeling happiness, relaxation, better, calmness, and good. Observers noted positive participant and family changes during the AAI, including tone of voice, body language, facial expression (e.g., smiling), and openness. Patients often made efforts to make physical contact for the majority of the visit, often despite pain and immobility. There was also frequent sharing of stories about patients’ pets, which seemed to serve as a comfort within the emergency department environment. Conclusion: Animal-assisted interventions with a therapy dog team in an emergency department is a ‘pawsitive’ addition to the patient experience. An important next step is to measure whether the positive impact continued post visit.