The effect of ED crowding on education

Objective

We studied if emergency department (ED) crowding affects the quality of resident and medical student education on individual patient encounters.

Methods

We performed a cross-sectional study of a ED faculty-learner interactions over a 5-week period in an academic ED. Research assistants administered surveys to residents and senior medical students assessing attending physicians on 4 domains (teaching, clinical care, approachability, and helpfulness) using a scale (ER score for teaching on individual patients) validated for use during ED rotations. Each domain was assessed on a 5-point scale with a highest score of 20 representing superb/outstanding. We tested the association between measures of ED crowding (waiting room number, occupancy, number of admitted patients, and patient-hours) at the time of assessment with the ER score and individual domain scores using correlation coefficients and regression analysis with clustering on the attending physician.

Results

Forty-three residents (22 ED, 21 non-ED) and 3 medical students assessed 34 attending physicians in 352 separate encounters. Median ER score was 16/20 (interquartile range, 12-16). Emergency department crowding levels and ER scores on individual patients were not significantly correlated, nor were ED crowding and individual domains. In the adjusted analysis, ED crowding was not associated with an ER score of 16 or higher, nor was any ED crowding measure associated individual assessments of teaching, clinical care, approachability, or helpfulness.

Conclusion

Emergency department crowding is not associated with the quality of education on individual patients.     

ED crowding and the use of nontraditional beds

Background and Objectives

In an effort to compensate for crowding, many emergency departments (EDs) evaluate and treat patients in nontraditional settings such as gurneys in hallways and conference rooms. The impact of this practice on ED evaluation time is unknown.

Research Design and Subjects

A historical cohort of adult ED visits to an academic hospital between August 1, 2009 and August 1, 2010, was used to evaluate the relationship between ED bed assignment (traditional, hallway, or conference room bed) and mean ED evaluation time, defined as the time spent in an ED bed before admission or discharge. Chief complaints were categorized into the 5 most frequent categories: abdominal/genitourinary, joint/muscle, general (fever, malaise), head/neck, and other. Multiple linear regression and marginal prediction were used to calculate the mean ED evaluation times for each bed type, overall, and by chief complaint category.

Results

During the study period, 15?073 patient visits met the inclusion criteria. After adjustment for patient and ED factors, assignments to hallway and conference room beds were associated with increases in a mean ED evaluation time of 13.3 minutes (95% confidence interval, 13.2-13.3) and 10.9 minutes (95% confidence interval, 10.8-10.9), respectively, compared with the traditional bed ED evaluation time. This varied by chief complaint category.

Conclusions

Use of nontraditional beds is associated with increases in mean ED evaluation time; however, these increases are small and may be further minimized by restricting the use of nontraditional beds to patients with specific chief complaints. Nontraditional beds may have a role in improving ED throughput during times of crowding.     

ED crowding is associated with an increased time to pneumonia treatment

Objective

We measured the correlation between emergency department (ED) occupancy rate and time to antibiotic administration for patients with pneumonia treated in a community hospital setting.

Methods

We reviewed quality improvement data on patients treated for pneumonia in our ED and admitted over a 5-month period. The outcomes were timeliness of antibiotic therapy (within 4 hours of arrival) and overall time to antibiotic administration. Emergency department crowding was measured as the ED occupancy rate. We calculated (1) the Spearman correlation between occupancy rate at time of patient presentation and the time to antibiotic administration, (2) the odds ratio of receiving antibiotics within 4 hours with increasing ED occupancy, and (3) the ability of the occupancy rate to predict failure of achieving the 4-hour goal with the receiver operating characteristic curve.

Results

A total of 334 patients were treated over the study period, of which 262 had complete data available. Occupancy rate ranged from 20% to 245%, and median was 137%. Eighty-one percent received antibiotics within 4 hours; the median time was 150 minutes. Time to antibiotics showed a positive correlation with occupancy rate (Spearman ρ = 0.17, P = .008). An increasing ED occupancy rate was associated with decreased odds of receiving antibiotics within 4 hours (odds ratio, 0.31; 95% confidence interval, 0.13-0.75). Receiver operating characteristic curve area was 0.62 (95% confidence interval, 0.54-0.70; P = .009).

Conclusion

Emergency department occupancy rate was associated with increased time to antibiotic treatment for patients admitted with pneumonia. Occupancy rate had fair success in predicting failure of treatment within 4 hours.     

National ED crowding and hospital quality: results from the 2013 Hospital Compare data

Objectives

We explored Hospital Compare data on emergency department (ED) crowding metrics to assess characteristics of reporting vs nonreporting hospitals, whether hospitals ranked as the US News Best Hospitals (2012-2013) vs unranked hospitals differed in ED performance and relationships between ED crowding and other reported hospital quality measures.

Methods

An ecological study was conducted using data from Hospital Compare data sets released March 2013 and from a popular press publication, US News Best Hospitals 2012 to 2013. We compared hospitals on 5 ED crowding measures: left-without-being-seen rates, waiting times, boarding times, and length of stay for admitted and discharged patients.

Results

Of 4810 hospitals included in the Hospital Compare sample, 2990 (62.2%) reported all ED 5 crowding measures. Median ED length of stay for admitted patients was 262 minutes (interquartile range [IQR], 215-326), median boarding was 88 minutes (IQR, 60-128), median ED length of stay for discharged patients was 139 minutes (IQR, 114-168), and median waiting time was 30 minutes (IQR, 20-44). Hospitals ranked as US News Best Hospitals 2012 to 2013 (n = 650) reported poorer performance on ED crowding measures than unranked hospitals (n = 4160) across all measures. Emergency department boarding times were associated with readmission rates for acute myocardial infarction (r = 0.14, P < .001) and pneumonia (r = 0.17, P < .001) as well as central line–associated bloodstream infections (r = 0.37, P < .001).

Conclusions

There is great variation in measures of ED crowding across the United States. Emergency department crowding was related to several measures of in-patient quality, which suggests that ED crowding should be a hospital-wide priority for quality improvement efforts.     

The effects of a physician-nurse patient care team on patient satisfaction in an academic ED

The objectives were to investigate the effects of a RN/MD patient care team operational change on ED patient satisfaction. In period 1, RNs had standard room assignments and MDs evaluated patients based upon physician availability and perceived patient load. In period 2, RNs and MDs were organized into 2 patient care "teams" and patients were assigned to teams on an alternating basis. Patient satisfaction was rated using the standard ED Press, Ganey survey instrument. A total of 508 surveys were returned in period 1 and 454 in period 2. From period 1 to 2, overall ED patient satisfaction improved from 78.2 +/- 20.4% to 82.2 +/- 17.2% (improvement from 23rd to 59th percentile, P 相似文献   

Association between ED crowding and delay in resuscitation effort

Study objectiveFew investigations have been performed that address why emergency department (ED) crowding is associated with an increase in hospital mortality for emergency patients. The purpose of this study was to evaluate whether ED crowding is associated with delayed resuscitation efforts (DREs) that resulted in hospital mortality.MethodsThis is a retrospective observational study performed at a single urban tertiary ED. All adult patients who entered the resuscitation room and underwent resuscitative procedures from October 2008 to May 2010 were enrolled in the study. Demographic data were collected from a designed resuscitation room registry. The ED electronic log data were used for calculating the crowding status. A crowded day was defined as a daily number of patients greater than 93, which was a cut-off derived from a sensitivity analysis. The primary outcome was a DRE, which occurred when a patient was located in the hallway or waiting room, then entered the resuscitation room, and received resuscitative procedures after the patient had clinically deteriorated. A secondary outcome was hospital mortality. Matched samples were selected using propensity scores to consider the clinical parameters and emergency severity index when the patients received triage immediately after registration. A logistic regression analysis was modeled to estimate the odds ratios (ORs) with 95% confidence intervals (CIs) on the DRE.ResultsA total of 1296 patients underwent resuscitative procedures in the resuscitation room. Of these, 226 (17.4%) were classified as the DRE group. A final 396 cases (30.6%) were matched and analyzed between DRE and non-DRE using the propensity score. The incidence of DRE was significantly higher on crowded days (OR, 2.00; 95% CI, 1.28-3.15). Mortality during the ED stay or during the total hospital stay was significantly higher in the DRE group (OR, 3.39; 95% CI, 1.22-9.45 and OR, 3.96; 95% CI, 2.28-6.88, respectively) compared with the non-DRE group.ConclusionDelays in resuscitation efforts occurred more frequently on crowded days and were associated with higher in-hospital mortality.     

急诊科拥挤度定量评估:新的思路,新的期待

随着急诊科拥挤现象的日益加剧[1],建立规范化拥挤度定量评估方法,获得急诊科拥挤问题的翔实客观数据,为拥挤问题多中心干预研究提供方法学依据,从而为决策者制定国家医疗卫生政策提供科学证据,是当前急诊科管理者亟需解决的课题.理想的急诊科拥挤度定量评估方法应满足:可行性、动态性、预警性、重复性、准确性、实用性、良好的成本效益及科研价值等8个方面[2].     

Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED

OBJECTIVE: We hypothesize that the number of patients who leave without being seen is correlated with the simple-to-use National Emergency Department Overcrowding Scale (NEDOCS). METHODS: Results of a 6-item ED overcrowding scale (NEDOCS) were collected prospectively over a 17-day study period. The following additional data were extracted from records for each 2-hour study period: (1) number of registered patients, (2) number of ambulances that arrived, and (3) number of patients signed in that hour who eventually left without being seen. Spearman correlation coefficients were computed for the leaving without being seen (LWBS) rate with the NEDOCS score at the time of patient presentation and 2, 4, and 6 hours later. RESULTS: The study period represents two hundred fourteen 2-hour periods. The LWBS rate was determined for 100% of the times; NEDOCS scores were determined for a sampling of 62% of the times spread equally over all hours of the day and days of the week. Correlation between the NEDOCS score and LWBS was 0.665. CONCLUSION: The NEDOCS score is well correlated with LWBS.     

Attending documentation contribution to billing at an academic ED with an electronic health record

Introduction

In emergency medicine (EM), patient care documentation serves many functions, including supporting reimbursement. In addition, many electronic health record systems facilitate automatically populating certain data fields. As a result, in the academic model, the attending's note may now more often recapitulate many of the same elements found in the resident's or physician assistant's (PA) note. We sought to determine the value of additional attending documentation, and how often the attending documentation prevented a downcoding event.

Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED

Background

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of purulent skin and soft-tissue infections (SSTIs) in the Unites States. Little is known regarding health care provider management strategies for abscesses in the emergency department (ED). Understanding variability in practice patterns could be an important step in implementing evidence-based guidelines.

Objectives

The objectives of this study are to describe practice patterns for purulent SSTI in a single, urban, academic ED, including antibiotic selection and incision and drainage (I &; D) technique, and to compare these practices with current evidence.

Methods

Prospective data were collected on a convenience sample of adults presenting to our urban, academic ED (annual volume, 65 000 per year) between June 2009 and May 2010. Characteristics of patients and their providers were collected as well as specific management strategies including use of irrigation, packing, and antibiotics.

Results

One hundred forty-five patients were enrolled. Most SSTIs were single (80.4% abscesses), most commonly on the extremities (29.8%). Both I &; D and antibiotics were used 79.9% of the time, with the largest predictor for the addition of antibiotics being erythema more than 2 cm (odds ratio, 4.52; 95% confidence interval, 1.39-14.7); I &; D technique varied by provider-type and experience. Providers suspected MRSA in 75% of cases, despite only 48% demonstrating MRSA on culture. Many patients received antimicrobials after I &; D, even in those with 2 cm or less abscesses (57.5%).

Conclusions

Practice patterns vary significantly, especially antibiotic overuse, at least in this urban academic ED. Further study should be undertaken to evaluate factors that influence management strategies for SSTI.     

The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis

Objectives

We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis.

Methods

A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the χ² test.

Results

Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68).

Conclusions

The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution.     

多维急诊科拥挤评分量表和国家急诊科拥挤度评分改良模型应用研究

目的 城市急诊科拥挤现象日益加剧,但相关研究受到方法学的制约,本研究旨在探寻新的拥挤度评价系统或方法,并进行有效性验证.方法 通过建立导致急诊科拥挤的入口、过程、出口3个环节的相关变量库,筛选其中有效变量,编制多维急诊科拥挤评分量表(MEDOS),再进一步与视觉模拟评分法(VAS)和改良国家急诊科拥挤度评分(NEDOCSBJ)进行一致性检验.结果 为期6个月研究,共552个拥挤度测量点.以医生和护士VAS均值(VAS-m)作为结局变量,急诊在床治疗患者数/急诊额定床位数(Pbed/Bt)、生命支持设备数(Xn)、最近一个看医师患者候诊时间(Wtime)和流出道梗阻率(ABI)作为自变量,进行多元线性回归分析,得到改良NEDOCS模型(NEDOCSBJ):NEDOCSBJ=83.563× (Pbed/Bt) +7.201× (Xn)+0.116×Wtime+ 0.302×ABI+2.835.MEDOS均值(n =552)为25.4±5.8;MEDOS与VAS-m、NEDOCSBJ显著性相关,r分别为0.664和0.939,P均＜0.00 1.NEDOCSBJ与MEDOS间,组内相关分析(ICC)和Bland-Altman图显示两者有较好的一致性,两者差值均值为11.96分,可能存在系统性误差,从临床专业角度来看其95％一致性界限(-6.74 ～ 30.66,＜40分)和差值均值(11.96分)尚可接受.结论 NEDOCSBJ模型对急诊科拥挤度评估和研究具有重要潜在价值,但因其受到自变量易获得性等诸多因素制约,不利于在国内广泛应用;而MEDOS因其直观量化、可即时评估、采集信息点多(均衡性好)等优点,且NEDOCSBJ与具有较好的一致性,在急诊临床管理学研究中具有良好的应用前景.     

The ED is an efficient place to treat ED patients

The purpose of this study was to determine what percentage of ED patients would be more efficiently treated in an offsite clinic. A stratified sample consisting of 650 ED visits were reviewed. Patient care was classified as more efficiently delivered in ED or clinic using prospectively developed criteria. Five hundred fifty-three (85%; 95% confidence interval [CI], 82-88%) visits met the definition of efficient ED utilization. One (0.15%; 95% CI, 0.01-0.99%) met the criteria for efficient clinic utilization. The other 96 (15%; 95% CI, 12-18%) failed to meet the definition of efficient for either site; 92 of these failed 2 or more clinic criteria. Only 25 (3.9%; 95% CI, 2.6-5.7%) were seen for nonacute problems. Few ED patients would be more efficiently seen in a clinic.