The Effect of Physician Triage on Emergency Department Length of Stay

Background: Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist. Objectives: We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion. Methods: This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period. Results: We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month. Conclusion: Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.     

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

Objectives: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center. Methods: This was a pre‐post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a five‐month pre‐expansion period (November 1, 2004, to March 1, 2005) and a five‐month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders. Results: From pre‐expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI =?74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI =?4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI =?4.0 to 3.5). Mean (±SD) total LOS increased from 4.6 (±1.9) to 5.6 (±2.3) hours, and mean (±SD) admission hold LOS also increased from 3.0 (±0.2) to 4.1 (±0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre‐expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode. Conclusions: An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital.     

Factors Associated with Patients Who Leave without Being Seen

Objectives: Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS. Methods: A modified case‐crossover design to determine the transient effects on the risk of acute events was used. Over a four‐month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed‐rank test, and conditional logistic regression analyses were used to determine significant variables. Results: Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p < 0.01) and completion of an emergency medicine residency (p < 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important. Conclusions: ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.     

Reliability of Computerized Emergency Triage

Objectives: Emergency department (ED) triage prioritizes patients based on urgency of care. This study compared agreement between two blinded, independent users of a Web-based triage tool (eTRIAGE) and examined the effects of ED crowding on triage reliability.
Methods: Consecutive patients presenting to a large, urban, tertiary care ED were assessed by the duty triage nurse and an independent study nurse, both using eTRIAGE. Triage score distribution and agreement are reported. The study nurse collected data on ED activity, and agreement during different levels of ED crowding is reported. Two methods of interrater agreement were used: the linear-weighted κ and quadratic-weighted κ .
Results: A total of 575 patients were assessed over nine weeks, and complete data were available for 569 patients (99.0%). Agreement between the two nurses was moderate if using linear κ (weighted κ = 0.52; 95% confidence interval = 0.46 to 0.57) and good if using quadratic κ (weighted κ = 0.66; 95% confidence interval = 0.60 to 0.71). ED overcrowding data were available for 353 patients (62.0%). Agreement did not significantly differ with respect to periods of ambulance diversion, number of admitted inpatients occupying stretchers, number of patients in the waiting room, number of patients registered in two hours, or nurse perception of busyness.
Conclusions: This study demonstrated different agreement depending on the method used to calculate interrater reliability. Using the standard methods, it found good agreement between two independent users of a computerized triage tool. The level of agreement was not affected by various measures of ED crowding.     

PARTICIPANT DIRECTORY

Objective. To determine the effect of pre-emptive ambulance distribution based on the implementation of a real-time, Internet-accessible emergency department (ED) workload schematic andprehospital Australasian Triage Scale (ATS) allocations on ambulance diversion in Western Australia. Methods. Comparison of July–December 2002 andJuly–December 2003 metropolitan Perth ED cubicle occupancy, ambulance diversion, ambulance distribution, andambulance unloading delays at four inner andfour outer metropolitan EDs. Results. Ambulance diversion fell from 1,788 hours in 2002 to 1,138 hours in 2003 (p < 0.001) despite an increase in mean weekly ED cubicle occupancy from 31 patients (95% confidence internal [CI] 29–33) in 2002 to 39 patients in 2003 (95% CI 36–43, p < 0.001). Inner metropolitan ED ambulance attendances fell 2.7% from 27,475 in 2002 to 26,743 in 2003, andouter metropolitan correspondingly rose from 5,877 to 6,628 ambulance attendances (p < 0.001). Unloading delays were similar in 2002 (219, 0.66%) and2003 (223, 0.67%, p = 0.84); however, median duration of unloading delays increased from 38 minutes (interquartile range [IQR] 18–68) in 2002 to 50 minutes (IQR 25–108) in 2003 (p < 0.001). Conclusions. The implementation of pre-emptive ambulance distribution using Internet-accessible ED information andprehospital ATS allocations was associated with reduced ambulance diversion, probably consequent upon the redistribution of ambulances from inner to outer metropolitan EDs. The rise in ED cubicle occupancy between the study periods suggests that this approach to reducing ambulance diversion should be viewed only as complementary to direct efforts to reduce ambulance diversion by improving hospital inpatient flow andthe balance between acute andelective hospital inpatient accommodation.     

Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial

Background Triage liaison physicians (TLPs) have been employed in overcrowded emergency departments (EDs); however, their effectiveness remains unclear.
Objectives To evaluate the implementation of TLP shifts at an academic tertiary care adult ED using comprehensive outcome reporting.
Methods A six-week TLP clinical research project was conducted between December 9, 2005, and February 9, 2006. A TLP was deployed for nine hours (11 ^am to 8 ^pm) daily to initiate patient management, assist triage nurses, answer all medical consult or transfer calls, and manage ED administrative matters. The study was divided into three two-week blocks; within each block, seven days were randomized to TLP shifts and the other seven to control shifts. Outcomes included patient length of stay, proportion of patients who left without complete assessment, staff satisfaction, and episodes of ambulance diversion.
Results TLPs assessed a median of 14 patients per shift (interquartile range, 13–17), received 15 telephone calls per shift (interquartile range, 14–20), and spent 17–81 minutes per shift consulting on the telephone. The number of patients and their age, gender, and triage score during the TLP and control shifts were similar. Overall, length of stay was decreased by 36 minutes compared with control days (4:21 vs. 4:57; p = 0.001). Left without complete assessment cases decreased from 6.6% to 5.4% (a 20% relative decrease) during the TLP coverage. The ambulance wait time and number of episodes of ambulance diversion were similar on TLP and control days.
Conclusions A TLP improved important outcomes in an overcrowded ED and could improve delivery of emergency medical care in similar tertiary care EDs.     

Ambulance Diversion as a Proxy for Emergency Department Crowding: The Effect on Pediatric Mortality in a Metropolitan Area

Objectives: The objective was to determine the prevalence of emergency department (ED) ambulance diversion among Houston pediatric hospitals and its association with mortality of pediatric patients. Methods: Hospital diversion and patient data between August 2002 and December 2004 were used to examine the impact of diversion on mortality of children under age 18 years. Patients were assumed to be exposed to ED crowding if diversion and admission or ED arrival times overlapped. Univariate and logistic regression were performed to determine if diversion was associated with mortality while controlling for age, illness severity, injury, and transfer status. Results: Mean hospital diversion hours as a percentage of operating hours were 10.58 (standard deviation [SD] ± 9). Overall, of 63,780 admissions, there were 4,095 (6.4%) children admitted during diversion. Fewer severely ill patients were admitted during diversion than nondiversion times (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.66 to 0.78). The presence of diversion was protective for mortality (OR = 0.51; 95% CI = 0.34 to 0.77) in bivariate analysis. Mortality was associated with presence of major or extreme illness (OR = 60.7; 95% CI = 45.2 to 81.5), injury (OR=1.7; 95% CI = 1.4 to 2.1), and transfer status (OR = 6.3; 95% CI = 5.4 to 7.3). Using conditional logistic regression, major or extreme illness (OR = 50.7; 95% CI = 37.7 to 68.3), injury (OR 3.7; 95% CI = 2.9 to 4.7), and transfer (OR = 2.7; 95% CI = 2.2, 3.2) were associated with mortality, but diversion did not show any association with mortality. After combining ED and inpatient deaths, no association between diversion and mortality was observed. Conclusions: Hospital diversion due to ED crowding is common in pediatrics. The authors found no evidence of an association between diversion and ED and inpatient pediatric mortality.     

Emergency Department Utilization in the United States and Ontario, Canada

Objectives: The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics.
Methods: This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year.
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada.
Conclusions: ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.     

Description and Evaluation of a Pilot Physician-directed Emergency Medical Services Diversion Control Program

Objectives: To describe the characteristics and feasibility of a physician‐directed ambulance destination‐control program to reduce emergency department (ED) overcrowding, as measured by hospital ambulance diversion hours. Methods: This controlled trial took place in Rochester, New York and included a university hospital and a university‐affiliated community hospital. During July 2003, emergency medical services (EMS) providers were asked to call an EMS destination‐control physician for patients requesting transport to either hospital. The destination‐control physician determined the optimal patient destination by using patient and system variables as well as EMS providers' and patients' input. Program process measures were evaluated to characterize the program. Administrative data were reviewed to compare system characteristics between the intervention program month and a control month. Results: During the intervention month, 2,708 patients were transported to the participating hospitals. EMS providers contacted the destination‐control physician for 1,866 (69%) patients. The original destination was changed for 253 (14%) patients. Reasons for redirecting patients included system needs, patient needs, physician affiliation, recent ED or hospital care, patient wishes, and primary care physician wishes. During the intervention month, EMS diversion decreased 190 (41%) hours at the university hospital and 62 (61%) hours at the community hospital, as compared with the control month. Conclusions: A voluntary, physician‐directed destination‐control program that directs EMS units to the ED most able to provide appropriate and timely care is feasible. Patients were redirected to maximize continuity of care and optimally use available emergency health care resources. This type of program may be effective in reducing overcrowding.     

Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia

Objective: Access block refers to the situation where patients in the emergency department (ED) requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame. We systematically evaluated the relationship between access block, ED overcrowding, ambulance diversion, and ED activity.

Methods: This was a retrospective analysis of data from the Emergency Department Information System for the three major central metropolitan EDs in Perth, Western Australia, for the calendar years 2001–2. Bivariate analyses were performed in order to study the relationship between a range of emergency department workload variables, including access block (>8 hour total ED stay for admitted patients), ambulance diversion, ED overcrowding, and ED waiting times.

Results: We studied 259 580 ED attendances. Total diversion hours increased 74% from 3.39 hours/day in 2001 to 5.90 hours/day in 2002. ED overcrowding (r = 0.96; 95% confidence interval (CI) 0.91 to 0.98), ambulance diversion (r = 0.75; 95% CI 0.49 to 0.88), and ED waiting times for care (r = 0.83; 95% CI 0.65 to 0.93) were strongly correlated with high levels of ED occupancy by access blocked patients. Total attendances, admissions, discharges, and low acuity patient attendances were not associated with ambulance diversion.

Conclusion: Reducing access block should be the highest priority in allocating resources to reduce ED overcrowding. This would result in reduced overcrowding, reduced ambulance diversion, and improved ED waiting times. Improving hospital inpatient flow, which would directly reduce access block, is most likely to achieve this.

     

Emergency Department Overcrowding Following Systematic Hospital Restructuring Trends at Twenty Hospitals over Ten Years

OBJECTIVE: Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. METHODS: Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n = 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. RESULTS: Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n = 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n = 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. CONCLUSIONS: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.     

Clinical review: impact of emergency department care on intensive care unit costs

Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.     

U TILIZATION AND I MPACT OF A MBULANCE D IVERSION AT THE C OMMUNITY L EVEL

Objective. To evaluate the utilization and impact of ambulance diversion in the metropolitan area of Syracuse, New York. Methods. This was a retrospective review of the ambulance diversion system operated by the hospitals of Syracuse, New York. This system allows each emergency department to divert incoming ambulances during periods of extreme overcrowding. Data collected included numbers of hours on ambulance diversion by hospital, numbers of hours when all four hospitals were on diversion simultaneously, and numbers of ambulances received while the hospitals were on and off diversion. Results. For three of the five years evaluated, ambulance diversion hours were most numerous during the period between January and March. For the most recent year studied (2000), ambulance diversion hours did not decline after the first quarter. During periods of diversion, hospital emergency departments received 30%–50% fewer ambulances than they did while open. Conclusion. This study demonstrated that, in Syracuse, New York, ambulance diversion was once a seasonal phenomenon, but is increasingly occurring throughout the year because of staff and resource limitations. It also demonstrated that ambulance diversion can be employed to reduce numbers of incoming transports.     

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.     

The impact of emergency department overcrowding on resident education

Background

Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.

Objectives

To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.

Materials and Methods

A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann–Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.

Results

During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7–10), compared to 8 (IQR 8–10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4–13.2), compared to 13.9 (95% CI 12.7–15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6–1.2), compared to 1.3 (95% CI 1–1.6) in group N (p = 0.047).

Conclusions

During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.     

Clinical and Economic Factors Associated with Ambulance Use to the Emergency Department

Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross‐sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air‐medical transport, walk‐in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0–10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight–8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ≥65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means.     

Access block and ED overcrowding

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20–30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998–1999) to 2.4 beds per 1000 (2002–2007) in 2002, and has remained steady at between 2.5–2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998–1999 rates, the number of available beds in 2006–2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.     

Recently Discharged Inpatients as a Source of Emergency Department Overcrowding

OBJECTIVE: To assess the impact on the emergency department (ED) of recently discharged inpatients and how they contribute to and worsen the current situation of ED overcrowding. METHODS: Retrospective, observational study of medical records and billing data of all patients presenting to the ED within seven days of inpatient discharge from the hospital ("returns") in September 2000. The data were collected from electronic logs. Billing charges were used to estimate ED resources. Medical records were reviewed to classify visits: 1) new problem, 2) related problem, likely preventable, 3) related problem, not likely preventable, 4) unable to classify, or 5) incomplete chart. RESULTS: One-hundred seventy-four returns occurred among 6,290 total ED visits (3%). Significant differences between returns and total ED patients were noted for length of stay (LOS) (6.58 vs 5.22 hours, p = 0.000), percent admitted (47% vs 19%, p = 0.000), and ED billing (1,415.67 dollars vs 391.00 dollars, p = 0.000). The highest rate of admission was for patients presenting 48-72 hours after inpatient discharge (65.4%). Admission rate was higher for patients presenting >48 hours than <48 hours (54% vs 33%, p = 0.01). A review of the medical records (117/174) revealed: 15 new problems (13%); 16 related, likely preventable (14%); 72 related, not likely preventable (62%); 4 unable to assess (2%); and 10 incomplete charts (9%). CONCLUSIONS: The ED is appropriately utilized as a safety net for discharged inpatients. Though "returns" are a small percentage of ED patients, they have longer LOSs, have higher ED charges, and are more frequently admitted. Returns increase the strain on an already overcrowded ED.     

Demand on ED resources during periods of widespread influenza activity

The purpose of this study was to investigate ED resource demand during periods of Centers for Disease Control and Prevention (CDC)-declared widespread influenza activity (WIA). An observational analysis of secondary data describing ED resource demand was performed using computerized ED patient data over a 130-week period. Measures of ED resource utilization were compared during WIA and non-WIA periods. These measures included weekly census; percentage of patients triaged as having fever, infection, or respiratory (flu index) chief complaints; admission rate, ED LOS (length of stay), total bed time (TBT), the number of patients who left the ED without being seen by a physician (LWBS), and ED saturation time. The study included 34 weeks of CDC-designated WIA occurring over 3 distinct periods. During WIA, the flu index was elevated, 23% (95% confidence interval [CI], 20-25) versus 17% (95% CI, 16-17). There was increased resource utilization during WIA periods compared with the non-WIA periods for the following parameters: admission rate (24% [95% CI, 24-25%] versus 23% [23-23%]), ED LOS admitted (296 [95% CI, 280-313] versus 271 [95% CI, 265-277]), ED LOS discharged (162 [95% CI, 156-168] versus 152 [95% CI, 150-154]), ED saturation time (1292 [95% CI, 689-1894] versus 409 [95% CI, 209-609]) and LWBS (31 [95% CI, 19-42] versus 14 [95% CI, 12-15]). Although each WIA period was marked by an initial spike in patient volume, weekly census did not increase (1365 [95% CI, 1297-1433] during WIA versus 1297 [95% CI, 1275-1320] during non-WIA). An association between WIA and greater ED resource demand was observed. A spike in census was observed at the onset of each WIA period. In addition, the flu index increased during WIA, suggesting the use of the ED as a site for syndromic surveillance of WIA onset.