Prospective Evaluation of Daily Performance Metrics to Reduce Emergency Department Length of Stay for Surgical Consults

Background

As part of a quality improvement initiative to reduce Emergency Department (ED) length of stay (LOS) for surgical consult patients, we e-mailed performance metrics to key stakeholders on a daily basis. ED and Surgery leadership used these daily metrics to identify and remedy contributing factors for increased ED LOS in patients who received surgical consults.

Objective

To evaluate whether a quality improvement process driven by a daily performance metric e-mail would be associated with a change in ED LOS for surgical consult patients.

Methods

Prospective before-after study looking at ED LOS for surgical consult patients after an e-mail intervention at a tertiary academic teaching hospital. All consecutive adult ED patients between July 1, 2010 and October 1, 2010 who received a general surgical consult were enrolled. The primary outcome measure was ED LOS, and secondary outcome measure was time to consultation.

Results

There were 916 patients who had surgical consults placed during the study period; 459 patients presented before the intervention and 457 patients presented after the intervention. The median LOS decreased 54 min, from 463 min (interquartile range [IQR] 326–617) before the intervention to 409 min (IQR 294.5–528.5) after the intervention (p < 0.001). Time to consultation decreased 25 min, from a median of 160 min (IQR 87–265) to 135 min (IQR 70–239.5) (p = 0.002). There was no difference in age, severity, number of consults, or disposition. There was also no difference in median LOS for other consultation services or in previous years during the same time period.

Conclusions

ED LOS and time to consultation were decreased for surgical consult patients after initiation of daily performance metric e-mails.     

Symptom to door interval in febrile neutropenia: perspective in India

Purpose

Febrile neutropenia (FN) is an oncological emergency to be treated within an hour. In a developing country, patients are often unable to reach hospital speedily. Our aim was to determine the symptom to door interval (SDI) in febrile neutropenic children with acute lymphoblastic leukaemia [ALL] and to identify factors resulting in delay.

Methods

All consecutive children of ALL (< 14 years) presenting with FN over a period of 1 year were evaluated. Data for demographics, clinical details, phase of therapy, profile of caregivers, travelling time, SDI, reasons for delay, modes of transport, complications, invasive bacterial infections (IBI), length of hospital stay and outcome were recorded.

Results

Among 320 FN episodes, median SDI (in hours) was 24 (IQR 8, 36). SDI during intensive phases was significantly less as compared to nonintensive phases 12 (IQR 6, 24) and 24 (IQR 24, 48) (p?<?0.001). Children on induction phase reported to hospital at earliest [median 8 (IQR 4, 12)], while those on maintenance phase came late [median 36 (24, 48)]. Median travelling time was 15 min (IQR 15, 25) for patients on intensive phase and was 180 min (IQR 60, 285) for those on nonintensive phase (p<?0.001). Ingestion of acetaminophen at home (30 %), inability to realise the gravity of the situation (27 %), unawareness of parents (9 %) and nonavailability of transport (12 %) were the most common reasons for delay. No significant association of SDI was seen with complications, IBI, duration of hospital stay and mortality (p?>?0.05).

Conclusions

Considerable time lag was seen between onset of symptoms and reaching hospital. Health education and establishment of shared care are urgent needs in countries where tertiary care facilities are limited.     

Impact of Physician-Assisted Triage on Timing of Antibiotic Delivery in Patients Admitted to the Hospital with Community-Acquired Pneumonia (CAP)

Background

Time to antibiotic delivery in patients with diagnosis of pneumonia is a publicly reported quality measure.

Objective

We aim to describe the impact of emergency department (ED) physician-assisted triage (PAT) on The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) pneumonia core quality measures of timing to antibiotic delivery.

Methods

Retrospective case series studies of patients admitted to the hospital through the ED with diagnosis of community-acquired pneumonia were identified over a period of 48 months. Patients were included in the study if they met TJC/CMS PN-5 (antibiotic timing) criteria. We compared antibiotic delivery timing before and after implementation of PAT in moderate-acuity patients using Wilcoxon rank sum tests. A linear regression analysis was done to account for age, sex, ED volume, and acuity level.

Results

A total of 659 patients were identified: 497 patients and 162 patients enrolled pre- and post-implementation of a PAT, respectively. The median antibiotic delivery times for moderate-acuity patients during open hours of operation of PAT were 180 min (pre) and 195 min (post), p = 0.027; this was unchanged when ED volume, age, sex, and acuity level were accounted for. A total of 43 patients (9%) and 13 patients (8%) failed to receive antibiotics within 6 h of ED presentation before and after implementation of PAT, respectively.

Conclusion

In this study, implementation of PAT did not result in overall decrease in antibiotic delivery time in patients admitted to the hospital with CAP. We postulate several explanations for this delay in antibiotic delivery time.     

Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis

Objectives

The Quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis.

Improving door-to-antibiotic time in severely septic emergency department patients

Background

The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic.

Study Objective

To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED.

Methods

Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h.

Results

The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5–45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53–102.29). The percentage of severely septic patients receiving antibiotics within 3 h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12–0.42).

Conclusion

Storing key antibiotics in an institution’s severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival.     

Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures

Objective

To determine if prehospital identification of sepsis will affect time to Centers for Medicare and Medicaid services (CMS) sepsis core measures and improve clinical outcomes.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.     

Timing of antibiotics,volume, and vasoactive infusions in children with sepsis admitted to intensive care

IntroductionEarly administration of antibiotics for sepsis, and of fluid boluses and vasoactive agents for septic shock, is recommended. Evidence for this in children is limited.MethodsThe Alberta Sepsis Network prospectively enrolled eligible children admitted to the Pediatric Intensive Care Unit (PICU) with sepsis from 04/2012-10/2014. Demographics, severity of illness, and outcomes variables were prospectively entered into the ASN database after deferred consent. Timing of interventions were determined by retrospective chart review using a study manual and case-report-form. We aimed to determine the association of intervention timing and outcome in children with sepsis. Univariate (t-test and Fisher’s Exact) and multiple linear regression statistics evaluated predictors of outcomes of PICU length of stay (LOS) and ventilation days.ResultsSeventy-nine children, age median 60 (IQR 22–133) months, 40 (51 %) female, 39 (49 %) with severe underlying co-morbidity, 44 (56 %) with septic shock, and median PRISM-III 10.5 [IQR 6.0-17.0] were enrolled. Most patients presented in an ED: 36 (46 %) at an outlying hospital ED, and 21 (27 %) at the Children’s Hospital ED. Most infections were pneumonia with/without empyema (42, 53 %), meningitis (11, 14 %), or bacteremia (10, 13 %). The time from presentation to acceptable antibiotic administration was a median of 115.0 [IQR 59.0-323.0] minutes; 20 (25 %) of patients received their antibiotics in the first hour from presentation. Independent predictors of PICU LOS were PRISM-III, and severe underlying co-morbidity, but not time to antibiotics. In the septic shock subgroup, the volume of fluid boluses given in the first 2 hours was independently associated with longer PICU LOS (effect size 0.22 days; 95 % CI 0.5, 0.38; per ml/kg). Independent predictors of ventilator days were PRISM-III score and severe underlying co-morbidity. In the septic shock subgroup, volume of fluid boluses in the first 2 hours was independently associated with more ventilator days (effect size 0.09 days; 95 % CI 0.02, 0.15; per ml/kg).ConclusionHigher volume of early fluid boluses in children with sepsis and septic shock was independently associated with longer PICU LOS and ventilator days. More study on the benefits and harms of fluid bolus therapy in children are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1010-x) contains supplementary material, which is available to authorized users.     

The usefulness of the semiquantitative procalcitonin test kit as a guideline for starting antibiotic administration

Objectives

The Surviving Sepsis Campaign has recommended that antibiotic therapy should be started within the first hour of recognizing severe sepsis. Procalcitonin has recently been proposed as a biomarker of bacterial infection, although the quantitative procalcitonin assay is often time consuming, and it is not always available in many emergency departments (EDs). Our aim is to evaluate usefulness of the semiquantitative procalcitonin fast kit as a guideline for starting antibiotic administration for patients with severe sepsis or septic shock that requires prompt antibiotic therapy in the ED.

Methods

We include those patients who were admitted to the ED and who were suspected of having infection. The procalcitonin concentration was determined by semiquantitative PCT-Q strips, and the points of the severity scoring system were calculated. The receiver operating characteristic curve was used to assess the diagnostic value of the PCT-Q strips to predict severe sepsis or septic shock.

Results

Of the 80 recruited patients, 33 patients were categorized as having severe sepsis or septic shock according to the definition. At a procalcitonin cutoff level of 2 ng/mL or greater, the sensitivity of the PCT-Q for detecting severe sepsis or septic shock was 93.94% and the specificity was 87.23. The receiver operating characteristic curve for PCT-Q to predict severe sepsis or septic shock had an area under the curve of 0.916.

Conclusion

PCT-Q is probably a fast, useful method for detecting severe sepsis in the ED, and it can be used as a guideline for antibiotic treatment.     

The Use of Ketamine for Acute Treatment of Pain: A Randomized,Double-Blind,Placebo-Controlled Trial

Background

Pain is one of the most common reasons for emergency department (ED) visits in the United States. Ketamine is a sedative with N-methyl-D-aspartate (NMDA) receptor antagonism. Recent literature has suggested that the use of subdissociative dose ketamine (SDDK) may be safe and effective for acute pain.

Multiple gene-to-gene interactions in children with sepsis: a combination of five gene variants predicts outcome of life-threatening sepsis

Introduction

The aim of the study was to identify the dependency structure of genetic variants that can influence the outcome for paediatric patients with sepsis.

Methods

We evaluated the role of single nucleotide polymorphisms for five genes: bactericidal permeability increasing protein (BPI; rs5743507), lipopolysaccharide-binding protein (LBP; rs2232618), toll-like receptor 4 (TLR4; rs4986790), heat shock protein 70 (HSP 70; rs2227956), and interleukin 6 (IL-6; rs1800795) in 598 children aged 0 to 19 years that were admitted to a paediatric intensive care unit with fever, systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, or multiple organ dysfunction syndrome. A control group of 529 healthy individuals was included. Multi-way contingency tables were constructed and statistically evaluated using log-linear models. Typical gene combinations were found for both study groups.

Results

Detailed analyses of the five studied gene profiles revealed significant differences in sepsis survival. Stratification into high-risk, intermediate-risk, and low-risk groups of paediatric patients can predict the severity of sepsis.

Conclusions

Analysis of single nucleotide polymorphisms for five genes can be used as a predictor of sepsis outcome in children.     

Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction

Background

Recently developed crowding measures, such as the Emergency Department (ED) Work Index (EDWIN) score, provide a quantifiable measurement of overcrowding in the ED.

Aims

We sought to determine the association between overcrowding, measured with the EDWIN score, and the time required to initiate percutaneous coronary intervention (PCI) for patients presenting to the ED with acute myocardial infarction (AMI).

Methods

We retrospectively reviewed the performance improvement (PI) data on all patients presenting to the ED over a 2-month period with chest pain and whose subsequent ECG showed AMI requiring PCI. We recorded the time from patient presentation to the (1) time to first ECG, (2) time to patient arrival in the catheterization laboratory, and (3) time to catheter balloon inflation. We calculated EDWIN scores using data archived from our electronic tracking board and compared the proportion of patients who achieved our established ED goal times between patients presenting during low crowding (EDWIN?Results Seventeen patients underwent emergent PCI in the study period. Patients presenting to the ED during periods of low crowding had shorter times to balloon inflation (median of 84 min, IQR 80 to 93 min) than patients presenting to the ED during periods of high crowding (median of 107 min, IQR 94 to 122 min), P?=?0.008. Times to first ECG and to arrival in the catheterization laboratory were not significantly different between patients presenting during low and high crowding conditions.

Conclusion

Overcrowding appears to be associated with a decreased likelihood of timely treatment for acute AMI in our ED.     

Comparison of drug administration logistics between prothrombin complex concentrates and plasma in the emergency department

Background

Prothrombin complex concentrate (PCC) is used as an alternative to fresh frozen plasma (FFP) for emergency bleeding. The primary objective of this study was to compare the time from order to start of administration between 3-factor PCC (PCC3), 4-factor (PCC4), and FFP in the emergency department (ED). The secondary objective was to evaluate the effect of an ED pharmacist on time to administration of PCCs.

Emergency Department Management of Pediatric Patients with Cyanotic Heart Disease and Fever

Background

Children with cyanotic congenital heart disease (CCHD) are living longer and presenting to the Emergency Department (ED) in larger numbers. A greater understanding of their diagnoses and appropriate management strategies can improve outcomes.

Objective

Our objective was to describe the ED diagnoses, management, and dispositions of pediatric CCHD patients who present with fever.

Methods

We retrospectively analyzed pediatric ED patients age 18 years or younger with a previous diagnosis of CCHD who presented with a fever from January 2000 to December 2005.

Results

Of 809 total ED encounters, 248 (30.6%) were eligible for inclusion. Of those meeting inclusion criteria, 59 (23.8%) required supplemental oxygen and 67 (27%) received intravenous fluid. ED diagnoses were febrile illness in 120 (48.4%), pneumonia in 35 (14.1%), upper respiratory infection in 19 (7.7%), viral syndrome in 17 (6.9%), gastroenteritis in 17 (6.9%), otitis media in 10 (4.0%), bronchiolitis in 5 (2.0%), pharyngitis in 3 (1.2%), croup in 3 (1.2%), bronchitis in 3 (1.2%), urinary tract infection in 3 (1.2%), mononucleosis in 2 (0.8%), pericarditis in 2 (0.8%), influenza in 1 (0.4%), cellulitis in 1 (0.4%), bacteremia in 1 (0.4%), and potential endocarditis in 1 (0.4%). In terms of patient disposition, 53.2% were discharged, 44.4% were floor admissions, and 2.4% were intensive care unit admissions.

Conclusions

A cardiac cause of fever in CCHD patients is rare. Because of limited cardiopulmonary reserve, they might require supplemental oxygen, intravenous fluids, and hospital admission.     

Delays in antibiotic redosing: Association with inpatient mortality and risk factors for delay

ObjectiveAlthough timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration.MethodsWe performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality.ResultsA total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05–2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75–0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27–1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30–1.81 for ESI 1–2 versus 3–5).ConclusionsDelays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.     

Intranasal fentanyl in 1–3‐year‐olds: A prospective study of the effectiveness of intranasal fentanyl as acute analgesia

The primary objective of the present study was to determine the effectiveness of intranasal fentanyl analgesia in children aged 1–3 years with acute moderate to severe pain presenting to the ED. We also aimed to gather information on the safety and acceptability of intranasal fentanyl in this age group. Two paediatric ED enrolled children aged 1–3 years, with acute moderate or severe pain. Intranasal fentanyl was administered (1.5 µg/kg) via a mucosal atomiser device using a 50 µg/mL solution of fentanyl. Physiological parameters (heart rate, respiratory rate, oxygen saturations and level of consciousness) were measured at regular intervals. Objective pain assessment was completed using the Faces, Legs, Arms, Cry, Consolability (FLACC) score. Forty‐six children presenting with acute moderate to severe pain were included. The median FLACC score before intranasal fentanyl administration was 8 (interquartile range [IQR] 5–10), decreasing to 2 (IQR 0–4) 10 min post fentanyl (P < 0.0001) and 0 (IQR 0–2) 30 min post fentanyl (P < 0.0001). A clinically significant decrease in FLACC scores was seen in 93% of children 10 min post fentanyl administration and 98% of children 30 min post fentanyl. Intranasal fentanyl delivery using a mucosal atomiser was well tolerated by all children. There were no adverse drug reactions or adverse events detected. Intranasal fentanyl is an effective, safe and well‐tolerated mode of analgesia for children aged 1–3 years with moderate to severe pain.     

Platelet inhibition and GP IIb/IIIa receptor occupancy by intracoronary versus intravenous bolus administration of abciximab in patients with ST-elevation myocardial infarction

Background

In patients with ST-elevation myocardial infarction (STEMI), direct intracoronary bolus administration of the glycoprotein (GP) IIb/IIIa receptor antagonist abciximab is associated with a reduction in infarct size, better myocardial salvage, less microvascular obstruction and improved myocardial blush grade as compared to intravenous bolus injection, presumably caused by higher local drug concentrations leading to a more pronounced inhibition of platelet aggregation. We investigated whether there are differences in the degree of GP IIb/IIIa receptor occupancy and platelet inhibition in blood drawn from the coronary sinus (CS) shortly after intracoronary versus intravenous abciximab bolus administration.

Methods

A total of 16 patients with acute STEMI undergoing primary percutaneous coronary intervention within 12?h of symptom onset underwent blood sampling from the CS before, immediately after and 30?min after abciximab bolus administration (intracoronary bolus: n?=?8 patients; intravenous bolus: n?=?8 patients).

Results

Immediately after bolus application, GP IIb/IIIa receptor occupancy in CS blood was significantly higher in patients who received direct intracoronary bolus injection compared to administration via a peripheral vein (intracoronary bolus: 93.5% [IQR 92.7?C95.4]; intravenous bolus: 74.0% [IQR 17.6?C94.0], p?=?0.04). The degree of platelet inhibition was also markedly higher with intracoronary compared to intravenous dosing. At late sampling after 30?min no significant differences were found between groups for both platelet reactivity and GP IIb/IIIa receptor occupancy.

Conclusions

Acutely, direct intracoronary bolus injection resulted in a more pronounced local inhibition of platelet function and a higher degree of GP IIb/IIIa receptor occupancy as compared to standard intravenous bolus injection.     

Emergency Physician–Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series

Background

Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation.