Is Medical Clearance Necessary for Pediatric Psychiatric Patients?

Background

Although most studies have found low rates of organic illness in patients with isolated psychiatric complaints, psychiatric patients are frequently brought to emergency departments (EDs) for medical clearance.

Study Objectives

To assess the utility of ED medical clearance before transfer of pediatric patients on psychiatric holds to inpatient psychiatric facilities, and to evaluate charges associated with ED medical clearance.

Methods

Retrospective study of pediatric psychiatric patients in one urban pediatric ED with 22,000 annual patient visits over an 18-month period. Patients were included if transported to the ED for medical clearance after being placed on an involuntary psychiatric hold in the prehospital setting. Main outcome measures were charges for screening laboratory tests and secondary ambulance transfers and wages for sitters resulting from ED visits for medical screening examinations of patients on psychiatric holds. We also determined what percentage of patients truly warranted a medical screen and the percentage of psychiatric holds overturned, avoiding transfer to a psychiatric hospital.

Results

There were 789 patients included; 72 (9.1%) were determined to require medical screening. Total charges for laboratory assessments and secondary ambulance transfers and wages for sitters were $1,241,295, or US$17,240 per patient requiring a medical screen. Only 35 (4.4%) holds were overturned in the ED.

Conclusion

Few patients brought to the ED on an involuntary hold required a medical screen. Use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) could have led to significant savings.     

Evaluation of the initiation of urine drug screens intended for use in transfer patients

Objective

The objective of this study was to determine if signs of clinical intoxication were present in patients who had transfer urine drug screens (UDS) performed and to determine the proportion of patients with UDS orders who were actually transferred to another facility.

Methods

Of all emergency department (ED) patient visits who had a transfer UDS ordered from November 19, 2011, to December 31, 2012, 54% of the population was randomly selected for review by 1 of 3 study investigators. For quality assurance, a random sample of 100 patient charts was independently reviewed by all 3 investigators to assure consistency in interpreting data. Demographics, clinical characteristics and history, disposition, and laboratory results were recorded.

Results

Of the 639 patients included in this study, only 18% were transferred to another psychiatric facility. Pediatric patients and those with presenting with suicidal ideation were more likely to be transferred to an outside facility. Thirty-six percent of the UDS were positive for at least one substance. Marijuana was the most common substance (23%), followed by cocaine (7%) and opiates (7%). There was no evidence that the UDS changed acute management decisions.

Conclusions

Few (< 6%) patients demonstrated any clinical characteristics that were consistent with an acute intoxication. Less than 20% of patients who had a transfer UDS were actually transferred to an outside facility corresponding with more than 80% not ordered appropriately according to the ED established guidelines. This number of inappropriate tests represented more than $152 000 of avoidable UDS cost during the study period.     

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients

Background

Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer.

Pain Scores among Emergency Department (ED) Patients: Comparison by ED Diagnosis

Background

Treatment for pain and pain-related conditions has been identified as the most common reason for Emergency Department (ED) visits.

Objective

This study was undertaken to characterize the distribution of self-reported pain scores for common ED diagnoses.

Methods

In this retrospective exploratory chart review, eligible participants included all adult ED patients age 18 years and over, with a self-reported triage pain score of 1 or higher during January–June 2011. Data were collected from ED electronic medical records.

Results

Among 1229 patients, the mean age was 44 years; 56% of patients were female, and 59% were white. The mean triage pain score for all patients was 7.1 (interquartile range 6–9). The most common reported diagnoses included: minor injuries (10%), abdominal pain (8%), and respiratory infections (8%). The diagnoses with the highest mean pain scores were: sickle cell crisis (mean pain score 8.7), back/neck/shoulder pain (8.5), and headache/migraine (8.3). Higher pain scores were significantly correlated with younger age (p < 0.001) and number of ED visits (p < 0.001). Demographic factors including female gender, African American race, and Medicaid insurance reported significantly higher pain scores (p < 0.001). Patients with multiple ED visits in the recent 12 months reported significantly higher pain scores (p < 0.001).

Conclusion

ED patients report a wide variety of pain scores. Factors associated with higher pain scores included younger age, female gender, African American race, Medicaid insurance status, multiple ED visits in the past year, and ED diagnoses of sickle cell crisis, back/neck/shoulder pain, and headache.     

Methamphetamine-related Psychiatric Visits to an Urban Academic Emergency Department: An Observational Study

Background

Methamphetamine, a stimulant of abuse, is associated with a significant number of Emergency Department (ED) visits. Methamphetamine use may produce psychiatric symptoms including acute psychosis, depression, and anxiety disorders.

Study Objectives

To characterize psychiatric emergencies either directly or indirectly attributable to methamphetamine use in an urban academic ED.

Methods

We analyzed a database of patients determined to have an ED visit that was either methamphetamine related or non-methamphetamine related. We retrospectively reviewed the records of the subset of ED visits from this database with psychiatric diagnoses. We compared the characteristics of patients with methamphetamine-related psychiatric visits (MRPVs) and non-methamphetamine-related psychiatric visits (non-MRPVs).

Results

We identified 130 patients with MRPVs. This represented 7.6% (130 of 1709) of all psychiatric visits. Patients with MRPV, compared to non-MRPV patients, were younger (34.4 years vs. 39.1 years, respectively, p = 0.0005), more likely to be uninsured (55% vs. 37%, respectively, p = 0.001), and less likely to have a past history of depression (10% vs. 19%, respectively, p = 0.011). Many characteristics between the two groups (MRPV vs. non-MRPV) were similar: likelihood of patient being placed on a psychiatric hold; hospital charges; previous histories of psychiatric visits; and history of anxiety, bipolar disorder, or schizophrenia.

Conclusions

Methamphetamine may be related to a significant proportion (7.6%) of psychiatric ED visits. Furthermore, patients with methamphetamine-associated psychiatric visits are younger, have lower rates of depression, are more likely to be uninsured, and are less likely to have a substance abuse-related chief complaint than patients with non-methamphetamine-associated ED psychiatric visits.     

The Effect of Gynecologic Algorithm Pathways on Emergency Department Visit Times

Background

The use of multidisciplinary algorithmic pathways is one strategy to improve efficiency and quality of care in Emergency Departments (EDs). To this end, in the fall of 2005, we implemented algorithmic pathways for evaluation of ED patients with common gynecologic complaints.

Objectives

The goals of this initiative were to improve length of stay as a marker for operational efficiency and to reduce health care disparities by ensuring consistent management regimens for all patients.

Methods

A retrospective observational comparison study was performed through a review of consults in the year preceding and the year after implementation of the pathways. The length of stay was calculated based on time of initial triage until discharge. The length of stay from both groups was compared using an unpaired Student's t-test analysis.

Results

There was an 85-min decrease in the mean visit time between the pre-intervention group (108 patients, 610 min, SD 345.4) and the post-intervention group (105 patients, 525 min, SD 251.5), p = 0.04.

Conclusions

Algorithmic pathways had a positive impact on patient care as measured by the average amount of time our patients spent in the ED. Gynecologic care in the ED was standardized, and length of stay for patients with gynecologic complaints decreased. The implementation of algorithms resulted in more consistent care with earlier initiation of pertinent studies, while facilitating more rapid critical decision-making by providers from both departments. Further analysis is required to examine cost-effectiveness as well as patient safety and provider satisfaction issues.     

Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest

Background

Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.

Objective

We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.

Methods

Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.

Conclusion

ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.     

Hypotension is Uncommon in Patients Presenting to the Emergency Department with Non-traumatic Cardiac Tamponade

Background

Cardiac tamponade is a life-threatening disease in which hypotension is believed to be a common finding. Prior inpatient studies have described normotensive or hypertensive cases of tamponade; however, because the data were not collected from the Emergency Department (ED), the hemodynamic spectrum may differ from those presenting to the ED.

Objectives

We hypothesized that hypotension is uncommon in patients presenting to the ED with non-traumatic tamponade.

Methods

A retrospective chart review was conducted between January 2002 and December 2007 of patients presenting to our ED who were subsequently diagnosed with cardiac tamponade.

Results

A total of 34 patients were identified with a diagnosis of tamponade. The mean blood pressure on ED arrival was 131/79 mm Hg. Upon initial presentation to the ED, 35% (n = 12) of patients were hypertensive, 50% (n = 17) were normotensive, and 15% (n = 5) were hypotensive. Of the 5 patients who were hypotensive on ED arrival, only 2 (6% of all patients) remained hypotensive upon admission to the hospital and before a pericardiocentesis. An average of 995 mL of fluid was removed from the pericardium. The chief complaint for the majority of patients in tamponade was shortness of breath (70%); 59% were tachycardic in the ED, and 72% had cardiomegaly on chest X-ray study.

Conclusions

Hypotension is uncommon in patients presenting to the ED with non-traumatic cardiac tamponade. The majority of patients are normotensive or even hypertensive. Thus, the emergency physician should not exclude the diagnosis of tamponade even in light of normotension or hypertension.     

Victims of Bullying in the Emergency Department with Behavioral Issues

Background

Bullying has become one of the most significant school problems experienced by our children. Victims of bullying are prone to a variety of psychological and behavioral symptoms. We noted that many children referred to the Emergency Department (ED) with behavioral symptoms provided a history of bullying.

Objectives

To measure the prevalence of bullying in children referred to the ED for behavioral symptoms and to determine its association with psychiatric disorders.

Methods

A retrospective cohort study was conducted in an urban hospital, identifying children from 8 to 19 years of age who presented to the ED with behavioral symptoms. We reviewed the ED psychiatry notes to retrieve the report indicating whether these children were bullied and had previous psychiatric diagnoses. These children were classified into bullied and non-bullied groups.

Results

Over the study period, 591 children visited the ED with behavioral issues. Out of 591, 143 (24%) children reported bullying. More boys (100) than girls (43) reported bullying (p = 0.034). The mean age of children in the bullied group was 10.6 years (95% confidence interval 10.1–11.2). One hundred eleven (77.6%) children in the bullied group had a prior psychiatric diagnosis. Children in the bullied group were hospitalized significantly less than children in the non-bullied group (10/143 [7%] vs. 80/368 [18%]; p = 0.002).

Conclusion

The prevalence of bullying among the ED children with behavioral symptoms is substantial. Every fourth child with behavioral symptoms reported bullying. Four in five children who reported bullying had a prior diagnosis of “disorder of behavior.”     

The Outcomes of Emergency Pharmacist Participation during Acute Myocardial Infarction

Background

Current guidelines recommend door-to-balloon times of 90 min or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction (STEMI).

Objectives

To determine if a clinical pharmacist for the ED (EPh) is associated with decreased door/diagnosis-to-cardiac catheterization laboratory (CCL) time and decreased door-to-balloon time.

Methods

A retrospective observational cohort study of ED patients with STEMI requiring urgent cardiac catheterization was conducted. Blinded data collection included timing of ED and CCL arrival, diagnostic electrocardiogram (ECG), and balloon angioplasty. For cases diagnosed after ED arrival, diagnosis time was substituted for door time. Diagnosis was the time ST elevations were evident on serial ECG. EPh present and not-present groups were compared. During the study period there were two EPhs and presence was determined by their scheduled time in the ED. Univariate and multivariate analyses was used to detect differences.

Results

Multivariate analysis of 120 patients, controlled for CCL staff presence and arrival by pre-hospital services, determined that EPh presence is associated with a mean 13.1-min (95% confidence interval [CI] 6.5–21.9) and 11.5-min (95% CI 3.9–21.5) decrease in door/diagnosis-to-CCL and door-to-balloon times, respectively. Patients were more likely to achieve a door/diagnosis-to-CCL time ≤ 30 min (odds ratio [OR] 3.1, 95% CI 1.3–7.8) and ≤ 45 min (OR 2.9, 95% CI–1.0, 8.5) and a door-to-balloon time ≤ 90 min (OR 1.9, 95% CI 0.7–5.5) more likely when the EPh was present.

Conclusions

EPh presence during STEMI presentation to the ED is independently associated with a decrease in door/diagnosis-to-CCL and door-to-balloon times.     

Risk Factors Associated with Delayed Diagnosis of Acute Pulmonary Embolism

Background

Prompt diagnosis and treatment of acute pulmonary embolism (PE) is essential to reduce mortality. Risk factors for PE are well known, but factors associated with delayed diagnosis are less clear.

Objective

Our objective was to identify clinical factors associated with delayed diagnosis of patients with acute PE presenting to a tertiary-care emergency department (ED).

Methods

We studied 400 consecutive adults who presented to our ED with acute, symptomatic PE. All patients were diagnosed by computed tomography (CT) angiography. Early diagnosis was defined as CT diagnosis < 12 h from ED arrival, and delayed diagnosis as CT diagnosis > 12 h. Univariate and multiple logistic regression models were used to identify factors associated with delayed diagnosis. Odds ratios with 95% confidence intervals are reported.

Results

The median time from arrival to diagnosis was 2.4 h (interquartile range 1.4–7.6), and 73 (18.3%) patients had delayed diagnosis. Patients aged > 65 years and those with coronary artery disease or congestive heart failure had longer times from ED arrival to CT diagnosis, whereas patients with recent immobility had shorter times. Patients diagnosed > 12 h were older and had higher rates of morbid obesity and coronary artery disease, whereas patients diagnosed < 12 h had higher rates of tachycardia. In multiple regression modeling, tachycardia and recent immobility remained associated with early diagnosis, whereas morbid obesity remained associated with delayed diagnosis.

Conclusions

Older patients with cardiovascular comorbidities had longer times from ED arrival to CT diagnosis. Our data suggest that these patients represent more of a diagnostic challenge than those presenting with traditional risk factors for PE, such as tachycardia and recent immobilization. Physicians should consider these factors to diagnosis acute PE promptly in the ED.     

Are Oral Medications Effective in the Management of Acute Agitation?

Background

Current expert guidelines recommend treating agitation with oral medications instead of intramuscular medications if possible. Oral medications are sometimes believed to be inappropriate for the emergency department (ED) as they require patient cooperation and may have a slower onset of action. This review examined published literature for the efficacy of oral agents in agitation.Clinical question: Are oral medications effective at managing acute agitation?

Methods

Structured review of PubMed of articles in which the first timepoints of evaluation were < 24 hours (i.e., the typical timecourse in the ED).

Results

11 articles included for final analysis.

Conclusions/Clinical Bottom Line

Treatment with oral medications is as effective as intramuscular medications in rapidly reducing psychotic agitation in the ED. Their use is thought to pose less risk to both patient and ED staff and is less coercive. There is little to no evidence about the use of oral medications for ED patients with extreme agitation.     

Atypical presentations of dengue disease in the elderly visiting the ED

Objective

The objective was to compare the clinical characteristics of elderly and young adult patients with dengue in the emergency department (ED).

Methods

Demographic characteristics, clinical presentation, disease severity, laboratory characteristics, and outcomes were analyzed prospectively as a case-control study.

Results

Of the 193 adults with serologically confirmed dengue disease in 2007, 31 (16.1%) were elderly patients (aged ≥ 65) and 162 were young adults (aged < 65). More dengue hemorrhagic fever (12.9% vs 2.5%, P = .02), a longer ED stay (13.3 vs 8.6 hours, P = .004), a longer hospital stay (7.4 vs 3.4 days, P < .001), a higher Simplified Acute Physiology Score II in the ED (29.7 vs 17.4, P < .001), and a higher rate of at least 1 comorbidity (61.8 vs 22.8%, P < .001) were found in the elderly. However, the length of the intensive care unit stay (elderly 0.7 vs young adults 0.3 day, P = .47) and the 14-day mortality rate (0% vs 0.6%, P = 1.00) were similar. Of note, in terms of clinical presentations of dengue in the ED, there were more elderly patients with isolated fever (41.9% vs 17.9%, P = .003) and fewer with typical presentation (41.9% vs 75.9%, P = < .001) than there were young adults.

Conclusions

The present study found a higher number of atypical presentations, a longer hospitalization, and a higher degree of clinical illness in elderly patients with dengue.     

Frequent Emergency Department Visits are More Prevalent in Psychiatric,Alcohol Abuse,and Dual Diagnosis Conditions than in Chronic Viral Illnesses Such as Hepatitis and Human Immunodeficiency Virus

Background

Repeat users of Emergency Departments (ED), so-called “frequent visitors,” place a substantial burden on limited ED resources. The illness features of frequent visitors have not been well defined, though chronic medical and psychiatric illness and substance abuse are implicated.

Study Objectives

This study assessed whether chronic conditions such as hepatitis C (HCV) and human immunodeficiency virus (HIV) are more prevalent in frequent ED users compared to a viral condition with relatively less disability, hepatitis B (HBV). As a comparison, psychiatric complaints and alcohol abuse were also compared in frequent and non-frequent visitors.

Methods

All visits to a university ED in a particular calendar year were retrospectively reviewed. Frequent visitors were defined as those who made four or more visits. Presenting complaints and past medical history were examined for HCV, HIV, HBV, psychiatric complaints, and alcohol abuse.

Results

Frequent visitors accounted for 28% of all ED visits. HCV, HIV, and alcohol abuse were more prevalent in frequent visitors than non-frequent visitors. People with HBV comprised a small proportion of both groups. Frequent visitors with psychiatric complaints were more prevalent than those with HBV or alcohol abuse. Psychiatric history comorbid with alcohol abuse and HCV with alcohol abuse were more prevalent in frequent vs. non-frequent visitors.

Conclusion

Although chronic hepatitis and psychiatric complaints are both implicated in frequent ED visits, patients with psychiatric complaints present to the ED more often. Patients with a “dual diagnosis” of psychiatric condition and alcohol abuse are likely to be frequent visitors. This population should be targeted for creative intervention strategies, both within and outside of the emergency system, that comprehensively screen for symptomatology and integrate mental health treatment with substance abuse interventions.     

The bougie: an inexpensive lifesaving airway device

Background

“Bougies,” otherwise known as endotracheal tube introducers, remain preferred devices for the emergency physician when faced with a difficult airway. Bougies have high success rates for the prehospital provider and the first-time emergency department (ED) user, with few reported complications. Inexpensive, disposable models provide simple yet valuable tools in the challenging patient with an anterior airway or limited neck mobility.

Objectives

Use of the bougie is similar to standard endotracheal intubation. Correct placement is determined by feeling “clicks” as the device passes over the tracheal rings and a “hold up” when entering the distal airways.

Case Reports

Three recent cases from our ED are briefly reported, in which the bougie was invaluable in the management of the difficult airway. All patients had limited visualization of the glottis but were intubated successfully.

Conclusion

This article discusses three example cases, and then reviews the history of the bougie, placement technique, and current evidence for use.     

The most frequent ED patients carry insurance and a significant burden of disease

Study Objective

The objective of this study was to determine factors that impact emergency department (ED) utilization among the most frequent ED users.

Methods

This prospective observational study consisting of questionnaires was conducted in an urban ED with an annual census of 95 000 patients. A convenience sample of the top 1% of adult frequent users (≥ 9 ED visits in the previous 12 months) was enrolled from February 2009 to March 2010. Patients were excluded because of intoxication, altered mental status, or acute psychosis.

Results

A total of 115 patients were enrolled, with an average age of 44 years and median number of 22 ± 13 ED visits in the preceding 12 months. Seventy-eight percent of frequent users reported adequate health insurance coverage, and 75% reported one or more chronic medical conditions. Despite the high rates of insured patients, 75% identified the ED as their primary health care site. Half of the cohort had 2 or more hospital admissions over the past 12 months, of which 24% were patients with end-stage renal disease.

Conclusions

The top 1% of frequent users usually had adequate health insurance and primary care access but were burdened by chronic conditions and frequent hospital admissions. Such patients may require more extensive coordinated medical management to decrease ED utilization.     

Pitfalls in the Care of the Psychiatric Patient in the Emergency Department

Background

Care of the psychiatric patient in the Emergency Department (ED) is evolving. As with other disease states, there are a number of pitfalls that complicate the care of the psychiatric patient.

Objective

The purpose of this article is to update Emergency Physicians concerning the pitfalls in caring for the psychiatric patient, and possible solutions to deal with these pitfalls.

Discussion

The article will address the burden of the psychiatric patient, staff attitudes, medical clearance process, treatment of the agitated patient, suicidal patients, and admission decisions.

Conclusions

Alternative care resources, collaboration with Psychiatry, staff education, improvement in the medical clearance process, proper use of restraint and seclusion, and appropriate choice of medication for agitated patients can help avoid some of the top pitfalls in the care of the psychiatric patient in the ED.     

Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge

Background

Monitoring unscheduled return visits to the Emergency Department (ED) is useful to identify medical errors.

Objective

To investigate the differences between unscheduled return visit admissions (URVA) and unscheduled return visit no admissions (URVNA) after ED discharge.

Methods

From January 1, 2008 to March 31, 2008, URVA and URVNA patients who returned within 3 days after ED discharge were enrolled in the study. We compared the clinical characteristics, underlying diseases, ED crowding indicators, staff experience at the patient's first visit, and several other risk factors. We used multivariate logistic regression to evaluate differences between the two groups and to identify predictors of admission from unscheduled return visits.

Results

The unscheduled return visit rate was 3.1%. Of the 413 patients included, 147 patients (36%) were admitted, and had a mortality rate of 4.1%. The most common reason for the return visit was an illness-based factor (47.9%). Compared to URVNA patients, unscheduled return visit admissions had higher prevalence rates for old age, non-ambulatory status, high-grade triage, and underlying diseases (e.g., malignancy, diabetes mellitus, hypertension, coronary artery disease, heart failure, and chronic obstructive pulmonary disease). The independent predictors for URVA were: age ≥ 65 years (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.5); high-grade triage (adjusted OR 2.1, 95% CI 1.3–3.2); and doctor-based factors (adjusted OR 3.5, 95% CI 2.0–6.1). More advanced staff experience (p = 0.490) and ED crowding were not significant predictors (p = 0.498 for whole-day number of patients, p = 0.095 for whole-shift number of patients).

Conclusion

Old age, high-grade triage, and doctor-based factors were found to be significant predictors for URVA, whereas advanced staff experience and ED crowding were not.     

Using demand analysis and system status management for predicting ED attendances and rostering

Introduction

It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically.

Objectives

To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand.

Methods

Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients.

Results

The yearly ED attendances increased from 113 387 (2004) to 120 764 (2005) and to 125 773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays.

Conclusion

We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.