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 cost of waiting: Association of ED boarding with hospitalization costs

BackgroundEmergency Department (ED) boarding, the practice of holding patients in the ED after they have been admitted to the hospital due to unavailability of inpatient beds, is common and contributes to the public health crisis of ED crowding. Prior work has documented the harms of ED boarding on access and quality of care. Limited studies examine the relationship between ED boarding and an equally important domain of quality—the cost of care. This study evaluates the relationship between ED boarding, ED characteristics and risk-adjusted hospitalization costs utilizing national publicly-reported measures.MethodsWe conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear regression analysis to examine the association between ED boarding and Medicare spending per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation time, and ED patient volume.ResultsA total of 2903 hospitals were included in the analysis. ED boarding was significantly correlated with MSPB (r = 0.1774; p-value: < 0.0001). In multivariate regression, ED boarding was also positively associated with MSPB (Beta: 0.00015; p < 0.0001) after adjustment for other hospital level crowding indicators.ConclusionWe found a strong relationship between measures of ED crowding, including ED boarding, and risk-adjusted hospital spending. Future work should elucidate the mediators of this relationship. Policymakers and administrators should consider the financial harms of ED boarding when devising strategies to improve hospital care access and flow.     

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.     

The impact of overcrowding on the bacterial contamination of blood cultures in the ED

Objectives

This study aims to determine the risk factors associated with the bacterial contamination of blood cultures among adults visiting the emergency department (ED).

Methods

Clinical variables and medical records of adults with bacterial growth of blood cultures in the ED as well as the degree of ED crowding, between August 2007 and July 2008, were prospectively collected.

Results

Of the 11?491 adults who underwent blood culture sampling, the medical records of 558 (4.86%) eligible patients with bacterial growth in their blood cultures were analyzed. Most patients (366, or 3.19%) had true bacteremia, whereas 192 (1.67%) were regarded as contaminated. In multivariate analyses, ED overcrowding (scoring was based on a National Emergency Department Overcrowding Study [NEDOCS] score ≥100 points) was independently associated with blood culture contamination (odds ratio [OR], 1.58; P = .04). In contrast, other medical comorbidities, such as liver cirrhosis (OR, 0.31; P = .02), thrombocytopenia (<100?000/mm³; OR, 0.28; P = .002), or high serum levels of C-reactive protein (>100 mg/L; OR, 0.24; P < .001), were negatively associated with blood culture contamination. On further analysis of the 5 crowding categories as stratified by NEDOCS scores, which included not busy and busy (0-60 points), extremely busy but not overcrowded (60-100), overcrowded (100-140), severely overcrowded (140-180), and dangerously overcrowded (180-200), there was a strong correlation between blood culture contamination rates and the degrees of ED crowding (γ = 0.99, P < .001).

Conclusions

Emergency department overcrowding may have an adverse impact on the quality of clinical care, including increasing the risk of blood culture contamination.     

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.     

The inaccuracy of determining overcrowding status by using the National ED Overcrowding Study Tool

Background

Emergency department (ED) crowding has become more common, and perceptions of crowding vary among different health care providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings.

Objective

The objectives of this study are to determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high-volume ED and assess the reliability and consistency of different providers’ perceptions of ED crowding.

Material and methods

This was a 2-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay and number of patients who left without being seen were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The interrater and intrarater agreements of ED crowding were tested.

Results

In phase 1, the subject ED was determined to be overcrowded more than 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average length of stay and the number of left without being seen patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between health care providers was reached (κ = 0.5402, P < .0001). Test-retest reliability among providers was high (r = 0.8833, P = .0007). The strength of agreement between study groups and the NEDOCS was weak (κ = 0.3695, P < .001).

Conclusion

Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high-volume ED setting.     

Choosing wisely in the ED: The diagnostic cascade of needless medical testing in a two-level study

BackgroundThe diagnostic cascade in the emergency department (ED) has not been fully elucidated.AimTo inspect whether the usage of consulting medicine and imaging contributes to hospital outcomes. We also propose a theoretical model for better understanding the diagnostic cascade of needless medical testing.MethodsA two-level study was conducted. The first local phase was a retrospective archive study that was conducted between 2014 and 2017 in a tertiary hospital. We extracted the number of requested imaging and consultations for each patient, and main time lags were calculated. The second-phase (January–April 2018) was conducted on a national level. We examined 22 hospitals with the emphasis on five hospital outcomes: recurrent ED visits (within 24 h), median waiting time at the ED, rate of early discharge at the same day and day after and percentage of patients spending >4 h in the ED.ResultsA 5% upsurge in CT scans was observed (p = .032), and a significant increase was found in the number of consultations (14%, p = .002). On a national level, a linear regression model found that the proportion of patients discharged from the hospital on the same day and on the day after and the proportion of patients staying in the ED > 4 h predict ED recurrence visits within 24 h (p = .025; R² = 46.3%).ConclusionsUpsurge in resource usage in the ED leads to a diagnostic cascade of health consumption. Further study is necessary to examine the proposed model in a global scale.     

ED overcrowding is associated with an increased frequency of medication errors

Objectives

Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.

Methods

We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.

Results

A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's ρ = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.

Conclusions

We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.     

Rest myocardial perfusion imaging: a valuable tool in ED

BackgroundAcute chest pain is a frequent cause of emergency department (ED) visits. Rest myocardial perfusion imaging (RMPI) during or immediately after an episode of chest pain can provide diagnostic and prognostic information concerning acute coronary syndromes.AimOur purpose was to evaluate the RMPI score in risk stratification of chest pain suspected to be of cardiac ischemic origin and negative troponin assessment.MethodsNinety-six patients without an ongoing myocardial infarction or a history of coronary artery disease and in whom RMPI was performed in the ED because of chest pain suspected to be related with acute myocardial ischemia were included.Follow-up was performed considering the occurrence of death, myocardial infarction, or revascularization in a 12-month period admission.ResultsFourteen (14.6%) patients had events. According to survival analysis, the variables related with events were a history of angina (hazard ratio [HR], 4.5; P ≤ .01), an ischemic electrocardiogram (HR, 4.0; P ≤ .01), the abnormal RMPI (HR, 11.4; P ≤ .05), and the RMPI score (HR, 1.1; P ≤ .0001). When the variables of interest were forced into a multivariate model, the χ² associated with the model that includes clinical and electrocardiogram information was 16.3 (P ≤ .005) and in the model that also includes RMPI score, it was 23.0 (P ≤ .0005).ConclusionIn a low- to intermediate-risk group of patients with suspected acute myocardial ischemia, RMPI gives not only diagnostic information but adds prognostic value to the traditional ED risk stratification tools.     

Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital

ObjectiveDescribe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital.MethodsA retrospective longitudinal registry study based on all ED visits with adult patients during 2009–2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician’s ratios) were extracted from the hospital’s electronic health record. Non-parametric analyses were conducted.ResultsThe proportion of unstable patients (triage level 1–2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8–9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18–79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3–5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5–7.9) compared to 15.5 min/year (95% CI: 15.2–15.8) for those being admitted.ConclusionFewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.     

Methods of laceration closure in the ED: A national perspective

BackgroundLaceration closure is one of the most common procedures performed in the emergency department (ED). While sutures and staples have been the traditional wound closure device, topical skin adhesives (TSA) were introduced in the United States 20 years ago as a non-invasive alternative for simple, low-tension wounds. We determined which closure devices were used to close ED lacerations and explored patient and provider characteristics associated with choosing TSA. We also tested the hypothesis that use of TSA would be associated with shorter ED length of stay (LOS) than sutures/staples.MethodsWe extracted demographic and clinical data on all patients with a laceration from the publicly available website of the National Hospital Ambulatory Medical Care Survey for the years 2012–2015. This database is provided by the National Center for Health Statistics of the CDC. Based on weighted sampling, national estimates are made for all ED visits in the US. We determined the association between patient characteristics (age, sex, insurance type, geographic location, laceration site, type of ED provider) and use of TSA. We also compared ED LOS between patients whose wounds were closed with TSA or sutures/staples using the t-test and a linear regression model.ResultsThere were an estimated 540 million ED patient visits, and 26.1 million patients (4.8%) had at least one laceration. Of the 15.4 million patients with a single laceration, 9.2 million were closed with either sutures/staples (7.2 million), TSA (1.5 million), or both (0.5 million). Mean (SE) age was 30 (1) years, 63% were male and 42% were under age 18 years. Lacerations were on the upper extremity (42%), face (30%), lower extremity (14%) and scalp (8%). Of patients with a single laceration closed with either TSA or sutures/staples, use of TSA did not differ by age, sex, year, geographic location or wound site. ED LOS was significantly shorter in patients whose wounds were closed with TSA (101 ± 7 vs. 136 ± 4 min; P < 0.001). After adjusting for potential confounding variables, use of TSA was associated with a 26 (95% CI 9–44) minute shorter ED LOS (P = 0.004) then sutures/staples.ConclusionTopical skin adhesives are used in about 1 of 4 wound closures in the ED. Use of TSA did not differ based on demographic characteristics or wound site. Use of TSA is associated with a shorter ED LOS than sutures/staples.     

ED use by older adults attempting suicide

Objective

The objective of this study was to describe patterns of older adult patient visits to emergency departments (EDs) for self-harm and suicide-related injuries.

Methods

A retrospective, secondary data analysis of the Nationwide Emergency Department Sample was conducted. Nationally representative estimates of patient visits by older adults attempting suicide were calculated using available sampling weights. Population estimates were calculated using estimates from the US Census Bureau.

Results

Findings suggest that 22 444 ED patient visits were made by adults aged 65 years and older for suicide-related injuries, representing an estimated population rate of 63 ED patient visits per 100 000 adults aged 65 years and older, with nearly half of all visits involving substance use. Total ED and hospital charges exceeded $353.9 million.

Conclusions

Effort is needed to better integrate and deliver suicide screening and support services in the ED, while also connecting at-risk older adults with mental health services before and after the ED encounter.     

Predictors of patient length of stay in 9 emergency departments

Objectives

Prolonged emergency department (ED) length of stay (LOS) is linked to adverse outcomes, decreased patient satisfaction, and ED crowding. This multicenter study identified factors associated with increased LOS.

Methods

This retrospective study included 9 EDs from across the United States. Emergency department daily operational metrics were collected from calendar year 2009. A multivariable linear population average model was used with log-transformed LOS as the dependent variable to identify which ED operational variables are predictors of LOS for ED discharged, admitted, and overall ED patient categories.

Results

Annual ED census ranged from 43 000 to 101 000 patients. The number of ED treatment beds ranged from 27 to 95. Median overall LOS for all sites was 5.4 hours. Daily percentage of admitted patients was found to be a significant predictor of discharged and admitted patient LOS. Higher daily percentage of discharged and eloped patients, more hours on ambulance diversion, and weekday (vs weekend) of patient presentation were significantly associated with prolonged LOS for discharged and admitted patients (P < .05). For each percentage of increase in discharged patients, there was a 1% associated decrease in overall LOS, whereas each percentage of increase in eloped patients was associated with a 1.2% increase in LOS.

Conclusions

Length of stay was increased on days with higher percentage daily admissions, higher elopements, higher periods of ambulance diversion, and during weekdays, whereas LOS was decreased on days with higher numbers of discharges and weekends. This is the first study to demonstrate this association across a broad group of hospitals.     

Limitations of Current Rehabilitation Practices in Pediatric Oncology: Implications for Improving Comprehensive Clinical Care

ObjectiveTo identify the proportion of hospitals/clinics in the United States (US) that have a comprehensive pediatric oncology rehabilitation program and characterize current practices.DesignCross-sectional survey of rehabilitation providers in the US and internationally.SettingElectronic or telephone survey.ParticipantsRehabilitation or supportive care practitioners employed at a hospital, outpatient clinic, or medical university (N=231).InterventionsElectronic and telephone survey. The full electronic survey contained 39 questions, provided opportunities for open-ended responses, and covered 3 main categories specific to pediatric cancer rehabilitation: service delivery, rehabilitation program practices, and education/training. The short telephone survey included 4 questions from the full survey and was designed to answer the primary study objective.Main Outcome MeasuresProportion of hospitals/clinics with a comprehensive pediatric oncology rehabilitation program.ResultsThis cohort includes rehabilitation providers from 191 hospitals/clinics, 49 states within the US, and 5 countries outside of the US. Of hospitals/clinics represented from the full and short survey, 145 (76%) do not have an established pediatric oncology rehabilitation program. Nearly half of full survey respondents reported no knowledge of the prospective surveillance model, and 65% reported no education was provided to them regarding pediatric cancer rehabilitation. Qualitative survey responses fell into 3 major themes: variability in approach to rehabilitation service delivery, program gaps, and need for additional educational opportunities.ConclusionsThere is evidence of limited comprehensive rehabilitation programming for children with cancer as demonstrated by the lack of programs with coordinated interdisciplinary care, variability in long-term follow-up, and absence of education and training. Research is needed to support the development and implementation of comprehensive pediatric oncology rehabilitation programs.     

One-way-street revisited: Streamlined admission of critically-ill trauma patients

IntroductionEmergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding.Materials & methodsThis was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing.ResultsA total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013–2014) to recent data (2015–2018).ConclusionThis study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.     

Work-related stressors and occurrence of adverse events in an ED

ObjectiveThe purpose of this study was to investigate the relationship between 12 work-related stressors and the occurrence of adverse events in an emergency department (ED).MethodsNurses and physicians, working in an ED at a Danish regional hospital, filled out a questionnaire on occurrence and emotional impact of 12 work-related stressors after each shift during a 4-week period. The questionnaire also instructed the participants to describe any adverse events that they were involved in during the shift.ResultsTwo hundred fourteen adverse events were reported during the 979 studied shifts. During the same period, only 27 adverse events were reported to the mandatory national reporting system, and only 10 of these were duplicates. A high variability of stressors and emotional impact among the different groups of participants was found. Linear regression analysis showed an association between involvement in adverse events and the occurrence and emotional impact of stressors across groups, whereas no significant association was found for age, seniority, shift type, or length.ConclusionThe study showed an association between the occurrence and impact of 12 work-related stressors and involvement in adverse events across the groups of participants. Furthermore, the study showed that most adverse events were not reported to the mandatory national reporting system.     

Prevalence of non-convulsive seizure and other electroencephalographic abnormalities in ED patients with altered mental status

Four to ten percent of patients evaluated in emergency departments (ED) present with altered mental status (AMS). The prevalence of non-convulsive seizure (NCS) and other electroencephalographic (EEG) abnormalities in this population is unknown.ObjectivesTo identify the prevalence of NCS and other EEG abnormalities in ED patients with AMS.MethodsA prospective observational study at 2 urban ED. Inclusion: patients ≥ 13 years old with AMS. Exclusion: An easily correctable cause of AMS (e.g. hypoglycemia). A 30-minute standard 21-electrode EEG was performed on each subject upon presentation. Outcome: prevalence of EEG abnormalities interpreted by a board-certified epileptologist. EEGs were later reviewed by 2 blinded epileptologists. Inter-rater agreement (IRA) of the blinded EEG interpretations is summarized with κ. A multiple logistic regression model was constructed to identify variables that could predict the outcome.ResultsTwo hundred fifty-nine patients were enrolled (median age: 60, 54% female). Overall, 202/259 of EEGs were interpreted as abnormal (78%, 95% confidence interval [CI], 73-83%). The most common abnormality was background slowing (58%, 95% CI, 52-68%) indicating underlying encephalopathy. NCS (including non-convulsive status epilepticus [NCSE]) was detected in 5% (95% CI, 3-8%) of patients. The regression analysis predicting EEG abnormality showed a highly significant effect of age (P < .001, adjusted odds ratio 1.66 [95% CI, 1.36-2.02] per 10-year age increment). IRA for EEG interpretations was modest (κ: 0.45, 95% CI, 0.36-0.54).ConclusionsThe prevalence of EEG abnormalities in ED patients with undifferentiated AMS is significant. ED physicians should consider EEG in the evaluation of patients with AMS and a high suspicion of NCS/NCSE.     

Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department

BackgroundEmergency Department (ED) patients who leave without being seen (LWBS) are associated with adverse safety and medico-legal consequences. While LWBS risk has been previously tied to demographic and acuity related factors, there is limited research examining crowding-related risk in the pediatric setting. The primary objective of this study was to determine the association between LWBS risk and crowding, using the National Emergency Department Overcrowding Score (NEDOCS) and occupancy rate as crowding metrics.MethodsWe performed a retrospective observational study on electronic health record (EHR) data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period. NEDOCS and occupancy rate were calculated for 15-min windows and matched to patient arrival time. We leveraged multiple logistic regression analyses to demonstrate the relationship between patientlevel LWBS risk and each crowding metric, controlling for characteristics drawn from the pre-arrival state. We performed a chi-squared test to determine whether a difference existed between the receiver operating characteristic (ROC) curves in the two models. Finally, we executed a dominance analysis using McFadden's pseudo-R 2 to determine the relative importance of each crowding metric in the models.ResultsA total of 54,890 patient encounters were studied, 1.22% of whom LWBS. The odds ratio for LWBS risk was 1.30 (95% CI 1.27–1.33) per 10-point increase in NEDOCS and 1.23 (95% CI 1.21–1.25). per 10% increase in occupancy rate. Area under the curve (AUC) was 86.9% for the NEDOCS model and 86.7% for the occupancy rate model. There was no statistically significant difference between the AUCs of the two models (p-value 0.27). Dominance analysis revealed that in each model, the most important variable studied was its respective crowding metric; NEDOCS accounted for 55.6% and occupancy rate accounted for 53.9% of predicted variance in LWBS.ConclusionNot only was ED overcrowding positively and significantly associated with individual LWBS risk, but it was the single most important factor that determined a patient's likelihood of LWBS in the pediatric ED. Because occupancy rate and NEDOCS are available in real time, each could serve as a monitor for individual LWBS risk in the pediatric ED.     

Differential impacts of inappropriate empirical therapy on ED patients with Staphylococcus aureus and streptococci bacteremia

BackgroundStaphylococcus aureus (S. aureus) and streptococci are leading Gram-positive pathogens causing community-onset bacteremia. The comparisons of initial presentations and impacts of inappropriate empirical antimicrobial therapy (EAT) on clinical outcomes between the two pathogens are lacking.MethodsIn a 6-year cohort study, adult patients with community-onset monomicrobial S. aureus or streptococci bacteremia in the emergency department (ED) were studied. Clinical variables were collected retrospectively from medical records; the primary outcome was 4-week mortality after ED arrival. The Cox regression model was studied for effects of inappropriate EAT on 4-week mortality, after adjustment of independent predictors of 4-week mortality recognized by the multivariate regression model.ResultsA difference of clinical manifestations between S. aureus (291 patients) and streptococci (223) bacteremia was exhibited, in terms of bacteremia sources and comorbidity types, but bacteremia and comorbidity severity at ED arrival were similar. Furthermore, a longer period of the time-to-defervescence and hospitalization as well as more frequencies of septic metastasis were disclosed in S. aureus bacteremia, compared to streptococcal bacteremia. Of note, a significant impact (adjusted odds ratio [ORa], 2.23; 95% confidence interval [CI], 1.25–3.96) of inappropriate EAT on 4-week mortality was evidenced in S. aureus bacteremia, but not in streptococcal bacteremia (ORa, 2.88; 95% CI, 0.85–9.86).ConclusionsFor adults having community-onset monomicrobial bacteremia, the similarity of bacteremia and comorbidity severity at ED arrivals were observed between causative microorganisms of S. aureus and streptococci, but a crucial impact of inappropriate EAT on short-term mortality was only observed in S. aureus.     

Determination of difficult intubation in the ED

Objective

The aim of this study is to determine the predictors of difficult intubation in the emergency setting.

Methods

This prospective observational clinical study was conducted in the emergency department (ED) of a University Hospital with an annually census of 50 000 visits from May 2005 to May 2007. All patients requiring intubation in the ED were included into the study. During the study period, same airway management protocol was used all intubations. The study form included patient's demographic and variables according to intubation such as the Cormack-Lehane grade, modified LEMON score, Glasgow Coma Scale score, success rate, and associated complications.

Results

A total of 366 patients were included in the study. The mean age of the study patients was 46.8 ± 22.8, and 68.6% (n = 251) of them were male. A total of 86 (23.5%) patients were classified in the difficult intubation group and 280 (76.5%) patients in easy intubation group. Logistic regression analysis performed by the variables found to be significant in the univariate analysis revealed thyroid-to-hyoid distance less than 2 fingers (odds ratio, 3.34; 95% confidence interval, 1.35-8.27; P = .009) as an independent factor complicating the intubation. Cormack and Lehane classification was strongly related to difficult intubation. Intubation was more difficult from grade 1 to 4 (11% vs 25.2% vs 34% vs 81.8%, respectively; P = .000).

Conclusions

The thyroid-to-hyoid distance less than 2 fingers is the only independent variable in predicting difficult intubation. Mallampati classification is not a useful tool in classifying the difficult intubation in the ED that the “LEMON” acrostic can be modified to “LEON”.