Failure of vital sign normalization is more strongly associated than single measures with mortality and outcomes

BackgroundModified Early Warning Systems (MEWS) scores offer proxies for morbidity and mortality that are easily acquired, but there are limited data on what changing MEWS scores within the ED indicate. We examined the correlation of changing MEWS scores during resuscitation in the ED and in-hospital morbidity and mortality.MethodsWe conducted a retrospective analysis on medical ED patients with simplified MEWS scores (without urine output or mental status) admitted to a single academic tertiary care center over one year. Triage-to-Last delta MEWS score and Triage-to-Max delta MEWS scores were calculated and correlated to in-hospital mortality, ICU admission, length of stay (LOS) and diagnosis of sepsis.ResultsOur analysis included 8322 ED patients with an ICU admission rate of 17% and a mortality rate of 2%. Every point of worsened MEWS after triage was more strongly associated with all-cause mortality (OR 2.41, 95% CI 1.96–2.97) than triage MEWS alone (OR 1.33, 95% CI 1.23–1.44; p < 0.001). Likewise, each point of worsened MEWS was associated with increased odds of ICU admission (Triage-to-Last: OR 2.12, 95% CI 1.92–2.33 and Triage-to-Max: OR 1.52, 95% CI 1.45–1.60, respectively). Among patients with suspected infection, similar associations are found.ConclusionsDynamic vital signs in the emergency department, as categorized by delta MEWS, and failure to normalize abnormalities, were associated with increased mortality, ICU admission, LOS, and the diagnosis of sepsis. Our results suggest that MEWS scores that do not normalize, from triage onward, are more strongly associated with outcome than any single score.     

Prognostic accuracy of qSOFA at triage in patients with suspected infection in a Brazilian emergency department

ObjectiveTo evaluate the prognostic accuracy of qSOFA for predicting in-hospital mortality among patients with suspected infection presenting to the ED of a public tertiary hospital in Brazil.MethodsWe performed a retrospective cohort study of consecutive adult patients (age ≥ 18 years) with suspected infection who presented to an academic tertiary ED in Porto Alegre (Southern Brazil) during an 18-month period. The qSOFA was calculated by using information collected at triage and patients were followed throughout hospitalization for the primary outcome of in-hospital mortality. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios with corresponding 95% CIs were calculated for the qSOFA and qSOFA65.ResultsA total of 7523 ED visits of patients with suspected infection in which an intravenous antibiotic was administered within 24 h were included, which resulted in 908 in-hospital deaths (12.1%). There were 690 (9.2%) patients whose triage qSOFA was ≥2 points. When such cutoff was used, the sensitivity for in-hospital death was 24.6% (95% CI 21.8 to 27.4%) and the specificity was 92.9% (95% CI 92.3% to 93.5%). The sensitivity increased to 67.4% (95% CI 64.2% to 70.3%) when a cutoff of ≥1 was tested, but the specificity decreased to 55.3% (95% CI 54.1% to 56.5%). Using a cutoff of ≥2, the qSOFA65 had a sensitivity of 51.0% (95% CI 47.7% to 54.3%) and a specificity of 75.7% (95% CI 74.6% to 76.7%).ConclusionsThe qSOFA score yielded very low sensitivity in predicting in-hospital mortality. Emergency physicians or ED triage nurses in low-to-middle income countries should not be using qSOFA or qSOFA65 as “rule-out” screening tools in the initial evaluation of patients with suspected infection.     

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.     

Impact of a qSOFA-based triage procedure on antibiotic timing in ED patients with sepsis: A prospective interventional study

BackgroundIt has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis.MethodsIn this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥ 2).ResultsA total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥ 2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%–21.7%) and 98.8% (95% CI, 97.0%–99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [−0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference − 2.9%, 95% CI [−13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%–128.3%), with a median number of 157 ED visits per day (IQR, 147–169).ConclusionsA qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection.Trial registration (ClinicalTrials.gov): NCT03299894.     

National trends in mental health-related emergency department visits by children and adults, 2009–2015

ObjectivesExamine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits.MethodsRetrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis.ResultsMental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15–64 year-olds and nearly 9% by 10–14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6–5.3) of all pediatric and 11.1% (95% CI 11.0–11.3) of adult ED treatment hours.ConclusionsMental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.     

Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States

ObjectivesThe objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP) in the ED.MethodsWe conducted a secondary analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2014–2015). Adults (age ≥18 years) who presented to the ED with a reason for visit or primary diagnosis of LBP were included in the final study sample. Patient visits were categorized into two groups based on whether they received opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. The primary outcome measure was ED LOS, which was log-transformed (as ED LOS was not normally distributed) for analysis. A multivariable linear regression analysis was used to evaluate the association between opioid use and ED LOS.ResultsThe study sample consisted of a national estimate of approximately 8.6 million ED visits for LBP (during 2014–2015), of which 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 min, respectively; p < 0.001). After adjusting for confounders in the multivariable analysis, patient visits that received opioids had a significantly longer ED LOS (coefficient 0.25; 95% CI 0.11 to 0.38; p < 0.001).ConclusionsIn a nationally representative sample of patient visits to ED due to LBP in the US, use of opioids in the ED was associated with an increased ED LOS.     

Association of triage hypothermia with in-hospital mortality among patients in the emergency department with suspected sepsis

PurposeTo identify if triage hypothermia (<36.0 °C) among emergency department (ED) encounters with sepsis are independently associated with mortality.MethodsWe analyzed data from a multi-stage probability sample survey of visits to United States EDs between 2007 and 2015, using two inclusion approaches: an explicit definition based on diagnosis codes for sepsis and a severe sepsis definition, combining evidence of infection with organ dysfunction. We used multivariable regression to determine an association between hypothermia and in-hospital mortality.ResultsOf 1.2 billion ED encounters (95% confidence interval [CI] 1.0–1.3 billion), 3.1 million (95% CI 2.7–3.5 million) met the explicit sepsis definition; 7.4% (95% CI 75.2–9.7%) had triage hypothermia. The adjusted odds ratio (aOR) for hypothermia for in-hospital mortality was 6.82 (95% CI 3.08–15.22). The severe sepsis definition identified 3.5 million (95% 3.1–4.0 million) encounters; 30.3% (95% CI 25.0–34.6%) had triage hypothermia. The aOR for hypothermia with mortality was 4.08 (95% CI 2.09–7.95). Depending on sepsis definition, 78.1–84.4% had other systemic inflammatory response syndrome vital sign abnormalities.ConclusionUp to one in three patients with sepsis have triage hypothermia, which is independently associated with mortality. 10–20% of patients with hypothermic sepsis do not have other vital sign abnormalities.     

The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest Pain

Objectives: While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin). Methods: A retrospective analysis was performed for patients ≥30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures. Results: Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0). Conclusions: There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non–ACS-related chest pain syndrome.     

Emergency Severity Index as a predictor of in-hospital mortality in suspected sepsis patients in the emergency department

ObjectivesTo demonstrate the accuracy, sensitivity, and specificity of the Emergency Severity Index (ESI), quick Sepsis-related Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) criteria, and National Early Warning Score (NEWS) for predicting in-hospital mortality and intensive care unit (ICU) admission in suspected sepsis patients.MethodsA retrospective cohort study conducted at a tertiary care hospital, Thailand. Suspected sepsis was defined by a combination of (1) hemoculture collection and (2) the initiation of intravenous antibiotics therapy during the emergency department (ED) visit. The accuracy of each scoring system for predicting in-hospital mortality and ICU admission was analyzed.ResultsA total of 8177 patients (median age: 62 years, 52.3% men) were enrolled in the study, 509 (6.2%) of whom died and 1810 (22.1%) of whom were admitted to the ICU. The ESI and NEWS had comparable accuracy for predicting in-hospital mortality (AUC of 0.70, 95% confidence interval [CI] 0.68 to 0.73 and AUC of 0.73, 95% CI 0.70 to 0.75) and ICU admission (AUC of 0.75, 95% CI 0.74 to 0.76 and AUC of 0.74, 95% CI 0.72 to 0.75). The ESI level 1–2 had the highest sensitivity for predicting in-hospital mortality (96.7%), and qSOFA ≥2 had the highest specificity (86.6%).ConclusionThe ESI was accurate and had the highest sensitivity for predicting in-hospital mortality and ICU admission in suspected sepsis patients in the ED. This confirms that the ESI is useful in both ED triage and predicting adverse outcomes in these patients.     

Denver ED Trauma Organ Failure Score predicts healthcare resource utilization in adult trauma patients

BackgroundEarly identification of trauma patients who need specialized healthcare resources may facilitate goal-directed resuscitation and effective secondary triage.ObjectiveTo estimate associations between Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score and healthcare resource utilization.MethodsRetrospective study of adult trauma patients at Denver Health Medical Center. The outcome was resource utilization including: intensive care unit (ICU) length of stay (LOS), hospital LOS, procedures, and costs. Multivariable regression analyses were used to estimate associations between moderate- or high-risk patients, as determined by the Denver ED TOF Score, and healthcare resource utilization.ResultsWe included 3000 patients with a median age of 42 (IQR 27–56) years, 71% male, median injury severity score 9 (IQR 5–16), and 83% blunt mechanism. Among the cohort, 1379 patients (46%) were admitted to the ICU and 122 (4%) died. The adjusted relative risk for high- and moderate-risk as compared to low risk for number of procedures performed was 2.31 (95% CI 2.07–2.57) and 1.80 (95% CI 1.59–2.03) respectively; ICU LOS was 2.87 (95% CI 2.70–3.05) and 1.71 (95% CI 1.60–1.83) respectively; hospital LOS was 3.33 (95% CI 3.21–3.45) and 1.97 (95% CI 1.90–2.05) respectively. The adjusted geometric mean for high-, moderate-, and low-risk for costs was $48,881 (95% CI $43,799–$54,552), $27,890 (95% CI $25,460–$30,551), and $12,983 (95% CI $12,493–$13,492), respectively.ConclusionsThe Denver ED TOF Score predicts healthcare resource utilization, and is a useful bedside tool to identify patients early after injury that are likely to require significant healthcare resources and specialized trauma care.     

Association between adopting emergency department crowding interventions and emergency departments' core performance measures

ObjectivesTo estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures.MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model.ResultsBetween 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75–0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76–0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41–0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73–0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79–0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35–0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57–0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64–0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72–0.98, P < .05) are associated with decrease in the odds of a patient LWBS.ConclusionsMajority of interventions did not significantly associated with ED' core performance measures.     

Racial/ethnic disparities in emergency department wait times in the United States, 2013–2017

BackgroundPrevious research shows that Black and Hispanic patients have longer ED wait times than White patients, but these data do not reflect recent changes such as the Affordable Care Act. In addition, previous research does not account for the non-normal distribution of wait times, wherein a sizable subgroup of patients seen promptly and those not seen promptly experience long wait times.MethodsWe utilized National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets (2013–2017) to examine mean ED wait time comparing visits by Black, Hispanic, and Asian patients to White patients. Using a two-part regression model, we adjusted for patient, hospital, and health system factors, and estimated differences, for each of five triage levels, in (a) likelihood of waiting at least 5 min and (b) difference in wait time among those not seen promptly.ResultsOur cohort included 38,800 White, 14,838 Black, 10,619 Hispanic, and 1257 Asian patient visits. Black (triage level 3) and Hispanic (triage levels 3 and 4) patients had longer mean wait times than White patients. Adjusted likelihood of not being seen promptly was lower among Blacks (triage levels 3, 4 and 5), Hispanics (triage level 5) and Asians (triage level 5) compared to Whites. Among those waiting at least 5 min, adjusted wait time was longer among Blacks in triage level 3 (5.2 min, 95% CI, 1.3 to 9.0) and level 4 (2.5 min, 95% CI, 0.2 to 4.9), Hispanics in triage level 4 (4.7 min, 95% CI, 1.7 to 7.7) and Asians in triage level 5 (16.3 min, 95% CI, 0.6 to 31.9) compared to Whites.ConclusionsMinority patients were less likely to wait to be seen, but waited longer if not seen promptly. These data exhibit that ED wait time disparities persist for African American and Hispanic patients and extend this observation to Asian patients.     

Boarding Inpatients in the Emergency Department Increases Discharged Patient Length of Stay

Background

Boarding of inpatients in the Emergency Department (ED) has been widely recognized as a major contributor to ED crowding and a cause of adverse outcomes. We hypothesize that these deleterious effects extend to those patients who are discharged from the ED by increasing their length of stay (LOS).

Study Objectives

This study investigates the impact of boarding inpatients on the ED LOS of discharged patients.

Methods

This retrospective, observational, cohort study investigated the association between ED boarder burden and discharged patient LOS over a 3-year period in an urban, academic tertiary care ED. Median ED LOS of 179,840 discharged patients was calculated for each quartile of the boarder burden at time of arrival, and Spearman correlation coefficients were used to summarize the relationship. Subgroup analyses were conducted, stratified by patient acuity defined by triage designation, and hour of arrival.

Results

Overall median discharged patient ED LOS increased by boarder burden quartile (205 [95% confidence interval (CI) 203–207], 215 [95% CI 214–217], 221 [95% CI 219–223], and 221 [95% CI 219–223] min, respectively), with a Spearman correlation of 0.25 between daily total boarder burden hours and median LOS. When stratified by patient acuity and hour of arrival (11:00 a.m.–11:00 p.m.), LOS of medium-acuity patients increased significantly by boarder burden quartile (252 [95% CI 247–255], 271 [95% CI 267–275], 285 [95% CI 95% CI 278–289], and 309 [95% CI 305–315] min, respectively) with a Spearman correlation of 0.18.

Conclusion

In this retrospective study, increasing boarder burden was associated with increasing LOS of patients discharged from the ED, with the greatest effect between 11:00 a.m. and 11:00 p.m. on medium-acuity patients. This relationship between LOS and ED capacity limitation by inpatient boarders has important implications, as ED and hospital leadership increasingly focus on ED LOS as a measure of efficiency and throughput.     

The effects of emergency department crowding on triage and hospital admission decisions

BackgroundEmergency department (ED) crowding is a recognized issue and it has been suggested that it can affect clinician decision-making.ObjectivesOur objective was to determine whether ED census was associated with changes in triage or disposition decisions made by ED nurses and physicians.MethodsWe performed a retrospective study using one year of data obtained from a US academic center ED (65,065 patient encounters after cleaning). Using a cumulative logit model, we investigated the association between a patient's acuity group (low, medium, and high) and ED census at triage time. We also used multivariate logistic regression to investigate the association between the disposition decision for a patient (admit or discharge) and the ED census at the disposition decision time. In both studies, control variables included census, age, gender, race, place of treatment, chief complaint, and certain interaction terms.ResultsWe found statistically significant correlation between ED census and triage/disposition decisions. For each additional patient in the ED, the odds of being assigned a high acuity versus medium or low acuity at triage is 1.011 times higher (95% confidence interval [CI] for Odds Ratio [OR] = [1.009,1.012]), and the odds of being assigned medium or high acuity versus low acuity at triage is 1.009 times higher (95% CI for OR = [1.008,1.010]). Similarly, the odds of being admitted versus discharged increases by 1.007 times (95% CI for OR = [1.006,1.008]) per additional patient in the ED at the time of disposition decision.ConclusionIncreased ED occupancy was found to be associated with more patients being classified as higher acuity as well as higher hospital admission rates. As an example, for a commonly observed patient category, our model predicts that as the ED occupancy increases from 25 to 75 patients, the probability of a patient being triaged as high acuity increases by about 50% and the probability of a patient being categorized as admit increases by around 25%.     

Emergency department care for patients with mental health problems,a longitudinal registry study and a before and after intervention study

ObjectiveTo describe the numbers and length of stay (LOS) of patients with mental health (MH) problems at a Dutch emergency department (ED) and the effect of a psychiatric intervention team (PIT) on patient flow.MethodsA longitudinal design was used to assess number of MH presentations and LOS during a 3-year period (2014–2016). In 2017, we introduced a PIT during ED peak hours, to reduce LOS for patients with MH problems. We evaluate the effects of the PIT on patients’ LOS with an 18-month before and after intervention study (2017–2018).ResultsTotal number of ED presentations increased with 4%. Total number of MH presentations increased with 23% from 2014 to 2016. LOS increased by 28 min (95 min vs. 123 min) for all presentations, while not changing for MH presentations (2014: 195 min, interquartile range (IQR) 120–293 and 2016: 190 min, IQR 116–296). In the before and after intervention study, number of MH presentations increased with 36% while LOS decreased with 46 min (p < 0.001).ConclusionsThe number of MH presentations increased over the three years while LOS remained similar. In the before and after intervention study, number of presentations increased even more while LOS decreased significantly. Specialist psychiatric input reduces ED LOS.     

The use of mechanical ventilation in the ED

Objectives

Although EDs are responsible for the initial care of critically ill patients and the amount of critical care provided in the ED is increasing, there are few data examining mechanical ventilation (MV) in the ED. In addition, characteristics of ED-based ventilation may affect planning for ventilator shortages during pandemic influenza or bioterrorist events. The study examined the epidemiology of MV in US EDs, including demographic, clinical, and hospital characteristics; indications for MV; ED length of stay (LOS); and in-hospital mortality.

Methods

This study was a retrospective review of the 1993 to 2007 National Hospital Ambulatory Medical Care Survey ED data sets. Ventilated patients were compared with ED patients admitted to the intensive care unit (ICU) and to all other ED visits.

Results

There were 3.6 million ED MV visits (95% confidence interval [CI], 3.2-4.0 million) over the study period. Sex, age, race, and payment source were similar for mechanically ventilated and ICU patients (P > .05 for all). Approximately 12.5% of ventilated patients underwent cardiopulmonary resuscitation compared with 1.7% of ICU admissions and 0.2% of all other ED visits (P < .0001). Accordingly, in-hospital mortality was significantly higher for ventilated patients (24%; 95% CI, 13.1%-34.9%) than both comparison groups (9.3% and 2.5%, respectively). Median LOS for ventilated patients was 197 minutes (interquartile range, 112-313 minutes) compared with 224 minutes for ICU admissions and 140 minutes for all other ED visits.

Conclusions

Patients undergoing ED MV have particularly high in-hospital mortality rates, but their ED LOS is sufficient for implementation of evidence-based ventilator interventions.     

Two-step predictive model for early detection of emergency department patients with prolonged stay and its management implications

ObjectiveTo develop a novel model for predicting Emergency Department (ED) prolonged length of stay (LOS) patients upon triage completion, and further investigate the benefit of a targeted intervention for patients with prolonged ED LOS.Materials and methodsA two-step model to predict patients with prolonged ED LOS (>16 h) was constructed. This model was initially used to predict ED resource usage and was subsequently adapted to predict patient ED LOS based on the number of ED resources using binary logistic regressions and was validated internally with accuracy. Finally, a discrete event simulation was used to move patients with predicted prolonged ED LOS directly to a virtual Clinical Decision Unit (CDU). The changes of ED crowding status (Overcrowding, Crowding, and Not-Crowding) and savings of ED bed-hour equivalents were estimated as the measures of the efficacy of this intervention.ResultsWe screened a total of 123,975 patient visits with final enrollment of 110,471 patient visits. The overall accuracy of the final model predicting prolonged patient LOS was 67.8%. The C-index of this model ranges from 0.72 to 0.82. By implementing the proposed intervention, the simulation showed a 12% (1044/8760) reduction of ED overcrowded status – an equivalent savings of 129.3 ED bed-hours per day.ConclusionsEarly prediction of prolonged ED LOS patients and subsequent (simulated) early CDU transfer could lead to more efficiently utilization of ED resources and improved efficacy of ED operations. This study provides evidence to support the implementation of this novel intervention into real healthcare practice.     

Assessment of ED triage of anaphylaxis patients based on the Emergency Severity Index

ObjectivesTo describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4).MethodsWe conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines.ResultsA total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28 min compared to 13 min, p < .001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20–4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31–0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38–0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38–0.82]), hypoxemia (OR, 0.34 [0.18–0.64]), or increased heart (OR 0.83 [0.73–0.95]) or respiratory (OR 0.70 [0.60–0.82]) rates.ConclusionPatients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage.     

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician

ObjectivesThe aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention.MethodsA before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a “team norm” imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011–September 30, 2011) and after (October 1, 2011–January 30, 2012) intervention were compared.ResultsPatients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention.ConclusionsThe intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly.     

Intensive care unit admission for patients with pulmonary hypertension presenting to U.S. Emergency Departments

IntroductionPulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients seeking emergency care, resulting in high acuity presentations and resource utilization. The objective was to characterize the rate of intensive care unit (ICU) admission for PH among adult patients presenting to the emergency department (ED) along with other important clinical outcomes.MethodsWe analyzed data from the State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) from two geographically separated U.S. states (New York and Nebraska). The primary outcome measure was admission to an ICU. Other measures of interest included the hospital admission rate, hospital length of stay (LOS), inpatient mortality, and rate of critical care procedures performed.ResultsFrom 2010 to 2014, in a sample of 34 million ED visits, patients with a diagnosis of PH accounted for 0.71% of all ED visits. Of the PH visits, 20.2% were admitted to the ICU, compared to 2.6% of all other visits (P < 0.001), with an aOR of 1.74 (95% CI 1. 72–1.76). The vast majority (94.6%) of PH patients were admitted to the hospital, compared to 20.5% for all other ED visits (P < 0.001). Hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients. With the exception of invasive mechanical ventilation, a significantly higher percentage of patients with PH admitted to the ICU than other patients underwent all critical care procedures evaluated.ConclusionsIn this study, patients with PH who sought emergency care in U.S. EDs from 2010 to 2014 were significantly more likely to require ICU admission than all other patients. They were also significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, increased risk of inpatient mortality, and underwent more critical care procedures. These findings indicate the high acuity of PH patients seeking emergency care and demonstrate the need for additional research into this population.