Safety and efficacy of intravenous combination sedatives in the ED

Objective

The objective of the study is to determine the safety of intravenously administered combination sedatives in the emergency department (ED).

Methods

This was a retrospective study of alcohol-intoxicated patients in the ED. We examined the incidence of adverse events in agitated patients who received combination sedatives intravenously and compared the efficacy of combination sedatives and single-agent sedatives.

Results

Of 1300 patient visits, there was a single adverse event, a dystonic reaction, in the combination sedative group, for an adverse event rate of less than 1%. Patients who received combination sedatives were less likely to require a second dose of sedative medication than patients who received a single-agent sedative (21% vs 44%).

Conclusions

Combination sedatives appear to be safe when administered intravenously in the ED. Combination sedatives may be more effective than single-agent sedatives in agitated alcohol-intoxicated patients.     

An association between occupancy rates in the emergency department and rates of violence toward staff

Background

Studies have explored possible causes of violent acts in the emergency department (ED), however, the association of violence with ED crowding has not been studied. Although the total number of violent acts would be expected to increase, it is not clear if the rate of violent acts also increases as occupancy levels rise.

Objective

The purpose of this study was to determine if there is an association between occupancy rates in the ED and rates of violence toward staff.

Methods

This was a retrospective chart review study. Violent incidents in a community, Level I trauma center ED were identified from review of orders of emergency detainment, adverse event forms, physical restraint logs, and pharmacy records from January 1, 2005 to June 1, 2008. Occupancy rates for all days were calculated and violent vs. non-violent days were compared using a standard two-sample t-test. Logistic regression analysis was then used to investigate other factors associated with violent incidents.

Results

A rate of violence of 1.3 incidents per 1000 patients was found. When comparing the occupancy rates of violent days (mean 95%, SD 26%) with non-violent days (mean 86%, SD 24%), a statistically significant association was found (p < 0.0001). Multivariate logistic regression confirmed a significant association between crowding and violence toward staff (odds ratio 4.290, 95% confidence interval 2.137–8.612).

Conclusion

These results suggest another possible negative effect that crowding has on ED staff and physicians. Policies and recommendations regarding ED operating procedures and staff safety during times of higher occupancy levels should be discussed.     

Operational and financial impact of physician screening in the ED

Background

Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

Study objective

We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center.

Methods

We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS.

Results

During the first year, we estimate the contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%.

Conclusions

In addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.     

Satisfaction and Emergency Department Revisits in Patients With Possible Acute Coronary Syndrome

Background

Patients with possible acute coronary syndrome (ACS) are typically instructed to return to the emergency department (ED) if their condition worsens. Little is known about the relationship between patient satisfaction in the ED and subsequent return visits.

Objective

Our aim was to determine the association between satisfaction with ED care and subsequent ED return visits.

Methods

One thousand and five consecutive ED patients with symptoms of possible ACS who participated in a prospective guideline implementation trial at two university hospitals completed a telephone survey at 30-day follow-up. Satisfaction with care at the initial ED visit was measured using items from the Press Ganey satisfaction questionnaire. Logistic regression was used to determine the association between individual satisfaction items and the occurrence of any ED revisits, and the association between satisfaction items and return visits to the same ED.

Results

Patients who reported superior ratings of person-centered care (“staff cared about you as a person”) were significantly less likely to return to any ED during 30-day follow-up: 59 vs. 71%, adjusted odds ratio = 0.57 (95% confidence interval 0.37−0.87). Among those with ED revisits, superior ratings of personal care and perceived waiting time for emergency physician evaluation were significantly associated with return to the same ED.

Conclusions

Although diagnostic workup and risk stratification are the primary focus in evaluating patients with possible ACS, greater attention to the patient's experience of care may have the positive impact of reducing ED return visits and increasing the likelihood that patients will return to the same ED for re-evaluation.     

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.     

Effectiveness of Case Management Strategies in Reducing Emergency Department Visits in Frequent User Patient Populations: A Systematic Review

Background

Case management (CM) is a commonly cited intervention aimed at reducing Emergency Department (ED) utilization by “frequent users,” a group of patients that utilize the ED at disproportionately high rates. Studies have investigated the impact of CM on a variety of outcomes in this patient population.

Objectives

We sought to examine the evidence of the effectiveness of the CM model in the frequent ED user patient population. We reviewed the available literature focusing on the impact of CM interventions on ED utilization, cost, disposition, and psychosocial variables in frequent ED users.

Discussion

Although there was heterogeneity across the 12 studies investigating the impact of CM interventions on frequent users of the ED, the majority of available evidence shows a benefit to CM interventions. Reductions in ED visitation and ED costs are supported with the strongest evidence.

Conclusion

CM interventions can improve both clinical and social outcomes among frequent ED users.     

The relationship between inpatient discharge timing and emergency department boarding

Background

Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling.

Study Objective

Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m.

Methods

A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies.

Results

A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4 h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0.

Conclusion

Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.     

Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Background

The Emergency Department (ED) is an environment at risk for medical errors.

Objective

Our aim was to determine the factors associated with the adverse events resulting from medical errors in the ED among patients who were admitted.

Methods

This was a prospective observational study. For a 1-month period, we included all ED patients who were subsequently admitted to the medical ward. Detection of medical errors was made by the admitting physician and then validated by two experts who reviewed all available data and medical charts pertaining to the patient’s hospital stay, including the first review from the ward physician. Related adverse events resulting from medical errors were then classified by type and severity. Adverse events were defined as medical errors that needed an intervention or caused harm to the patient. Univariate analysis examined relationships between characteristics of both patients and physicians and the risk of adverse events.

Results

From 197 analyzed patients, 130 errors were detected, of these, 34 were categorized as adverse events among 19 patients (10%). Seventy-six percent of these were categorized as proficiency errors. The only factors associated with a lower risk of adverse events were the transition of care involving a handoff within the ED (0% vs. 19%; p = 0.03) and the involvement of a resident (junior doctor) in addition to the senior physician (37% vs. 67%; p < 0.01).

Conclusions

In our study, the involvement of more than one physician was associated with a lower risk of adverse events.     

Characteristics and outcomes of injury-related ED visits among older adults

Objectives

The objectives of this study were to examine the epidemiology of injury among older adults treated in emergency departments (EDs) and to explore the effect of advanced age and nursing home residence on associated outcomes.

Methods

A secondary data analysis of a nationally representative sample from the National Hospital Ambulatory Care Survey was conducted using available sampling weights and data from the US Census Bureau. Weighted multivariate logistic regression was used to explore factors associated with injury outcomes, including hospitalization and receipt of potentially inappropriate medications.

Results

Nearly 21 million injury-related ED patient visits were made by older adults during the study period. Nearly 10% of episodes were identified as adverse events, which increased hospitalization risk 3-fold. Potentially inappropriate medications were provided during nearly 12% of encounters.

Conclusions

Injury reductions among elders could be achieved by reducing adverse events, whereas quality could be improved by reducing potentially inappropriate medication use 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.     

Delays in Service for Non-Emergent Patients Due to Arrival of Emergent Patients in the Emergency Department: A Case Study in Hong Kong

Background

In Hong Kong Emergency Departments (EDs), the timeliness of providing high-quality services has been compromised by the increasing attendance of non-emergent patients in addition to the unpredictable arrival of emergency patients.

Objectives

We sought to quantify the impact of the presence of emergent patients and other related factors on the delay in service for non-emergent patients.

Methods

We conducted a retrospective study in patients who visited the ED of a large hospital in Hong Kong from July 1, 2009 to June 30, 2010. We estimated waiting and length of stay (LOS) for individual non-emergent patients registered during day and evening shifts. Using multiple linear regression, we estimated waiting time and LOS as a function of the presence of emergent patients and other related factors such as patient demographics and clinical factors. In particular, we evaluated the influence of the arrival or presence of emergent patients on the odds of violating the 120-min waiting time target for semi-urgent patients.

Results

The arrival of a new emergent patient prolonged the waiting time and LOS of a non-emergent patient by 14.9% (95% confidence interval [CI] 14.2–15.5) and 10.8% (95% CI 10.6–11.0), respectively. An additional patient-hour needed for an emergent patient increased the probability of violating the waiting time target for non-emergent patients (odds ratio 2.3, 95% CI 2.2–2.4).

Conclusions

The arrival of an emergent patient significantly prolonged the waiting time and LOS for non-emergent patients. Discouraging non-urgent ED utilization and building a real-time decision-support system are critical methods needed to relieve staff pressure and guide contingent resource reallocation when emergent patients arrive.     

Outcomes in Canadian Emergency Department Syncope Patients – Are We Doing a Good Job?

Background

Little is known about the outcomes of adults with syncope seen in Canadian Emergency Departments (EDs).

Objectives

We sought to determine the frequency, timing, and type of serious adverse outcomes occurring in these patients, and the proportion that occur outside the hospital.

Methods

We conducted a health records review of syncope patients presenting to a tertiary care ED over an 18-month period. We included all patients older than 16 years of age who fulfilled the syncope definition (sudden transient loss of consciousness with spontaneous complete recovery), and excluded those with altered mental status, alcohol or illicit drug use, seizure, or trauma. We assessed for outcomes in the ED and after ED disposition. We also evaluated follow-up arrangements for patients discharged from the ED.

Results

Of the total 87,508 patient visits, 505 (0.6%) were due to syncope. The mean age was 58.5 years (range 16–101 years), 70.1% arrived by ambulance, and 12.3% were admitted to the hospital. Five patients died: 2 in the ED, 1 as an inpatient, and 2 after discharge. Overall, there were 49 (9.7%) serious outcomes, with dysrhythmias being the most common (4.6%); 22 (4.4%) occurred in the ED, 15 (3.0%) in the hospital, and 12 (2.4%) outside the hospital. Eight serious outcomes occurred in patients discharged from the ED without any planned follow-up.

Conclusion

Although syncope represented < 1% of all patient visits, morbidity was substantial, particularly in patients discharged from the ED. Future research should help clinicians identify syncope patients at high risk for serious outcomes.     

Applying the Boston Syncope Criteria to Near Syncope

Background

We recently demonstrated that near-syncope patients are as likely as syncope patients to experience adverse outcomes. The Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have adverse outcomes and reduce hospitalizations. It is unclear whether these guidelines could reduce hospitalization in near syncope as well.

Objective

To determine if BSC accurately predict which near-syncope patients require hospitalization.

Methods

A prospective observational study enrolled from August 2007 to October 2008 consecutive emergency department (ED) patients (aged > 18 years) with near syncope. BSC were first employed assuming that any patient with risk factors for adverse outcomes should be admitted, and then utilized using a modified rule: if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, patients may be discharged even with risk factors. Outcomes were identified by chart review and 30-day follow-up calls.

Results

Of 244 patients with near syncope, 111 were admitted, with 49 adverse outcomes. No adverse outcomes occurred among discharged patients. If BSC had been followed strictly, another 41 patients with risk factors would have been admitted and 34 discharged, a 3% increase in admission rate. However, using the modified criteria, only 68 patients would have required admission, a 38% reduction in admission, with no missed adverse outcomes on follow-up.

Conclusion

Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, these patients may be discharged even with risk factors.     

Restraint Use in the Elderly Emergency Department Patient

Background

The elderly frequently suffer from altered mental status and other medical conditions requiring physical or chemical restraint for safety in the Emergency Department (ED).

Objective

This study examined outcomes of restrained elderly patients in the ED.

Methods

A 2-year retrospective study was conducted in an urban community teaching hospital ED. Included were patients ≥65 years of age who were physically restrained in the ED and hospitalized. Data collected included age, gender, restraint indications, restraint type, restraint duration, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay, and disposition.

Results

There were 83 patients in the study. Forty-seven (56.6%) were nursing home residents. Twenty-seven (32.5%) were admitted to the intensive care unit. Thirty-five (42.2%) received both chemical and physical restraint. The average number of patient medications on arrival to the ED was eight, and 3 patients were on a medication that could adversely interact with a chemical restraint medication. The mean inpatient length of stay was 7.2 days (SD 5.7 days). Ten patients expired, 14 were discharged home, and 59 were discharged to a nursing facility (8 with new behavioral medications). Of the 36 patients originally presenting to the ED from home, only 11 (30.6%) were discharged back to home. There were no significant differences in outcome between patients who received a combination of both chemical and physical restraints and patients who received physical restraint alone.

Conclusion

In this 2-year retrospective study, elderly patients placed in physical restraints in the ED had no recorded adverse outcomes. In addition, there were no adverse outcomes when they received both physical and chemical restraint. Elderly patients who were originally admitted from home and subsequently required physical restraint were unlikely to return home.     

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.     

Staffing of the ED by non–emergency medicine-trained personnel: the VA experience

Study objective

VA (Veteran's Affairs) emergency departments (EDs) are generally staffed with physicians trained in internal medicine (IM), although recently, a movement has begun toward hiring emergency medicine (EM)-trained staff. At our institution, the ED is staffed by physicians of both specialties. This study examines the frequency of unscheduled return visits to the ED in an effort to compare the quality of emergency care given by physicians trained in IM and EM.

Methods

The record of all visits to a VA hospital ED during a 90-day period were examined, and all those visits resulting in a return ED visit within the 30 subsequent days were noted.

Results

The charts of 2891 consecutive ED patients were examined. The rate of revisits was significantly higher for the IM than for the EM-trained physicians (8.9% vs 5.5%, respectively; P < .001). The IM-trained physicians had a significantly higher rate of admissions upon revisit within 30 days than did the EM-trained physicians (3.5% vs 1.9%, respectively; P = .014). The IM-trained staff had lower initial hospitalization rates than the EM physicians (20% vs 43%, respectively; P < .0001).

Conclusions

The IM-trained physicians were less likely to hospitalize patients, although this can be partially explained by the lower acuity of patients during the hours that they covered. The IM-trained physicians were significantly more likely to have a patient return after discharge and also more likely to have a patient return in need of hospitalization. This may reflect a difference in training for the rapid diagnosis and risk stratification of ED patients.     

Is Emergency Department Cardioversion of Recent-onset Atrial Fibrillation Safe and Effective?

Background

Atrial fibrillation (AF) is a very common dysrhythmia presenting to Emergency Departments (EDs). Controversy exists regarding the optimal clinical therapy for these patients, which typically focuses on rhythm rate-control and admission or cardioversion and discharge home.

Clinical Question

Is ED cardioversion of recent-onset atrial fibrillation safe, effective, and does it result in positive meaningful patient outcomes?

Evidence Review

Five observation studies with nearly 1600 ED patients with atrial fibrillation treated with either rate-control or cardioversion were reviewed and results compiled.

Results

Overall, ED cardioversion for recent-onset AF seems safe and effective, with success rates ranging from 85.5% to 97% in these studies. Although further research should seek to identify patients at low risk for thromboembolic complication, more rigorously assess patient satisfaction, and show cost savings, emergency physicians should feel comfortable using this approach in select patients.

Conclusion

ED cardioversion for recent-onset AF seems safe and effective.     

Hourly Rounding in the Pediatric Emergency Department: Patient and Family Safety and Satisfaction Rounds

Background

Methods of increasing patient and family involvement in and understanding of their medical care are plentiful, and hourly rounding specifically has shown benefit in several clinical settings. Although the approach has shown a variety of advantages in other areas, its use in urgent care pediatric settings is not well described.

Objectives

This study evaluates the institution of patient satisfaction and safety rounding (“hourly rounding”) in the pediatric emergency department (ED) setting.

Methods

Hourly rounding was instituted in a tertiary care, urban pediatric ED using a formal mnemonic, after staff education, training, and observation to ensure standardization of approach. Pre- and postintervention data were collected, including frequency and type of nursing call bell usage, family discharge opinion survey, and vendor-collected survey results.

Results

Two weeks of nursing call bell activation data and 200 pre- and postintervention family discharge opinion surveys were collected, evenly divided between pre- and postimplementation data. Call bell activations prior to and after hourly rounding institution were 102 and 150 respectively, with accidental activations comprising the majority. Additionally, vendor-collected patient satisfaction data were analyzed. There were no changes in patient scoring when pre- and postimplementation data were compared.

Conclusions

This model of hourly rounding shows no measurable improvement in patient satisfaction or provider–patient communication using call bell data, family discharge opinion surveys, or vendor-collected patient satisfaction data. Further studies may be indicated to identify different methods of analyzing the effects of this method, and to examine alternative methods of improving these outcomes in the pediatric ED setting.