Improving patient flow in acute coronary syndromes in the face of hospital crowding

Background

The current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease.

Objective

To measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS.

Methods

Primary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post- availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death.

Results

In the post-implementation period there was a 30% (95% confidence interval [CI] 36–44%) reduction in admissions to telemetry with a 33% (95% CI 26–39%) reduction in ED LOS and a 20% (95% CI 7–34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p = 0.001).

Conclusion

The focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.     

Impact of trauma activation on the ED length of stay for nontraumatic patients

Introduction

Trauma activation prioritizes hospital resources for the assessment and treatment of trauma patient over all patients in the emergency department (ED). We hypothesized that length of stay (LOS) is longer for nontrauma patients during a trauma activation.

Methods

A retrospective, case-control chart review was conducted in a level I trauma center. Cases consist of patients who present 1 hour before and after the presentation of the trauma activation. Controls were patients presenting to the ED during the same period exactly 1 week before and after the cases. Confounding variables measured included sex, age, arrivals, and census for the 3 areas.

Results

Two hundred ninety-four trauma events occurred from January 1 until September 30, 2009. A significant difference was found between LOS of patients seen during a trauma activation with an average increase of 10.7 minutes in LOS (P =.0082; 95% confidence interval [CI], 2.8-18.7). This difference is attributable to the middle acuity area of the ED, in which the average increase in LOS was 20.3 minutes (P = .0004; 95% CI, 9.1-31.5). Significant LOS difference was not found when a trauma activation had an LOS of less than 60 minutes (P = .30; 95% CI, −7.1-61.7 for trauma LOS <60 minutes vs P = .02; 95% CI, 1.6-18.0 for trauma LOS ≥60 minutes).

Conclusion

This retrospective case-control chart review identified an increase in ED LOS for patient presenting during trauma activations. Resource prioritization should be accounted for during times when these critical patients enter the ED.     

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.     

Effect of Certificate of Need Law on Emergency Department Length of Stay

Background

The impact of the Certificate of Need (CON) law on Emergency Department (ED) care remains elusive in the academic literature.

Objectives

We study the impact of CON law on ED Length of Stay (LOS).

Methods

We examine ED LOS to detect any statistically significant difference between CON and non-CON states. We then estimate the effects of CON law on ED LOS by treating CON as an exogenous (endogenous) variable.

Results

We find that the CON legislation positively impacts ED care by reducing ED LOS (95% confidence interval [CI] −61.3 to −10.3), and we can't reject the hypothesis that the CON legislation can be treated as an exogenous variable in our model. An increase in the stringency of the CON law (measured by the threshold on equipment expenditure that is subject to a CON review) tends to diminish this positive impact on ED LOS (95% CI 9.9–68.0). The party affiliation of the Governor (95% CI 10.3–37.5), the political environment as a function of the agreement on voting between state senators (95% CI−64.8 to −12.9), proportion of young population (0–17 years) when compared with the elderly (>65 years) (95% CI−2299.7 to −184.1), proportion of population covered by privately purchased insurance (95% CI−819.3 to −59.9), etc., are found to significantly impact ED LOS in a state.

Conclusion

This study provides a better understanding of the impact of CON law on ED care, which extends the previous literature that has mainly focused on CON effects on inpatient care.     

Patient sex and quality of ED care for patients with myocardial infarction

Objective

The aim of the study was to assess the quality of care between male and female emergency department (ED) patients with acute myocardial infarction (AMI).

Methods

A 2-year retrospective cohort study of 2215 patients with AMI presenting immediately to 5 EDs from July 1, 2000, through June 30, 2002 was conducted. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from chart and electrocardiogram reviews. Multivariable regression models were used to assess the independent association between sex and the ED administration of aspirin, β-blockers, and reperfusion therapy to eligible patients with AMI.

Results

There were 849 women and 1366 men in the study. Female patients were older than male patients (74.3 years for women vs 66.8 years for men, P < .001). Among ideal patients, women were less likely than men to receive aspirin (76.3% of women vs 81.3% of men, P < .01), β-blockers (51.7% of women vs 61.4% of men, P < .01), and reperfusion therapy (64.0% of women vs 72.8% of men, P < .05). However, after adjustment for age, there was no longer a significant relationship between sex and the use of aspirin (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.03), β-blockers (OR, 0.94; 95% CI, 0.82-1.04), or reperfusion therapy (OR, 1.01; 95% CI, 0.89-1.09). In models adjusting for additional demographic, clinical, and hospital characteristics, there remained no association between sex and the processes of care.

Conclusion

Women with AMI treated in the ED have a lower likelihood of receiving aspirin, β-blocker, and reperfusion therapy. However, this association appears to be explained by the age difference between men and women with AMI. Although there are no apparent sex disparities in care, ED AMI management remains suboptimal for both sexes.     

Screening for Elderly Patients Admitted to the Emergency Department Requiring Specialized Geriatric Care

Background

There is a need for a brief geriatric assessment (BGA) tool to screen elderly patients admitted to the Emergency Department (ED) for their risk of a long hospital stay.

Objective

To examine whether a BGA administered to elderly patients admitted to the ED may predict the risk of a long hospital stay in the geriatric acute care unit.

Methods

This study had a prospective cohort study design, enrolling 424 elderly patients (mean age 84.0 ± 6.5 years, 31.6% male) who were evaluated in the ED using a BGA composed of the following items: age, gender, number of medications taken daily, history of falls during the past 6 months, Mini-Mental State Examination (MMSE) score, and non-use of home-help services (i.e., living alone without using any formal or informal home services or social help). The length of stay (LOS) was calculated in days. Patients were separated into three groups based on LOS: low (<8 days), intermediate (8–13 days), and high (>13 days).

Results

The prevalence of male gender was higher among patients with the longest LOS compared to those with intermediate LOS (p = 0.002). There were more patients with a history of falls in the high LOS group compared to the intermediate LOS group (p = 0.001) and the low LOS group (p < 0.001). The classification tree showed that male patients with an MMSE score <20 who fell with age under 85 years formed the end node with the greatest relative risk (RR) of a long hospital stay (RR = 14.3 with p < 0.001).

Conclusions

The combination of a history of falls, male gender, cognitive impairment, and age under 85 years identified elderly ED patients at high risk of a long hospital stay.     

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.     

Short-term Unscheduled Return Visits of Adult Patients to the Emergency Department

Background

Emergency department (ED) crowding is a major international concern that affects patients and providers.

Study Objective

We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding.

Methods

Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding.

Results

Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding.

Conclusion

Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.     

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies

Background

Emergency physicians often treat patients who require procedural sedation for the management of upper extremity fractures, dislocations, and abscesses (upper extremity emergencies). Unfortunately, procedural sedation is associated with several rare but potentially serious adverse effects and requires continuous hemodynamic monitoring and several dedicated staff members. The purpose of this study was to determine the role of ultrasound-guided supraclavicular brachial plexus nerve blocks in the emergency department (ED) as an alternative to procedural sedation for the management of upper extremity emergencies.

Methods

In a prospective trial, a convenience sample of ED patients with upper extremity emergencies that would normally require procedural sedation were assigned to receive either procedural sedation or an ultrasound-guided supraclavicular brachial plexus nerve block. Emergency department length of stay (ED LOS) was the primary outcome measure and was analyzed using a paired 2-tailed Student t test.

Results

A total of 12 subjects were enrolled. Average ED LOS for subjects receiving the brachial plexus nerve block was 106 minutes (95% confidence interval, 57-155 minutes). Average ED LOS for subjects receiving procedural sedation was 285 minutes (95% confidence interval, 228-343 minutes). The ED LOS was significantly shorter in the nerve block group (P < .0005). Patient satisfaction was high in both groups, and no significant complications occurred in either group.

Conclusions

In our population, ultrasound-guided brachial plexus nerve blocks resulted in shorter ED LOS compared to procedural sedation for patients with upper extremity fractures, dislocations, or abscesses.     

Aspirin administration in ED patients who presented with undifferentiated chest pain: age,race, and sex effects

Study Objectives

The study aimed to determine whether aspirin therapy was differentially administered according to race, sex, or age in patients with undifferentiated chest pain who presented to an urban academic emergency department.

Methods

This was a prospective observational cohort study of patients older than 24 years who presented with chest pain between July 1999 and March 2002. Patients were grouped according to 30-day final diagnosis: acute myocardial infarction AMI, unstable angina USA, and non–acute coronary syndrome (ACS) chest pain. Data were analyzed using Fisher exact test and relative risk regression using the Gaussian estimating equation.

Results

There were 4478 patient visits, of which 4470 (99.8%) had complete information. Mean age was 52.2 ± 15.8 years. Blacks were 70.1% (n = 3135), whites 26.3% (n = 1175), and other 3.6% (n = 159). Women comprised 59.0% (n = 2639) of the patients. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% vs 54%, P = .0009) or have an ACS diagnosis (82% vs 50%, P < .0001). By final diagnosis, there were no race, sex, or age differences for AMI or USA (P > .05). There were significant sex and age differences for non-ACS chest pain patients: men (53% vs 48% women, P = .0009) and older patients (>55 years, 60% vs 44% younger, P < .0001) had higher aspirin therapy due to administration to the patients with non-ACS chest pain.

Conclusion

For patients with undifferentiated chest pain, overall race, sex, and age differences were explained by higher rates of aspirin administered to older men with non-ACS chest pain.     

Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients

Objective

Guidelines recommend treating patients with a new or presumed new left bundle-branch block (LBBB) similar to those with an acute ST-segment elevation myocardial infarction. It is often unclear which emergency department (ED) patients with potentially ischemic symptoms actually have an acute myocardial infarction (AMI), even in the setting of LBBB. Our null hypothesis was that in ED patients with potential AMI, the presence of a new or presumed new LBBB would not predict an increased likelihood of AMI.

Methods

This was an observational cohort study. Patients older than 30 years who presented with chest pain or other ischemic equivalent and had an electrocardiogram (ECG) to evaluate potential acute coronary syndrome (ACS) were enrolled. Data collected include demographics, history, ECG, and cardiac markers. Electrocardiograms were classified according to the standardized guidelines, including LBBB not known to be old (new or presumed new LBBB), LBBB known to be old, or no LBBB. The hospital course was followed, and 30-day follow-up was performed on all patients. Our main outcome was AMI.

Results

There were 7937 visits (mean age, 54.3 ± 15 years, 57% female, 68% black): 55 had new or presumed new LBBB, 136 had old LBBB, and 7746 had no LBBB. The rate of AMI was not significantly different between the 3 groups (7.3% vs 5.2% vs 6.1%; P = .75). Revascularization (7.8% vs old 5.2% vs 4.3%; P = .04) and coronary artery disease were more common in patients with new or presumed new LBBB (19.2% vs 11.9% vs 10.1%; P = .0004).

Conclusions

Despite guideline recommendations that patients with potential ACS and new or presumed new LBBB should be treated similar to STEMI, ED patients with a new or presumed new LBBB are not at increased risk of AMI. In fact, the presence of LBBB, whether new or old, did not predict AMI. Caution should be used in applying recommendations derived from patients with definite AMI to ED patients with potential ACS that may or may not be sustaining an AMI.     

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.     

Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging

Background

Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED).

Objectives

The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast-enhanced confirmatory imaging on ED length of stay (LOS).

Methods

This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit.

Results

A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P < .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement.

Conclusions

For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.     

High rates of prasugrel and ticagrelor non-responder in patients treated with therapeutic hypothermia after cardiac arrest

Introduction

After cardiac arrest due to acute coronary syndromes (ACS) therapeutic hypothermia (HT) is the standard care to reduce neurologic damage. Additionally, the concomitant medical treatment with aspirin and a P2Y12 receptor inhibitor like clopidogrel (Cl), prasugrel (Pr) or ticagrelor (Ti) is mandatory. The platelet inhibitory effect of these drugs under hypothermia remains unclear.

Methods

164 patients with ACS were prospectively enrolled in this study. 84 patients were treated with HT, 80 patients were under normothermia (NT). All patients were treated with aspirin and one of the P2Y12 receptor inhibitors Cl, Pr or Ti. 24 h after the initial loading dose the platelet reactivity index (PRI/VASP-index) was determined to achieve the platelet inhibitory effect.

Results

In the HT-group the PRI/VASP-index was significantly higher compared to the NT-group (54.86% ± 25.1 vs. 28.98% ± 22.8; p < 0.001). In patients under HT receiving Cl, the platelet inhibition was most markedly reduced (HT vs. NT: 66.39% ± 19.1 vs. 33.36% ± 22.1; p < 0.001) compared to Pr (HT vs. NT: 37.6% ± 25.0 vs. 27.04% ± 25.5; p = 0.143) and Ti (HT vs. NT: 41.5% ± 21.0 vs. 17.83% ± 14.5; p = 0.009). The rate of non-responder defined as PRI/VASP-index > 50% was increased in HT compared to NT (60.7% vs. 22.5%; p < 0.001) with the highest rates in the group receiving Cl (CL: 82% vs. 26%, p < 0.001; Pr: 32% vs. 23%; n.s.; Ti: 30% vs. 8%, n.s.).

Conclusion

The platelet inhibitory effect in patients treated with HT after cardiac arrest is significantly reduced. This effect was most marked with the use of Cl. The new P2Y12-inhibitors Pr and Ti improved platelet inhibition in HT, but could not completely prevent non-responsiveness.     

Slow-onset and Fast-onset Symptom Presentations In Acute Coronary Syndrome (ACS): New Perspectives on Prehospital Delay in Patients with ACS

Background

Patient decision delay is the main reason why many patients fail to receive timely medical intervention for symptoms of acute coronary syndrome (ACS).

Study Objectives

This study examines the validity of slow-onset and fast-onset ACS presentations and their influence on ACS prehospital delay times. A fast-onset ACS presentation is characterized by sudden, continuous, and severe chest pain, and slow-onset ACS pertains to all other ACS presentations.

Methods

Baseline data pertaining to medical profiles, prehospital delay times, and ACS symptoms were recorded for all ACS patients who participated in a large multisite randomized control trial (RCT) in Dublin, Ireland. Patients were interviewed 2–4 days after their ACS event, and data were gathered using the ACS Response to Symptom Index.

Results

Only baseline data from the RCT, N = 893 patients, were analyzed. A total of 65% (n = 577) of patients experienced slow-onset ACS presentation, whereas 35% (n = 316) experienced fast-onset ACS. Patients who experienced slow-onset ACS were significantly more likely to have longer prehospital delays than patients with fast-onset ACS (3.5 h vs. 2.0 h, respectively, t = −5.63, df 890, p < 0.001). A multivariate analysis of delay revealed that, in the presence of other known delay factors, the only independent predictors of delay were slow-onset and fast-onset ACS (β = −.096, p < 0.002) and other factors associated with patient behavior.

Conclusion

Slow-onset ACS and fast-onset ACS presentations are associated with distinct behavioral patterns that significantly influence prehospital time frames. As such, slow-onset ACS and fast-onset ACS are legitimate ACS presentation phenomena that should be seriously considered when examining the factors associated with prehospital delay.     

Resident-Initiated Advanced Triage Effect on Emergency Department Patient Flow

Background

Emergency Department (ED) overcrowding is a national problem. Initiating orders in triage has been shown to decrease length of stay (LOS), however, nurse, physician assistant, and attending physician advanced triage have all been criticized.

Study Objectives

Our primary objective was to show that Emergency Medicine resident-initiated advanced triage shortens patient LOS. Our secondary objective was to evaluate whether or not resident triage decreases the number of patients who left prior to medical screening (LPTMS).

Methods

This prospective interventional study was performed in a 42-bed, Level III trauma center, academic ED in the United States, with an annual census of approximately 41,000 patients. A junior or senior Emergency Medicine resident initiated orders on 16 weekdays for 6 h daily on patients presenting to triage. Patients evaluated during the 6-h period on other weekdays served as the control. The study was powered to detect a reduction in LOS of 45 min. Multivariable median regression was used to compare length of stay and Fisher’s exact test to compare proportions.

Results

There were 1346 patients evaluated in the ED during the intervention time. Regression analysis showed a 37-min decrease in median LOS for patients on intervention days as compared to control days (p = 0.02). The proportion of patients who LPTMS was not statistically different (p = 0.7) for intervention days (96/1346, 7.13%) compared to control days (136/1810, 7.51%).

Conclusions

Resident-initiated advanced triage is an effective method to decrease patient LOS, however, our effect size is smaller than predicted and did not significantly affect the percent of patients leaving before medical screening.     

Impact of computerized physician order entry on ED patient length of stay

Objectives

We evaluated whether implementation of computerized physician order entry (CPOE) reduces length of stay (LOS) for discharged emergency department (ED) patients.

Methods

Emergency department LOS for discharged and admitted patients were analyzed in a university-affiliated ED before and after introduction of CPOE. Patient demographics and covariates that may affect LOS (mode of arrival, provider staffing, daily census, and admission rate) were measured.

Results

The study included 71?188 patients; 49?175 (69%) were discharged from the ED (28?687 before and 20?488 after CPOE). Length of stay for discharged patients decreased from 198 to 168 minutes (difference of −30; 95% confidence interval [CI], −28 to −33), whereas LOS for admitted patients increased from 405 to 441 minutes (difference of +36; 95% CI, 26-46). After controlling for covariates, CPOE implementation was associated with a 23-minute decrease in LOS for discharged patients (β = −23 [95% CI, −26 to −19]).

Conclusion

Implementation of CPOE was associated with a clinically significant (23-minute) decrease in LOS among patients who were discharged from the ED.     

Emergency physicians do not use more resources to evaluate obese patients with acute abdominal pain

Objective

We hypothesized that emergency physicians would use more resources to evaluate acute abdominal pain in obese patients as compared with that in nonobese patients.

Methods

We conducted a secondary analysis of a prospective cohort of adults with acute abdominal pain. Collected data included self-reported height and weight, demographics, medical history, laboratory and x-ray results, and final diagnosis. We followed the patients until they obtained their final diagnosis or for up to 21 days. Patients were grouped according to their body mass index (BMI): nonobese (BMI < 30 kg/m²), obese (BMI = 30-40 kg/m²), and morbidly obese (BMI > 40 mg/m²). The main outcome measure was laboratory and radiographic testing. χ² Tests and analysis of variance were used as appropriate.

Results

Of the 971 patients (mean age, 41 years; 62% black; 65% female), 665 (68%) were nonobese, 246 (25%) were obese, and 60 (6%) were morbidly obese. In comparing nonobese patients with obese patients, we found no difference in laboratory or radiographic testing (3.20 vs 3.21 tests; mean difference, 0.004; 95% confidence interval [CI], −0.26 to 0.27), physicians' pre–computed tomographic scan confidence level in their diagnosis (6.17 vs 6.04, mean difference, −0.13; 95% CI, −0.76 to 0.49), and emergency department (ED) length of stay (LOS; 7.40 vs 7.57 hours; mean difference, −0.17; 95% CI, −0.49 to 0.83). In comparing all 3 groups, we found no difference in diagnostic testing, ED LOS, surgical intervention (10% vs 5% vs 9%, P = .2), disposition, and final diagnosis (P > .05).

Conclusions

Physicians do not use more resources to identify the etiology of acute abdominal pain in obese patients as compared with that in nonobese patients. Furthermore, ED LOS, likelihood of surgical intervention, physicians' confidence level in their preimaging diagnosis, and final diagnosis do not appear to be influenced by BMI.     

Impact of positive fluid balance on critically ill surgical patients: A prospective observational study

Purpose

The purpose of this study is to determine the effect of postoperative fluid balance (FB) on subsequent outcomes in acute care surgery (ACS) patients admitted to the surgical intensive care unit (ICU).

Material and methods

Acute care surgery patients admitted to the surgical ICU from 06/2012 to 01/2013 were followed up prospectively. Patients were stratified by FB into FB-positive (+) and FB-negative (−) groups by surgical ICU day 5 or day of discharge from the surgical ICU.

Results

A total of 144 ACS patients met inclusion criteria. Although there was no statistically significant difference in crude mortality (11% for FB [−] vs 15.5% for FB [+]; P = .422], after adjusting for confounding factors, achieving an FB (−) status by day 5 during the surgical ICU stay was associated with an almost 70% survival benefit (adjusted odds ratio [95% confidence interval], 0.31 [0.13, 0.76]; P = .010). In addition, achieving a fluid negative status by day 1 provided a protective effect for both overall and infectious complications (adjusted odds ratio [95% confidence interval], 0.63 [0.45, 0.88]; P = .006 and 0.64 [0.46, 0.90]; P = .010, respectively).

Conclusions

In a cohort of critically ill ACS patients, achieving FB (−) status early during surgical ICU admission was associated with a nearly 70% reduction in the risk for mortality.