Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department

Implementing electronic health records (EHR) in healthcare settings incurs challenges, none more important than maintaining efficiency and safety during rollout. This report quantifies the impact of offloading low-acuity visits to an alternative care site from the emergency department (ED) during EHR implementation. In addition, the report evaluated the effect of EHR implementation on overall patient length of stay (LOS), time to medical provider, and provider productivity during implementation of the EHR. Overall LOS and time to doctor increased during EHR implementation. On average, admitted patients' LOS was 6-20% longer. For discharged patients, LOS was 12-22% longer. Attempts to reduce patient volumes by diverting patients to another clinic were not effective in minimizing delays in care during this EHR implementation. Delays in ED throughput during EHR implementation are real and significant despite additional providers in the ED, and in this setting resolved by 3 months post-implementation.     

Patient outcomes and length of stay in a stroke unit offering both acute and rehabilitation services

OBJECTIVES: To compare hospital length of stay (LOS) and outcome after stroke between patients in a stroke unit offering combined acute and rehabilitation services and patients treated elsewhere in New South Wales. DESIGN: Retrospective audit of two hospital databases (Diagnosis-Related Groups [DRG] database and Australian National Subacute Non-Acute Patient Classification System [AN-SNAP] database), with comparison with DRG and AN-SNAP data for NSW. SETTING AND PARTICIPANTS: 242 episodes of acute stroke in patients admitted to the stroke unit of a metropolitan teaching hospital between July 1999 and November 2000, 113 of whom also underwent rehabilitation in the unit; 9777 episodes of acute stroke in the NSW DRG database, and 2350 in the NSW AN-SNAP database. MAIN OUTCOME MEASURES: Acute and rehabilitation LOS; mortality in acute care; FIM (Functional Independence Measure) score at discharge and change in FIM score; and discharge destination. RESULTS: Patients in the combined stroke unit had shorter LOS and better functional outcome in all DRG and AN-SNAP groups, with both higher discharge FIM scores and greater gain in FIM scores than NSW patients. Acute stroke mortality of 12% and nursing home admission rate of 15.5% in the combined stroke unit were not significantly different from rates for NSW (15.7% and 11.2%, respectively). CONCLUSIONS: Combining acute and rehabilitation services in a stroke unit may reduce LOS and improve functional outcome of patients with acute stroke.     

Patient satisfaction following emergency admission via a surgical assessment unit and an emergency department

Aim

Acute surgical patients are admitted to our regional hospital through the emergency department (ED) and through a new surgical assessment unit (SAU). The aim of this study was to compare the efficiency of the two units in seeing and assessing acute surgical patients, as well as patients’ satisfaction with their experiences in both units.

Methods

A patient satisfaction scoring questionnaire was distributed to 115 consecutive surgical patients attending the SAU and ED over an 8-week period. Patients’ impressions of waiting times, pain management and interactions with staff were detailed. The actual times taken for assessment, admission and discharge were recorded and compared with those perceived by the patients.

Results

Patients’ perceptions of care were very high within both the ED and the SAU, with 95 % of SAU patients reporting their care as excellent or very good compared with 86 % of ED patients (p = 0.014). Patients were assessed considerably faster in the SAU compared with the ED, with an average wait from registration to admission or discharge totalling 5 h in the SAU compared with 12 h in the ED.

Conclusion

The SAU provides an effective and efficient mode of assessment of acute surgical patients. While patients were discharged faster from the SAU than the ED, patients rated both units highly in terms of satisfaction with the service provided.     

The crucial factor of hospital readmissions: a retrospective cohort study of patients evaluated in the emergency department and admitted to the department of medicine of a general hospital in Italy

Background

Early hospital readmissions, defined as rehospitalization within 30 days from a previous discharge, represent an economic and social burden for public health management. As data about early readmission in Italy are scarce, we aimed to relate the phenomenon of 30-day readmission to factors identified at the time of emergency department (ED) visits in subjects admitted to medical wards of a general hospital in Italy.

Methods

We performed a retrospective 30-month observational study, evaluating all patients admitted to the Department of Medicine of the Hospital of Ferrara, Italy. Our study compared early and late readmission: patients were evaluated on the basis of the ED admission diagnosis and classified differently on the basis of a concordant or discordant readmission diagnosis in respect to the diagnosis of a first hospitalization.

Results

Out of 13,237 patients admitted during the study period, 3,631 (27.4%) were readmitted; of those, 656 were 30-day rehospitalizations (5% of total admissions). Early rehospitalization occurred 12 days (median) later than previous discharge. The most frequent causes of rehospitalization were cardiovascular disease (CVD) in 29.3% and pulmonary disease (PD) in 29.7% of cases. Patients admitted with the same diagnosis were younger, had lower length of stay (LOS) and higher prevalence of CVD, PD and cancer. Age, CVD and PD were independently associated with 30-day readmission with concordant diagnosis and kidney disease with 30-day rehospitalization with a discordant diagnosis.

Conclusions

Comorbid patients are at higher risk for 30-day readmission. Reduction of LOS, especially in elderly subjects, could increase early rehospitalization rates.     

The potential lost hospital income from miscoded emergency department boarders in Ireland

Background

Emergency department (ED) boarders, namely patients who have been admitted under an in-patient service but remain on a trolley in the ED, have long been a problem in the Irish healthcare system.

Methods

We conducted a retrospective analysis of all ED boarders in Cork University Hospital (CUH) for a 6-month period from January to July 2011. Data were obtained from the Hospital In-Patient Enquiry Office (HIPE). The income generated by the hospital for a subset of these patients (January and February attendances) was obtained from the Finance Office in the hospital, based on diagnoses as recorded on the HIPE system. A convenience sample of two-thirds of the 39 acute hospitals nationally was surveyed to ascertain whether ED boarders were coded by individual HIPE offices as hospital in-patients or as ED attendees.

Results

A total of 806 patients were admitted to an in-patient service from January to July 2011 in CUH and subsequently discharged, having completed their entire stay in the ED. The income generated by a sub-sample of 228 patients (January and February ED boarders) was determined. The hospital was remunerated by €685,111 for these patients, i.e. an average income of €3,098 per patient. Only 8 hospitals of the 27 surveyed hospitals coded overnight ED Boarders as in-patients and were thus able to request income for these patients appropriately.

Conclusion

Discrepancies in coding of ED boarders may result in significant revenue losses for certain hospitals.     

西部农村急性心肌梗死患者住院时长及其影响因素分析

目的 了解我国西部农村地区急性心肌梗死（AMI）患者平均住院时长情况和变化趋势,探索与平均住院时长有关的医院水平影响因素。方法 通过随机抽样收集我国西部农村地区9省份30家医院2001、2006、2011年的AMI住院患者病历资料,将纳入研究的医院按照住院时间的中位数划分为3类。采用针对整群数据的卡方检验或方差分析对3类医院患者特征差异进行检验,采用Mann-Kendall法检验住院时长在3个研究年份的变化趋势。采用多因素广义线性模型检验医院特征对住院时长的影响。结果 本研究最终共纳入814份病历。3类医院所入选的AMI患者的入院时间、肾小球滤过率存在显著差异(P＜0.05)。2001、2006及2011年的平均住院时长分别为（14.6±16.6）、（11.6±8.7）和（12.2±7.4）d,各年份间无显著的变化趋势（P=0.50）。调整患者水平特征后的无并发症病例分析结果显示,3个年份的平均住院时长分别为（11.1±8.3）、（10.9±6.9）和（11.6±5.7）d,各年份间仍无显著的变化趋势（P=0.68）。非附属非教学医院的患者平均住院时长较长,增加约6 d（95%CI：1.58～10.19）,未开展冠脉造影医院的患者平均住院时长增加约3.7d（95%CI：0.46～6.99）。结论 我国西部农村地区医院AMI住院患者的平均住院时长仍不理想。2001~2011年平均住院时长无显著改善,进一步提高临床诊疗能力,缩短住院时长是改善我国西部农村地区AMI患者诊疗的关键。     

Factors associated with length of hospital stay among dialysis patients with nontraumatic acute abdomen: a retrospective observational study

INTRODUCTIONNontraumatic acute abdomen (NTAA) in dialysis patients is a challenging issue. The aetiologies of NTAA vary considerably depending on the renal replacement therapy (RRT) modality. Although haematological parameters and contributing factors have been reported to be associated with outcomes for dialysis patients, their clinical effect on the length of hospital stay (LOS) remains unknown.METHODSWe retrospectively analysed 52 dialysis patients (peritoneal dialysis [PD], n = 33; haemodialysis [HD], n = 19) and 30 non-dialysis patients (as controls) between January 2011 and December 2014. To attenuate the selection bias, non-dialysis patients with NTAA were matched to cases at a ratio of 1:1 by age, gender and comorbidities (diabetes mellitus and hypertension). Their demographic characteristics, laboratory data, clinical assessment scores and LOS were analysed.RESULTSThe PD group exhibited a significantly higher neutrophil percentage, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR); longer LOS; and lower lymphocyte percentage and absolute lymphocyte count than the control group. After multivariate analysis adjustment, female gender, longer RRT duration and higher intact parathyroid hormone (iPTH) levels were associated with a lower probability of being discharged home. In the dialysis group, a higher iPTH level (> 313 μg/mL) was positively correlated with longer LOS. iPTH level combined with NLR can be used as a surrogate marker for predicting longer LOS (p < 0.001).CONCLUSIONNTAA dialysis patients with female gender, longer RRT duration and higher iPTH levels are prone to experiencing longer LOS. In addition, the combination of iPTH and NLR is a significant determinant for LOS in NTAA dialysis patients.     

The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay

OBJECTIVES: To investigate the relationship between access block in the emergency department (ED) (defined as total time from arrival to transfer from the ED over eight hours) and inpatient length of stay (LOS). DESIGN AND SETTING: Retrospective cohort study of all admissions through the ED to a tertiary hospital in Canberra, Australian Capital Territory, during 1999. MAIN OUTCOME MEASURES: Total time in the ED and LOS, calculated in days from ED departure to hospital discharge (non-overnight admissions were assigned LOS of one day, and all LOS were truncated at 10 days). RESULTS: 11 906 admissions were included, and 919 experienced access block (7.7%). Mean LOS was 4.9 days in those who experienced access block (95% CI, 4.7-5.1), compared with 4.1 days in the no-block group (95% CI, 4.0-4.2; P < 0.0001). Subgroup analysis showed that this "access block effect" occurred across different severities of illness and diagnoses. A strong relationship was found between longer LOS and arrival of access-block patients on the inpatient ward outside office hours (0800-1600 weekdays). CONCLUSIONS: This is the first study to show an association between access block and a measure of outcome outside the ED. If the effect of access block on LOS is reproduced in other settings, there are major implications for hospital management.     

入院特征预测急性左心功能不全老年患者住院时间长短的初步研究

目的探讨急性左心功能不全老年患者住院时间与入院特征的关系。方法回顾性分析244例急性左心功能不全的老年患者（≥60岁）的临床资料,观察其人口学、病史、临床表现及辅助检查等入院特征与住院时间的关系。结果男性147例,占60.2%,女性97例,占39.8%,平均年龄（68.6±7.2）岁,平均住院时间（10.1±10.3）d。统计分析结果显示,性别（P=0.004）、入院时心功能水平（P=0.02）及入院前症状恶化持续时间（P=0.013）与住院时间有相关性。结论急性左心衰老年患者性别、入院时心功能水平及院前症状恶化持续时间对住院时间有预示作用。     

Contrasting treatment and outcomes of septic shock: presentation on hospital floors versus emergency department

Background Patients with septic shock have a high mortality. This study used the Surviving Sepsis Campaign （SSC）database to compare characteristics, treatments and outcomes of septic shock patients diagnosed in the emergency department （ED） to patients developing septic shock on hospital floors （HF）.Methods The studied population included patients admitted to the intensive care unit （ICU） of an urban tertiary care medical center over an 18-month period. Acute physiology and chronic health evaluation （APACHE Ⅱ） scores, need for mechanical ventilation （MV）, performance on four of the SSC resuscitation bundle indicators, ICU length of stay （LOS）,hospital LOS and in-hospital mortality were ascertained.Results Sixty-six ED and 27 HF septic shock patients were included in this study. Urinary tract infections （UTI） and pneumonia were the two most common sites of infection in the ED patients. The sources of infection for HF septic shock patients were fairly well distributed across etiologies. The time to achieve superior vena cava oxygen saturation （ScvO2）＞ 70% in HF patients （（10.8±9.1） hours） was longer when compared to the ED patients （（6.6±-6.1） hours） （P ＜0.05）.Hospital mortality for the ED and HF patients were 25.8% and 59.3%, respectively （P ＜0.05）. Use of MV during the first 24 hours of shock was 44% in the ED patients and 70% in the HF patients （P ＜0.05） and was linked to mortality.Conclusions When compared to HF patients, ED septic shock patients have lower in-hospital mortality, there was less use of MV during the first 24 hours following onset of septic shock and the HF patients required a longer time to achieve target ScvO2. The need for mechanical ventilation is independently associated with increased mortality.     

Stroke in patients aged over 75 years: outcome and predictors.

The outcome and predictors of stroke rehabilitation were studied prospectively in 96 patients (mean age 81.3 +/- 5.4 years) admitted to geriatric wards from a well-defined area over one year. Of these, 32 (33%) died (median survival 11 days), 52 (54%) returned home (median hospital stay 69 days) and 12 (13%) required long-term care (median hospital stay 164 days). Deaths and discharges showed a bimodal pattern; nearly 40% of the patients died or were discharged within 2 weeks of admission. Early death correlated with level of consciousness (P = 0.02), neurological deficit (P = 0.01) and prestroke Barthel scores (P = 0.04) on admission. Patients with right- rather than left-sided hemiparesis (P = 0.02), good motor power (P = 0.002) and without sensory deficit/inattention (P = 0.002) were discharged early. Discharge home was adversely affected by poor awareness of deficit (P = 0.02), hemianopia (P = 0.03) and incontinence (P = 0.02) assessed at 2 weeks. Stroke survivors with Barthel score < 6 and Mental Test Score < 4 at 2 weeks after stroke required long-term care.     

British Columbia sends patients to Seattle for coronary artery surgery. Bypassing the queue in Canada

Concern about waiting lists for elective procedures has become a highly visible challenge to the universal health insurance program in Canada. In response to lengthening queues for patients waiting for cardiac surgery, British Columbia made contracts with four Seattle hospitals to send a total of 200 patients for coronary artery bypass surgery. This article examines the cause of the queue for cardiac surgery in British Columbia and the events that led to outside contracting. Global hospital budgets and restrictions on capital expansion have limited hospital capacity for cardiac surgery. This constrained supply, combined with periodic shortages in critical care nurses and cardiac perfusion technologists, has resulted in a rapid increase in the waiting list. Reducing wide variations in the lengths of queues for individual surgeons may afford an opportunity to reduce long waits. While the patient queue for cardiac surgery has sparked a public debate about budget limits and health care needs, its clinical impact remains uncertain.     

A prospective study of the process of assessment and care management in the discharge of elderly patients from hospital.

Assessment and care management (ACM) of elderly patients prior to discharge from hospital has been in place since 1993. It involves a complex multi-disciplinary assessment of needs which may delay discharge from hospital. We prospectively studied the process of ACM in a group of patients discharged from hospital over a three month period. The times taken for completion of the necessary reports, and any delays in the process were recorded. The times of each individual step in the process were correlated to overall length of stay and to the length of the care management process. The effect of intercurrent illnesses or other delays was studied. Of the available sample (n = 83), 16 patients died and two required long term hospital care. The median length of stay of the remainder (n = 65) was 36 days (range 5-149 days). The median time from the start of the ACM process to discharge was 22 days (0-89 days). The strongest correlation with total length of stay was the time from admission until ACM commenced (rho = 0.661, p < 0.0001). The time spent in the ACM process was related strongly to the time taken for the Care Manager to process the applications (rho = 0.682, p < 0.0001). Delay was recorded in 17 (24%) cases, resulting in an increased length of stay (p < 0.001). While care management may help in appropriate placement after hospital discharge, these results suggest that it is prone to delays outside the hospital setting. Such delays result in patients waiting in hospital for care packages to be set up in the community. This has implications for acute hospital services.     

Effect of an acute medical admission unit on key quality indicators assessed by funnel plots

Objective

To determine the effect of the introduction of an acute medical admissions unit (AMAU) on key quality efficiency and outcome indicator comparisons between medical teams as assessed by funnel plots.

Methods

A retrospective analysis was performed of data relating to emergency medical patients admitted to St James'' Hospital, Dublin between 1 January 2002 and 31 December 2004, using data on discharges from hospital recorded in the hospital in‐patient enquiry system. The base year was 2002 during which patients were admitted to a variety of wards under the care of a named consultant physician. In 2003, two centrally located wards were reconfigured to function as an AMAU, and all emergency patients were admitted directly to this unit. The quality indicators examined between teams were length of stay (LOS) <30 days, LOS >30 days, and readmission rates.

Results

The impact of the AMAU reduced overall hospital LOS from 7 days in 2002 to 5 days in 2003/04 (p<0.0001). There was no change in readmission rates between teams over the 3 year period, with all teams displaying expected variability within control (95%) limits. Overall, the performance in LOS, both short term and long term, was significantly improved (p<0.0001), and was less varied between medical teams between 2002 and 2003/04.

Conclusions

Introduction of the AMAU improved performance among medical teams in LOS, both short term and long term, with no change in readmissions. Funnel plots are a powerful graphical technique for presenting quality performance indicator variation between teams over time.     

Does age affect outcomes of out-of-hospital cardiopulmonary resuscitation?

We examined the relation between age and outcomes in patients treated for out-of-hospital cardiac arrest in Seattle, Wash. Considering all out-of-hospital cardiac arrests treated by paramedics over a recent 5-year period, 386 (27%) of 1405 consecutive patients aged 70 years or older were resuscitated and admitted to a hospital vs 474 (29%) of 1624 younger patients; 140 elderly patients (10%) were discharged alive vs 223 younger patients (14%). Of the 140 elderly patients, 112 went home and 28 went to a nursing home. Considering only patients whose initial rhythms were ventricular fibrillation, the percent of patients discharged alive was substantially higher: 120 (24%) of 493 for elderly patients and 194 (30%) of 639 for younger patients. Elderly patients can benefit from attempted resuscitation from out-of-hospital cardiac arrest.     

术前强化信息支持联合PMRT护理干预在胸腔镜下肺切除术病人中的应用效果

目的探讨术前实施强化信息支持联合渐进性肌肉放松训练(progressive muscle relaxation training,PMRT)护理干预对胸腔镜下肺切除术病人焦虑的影响。方法选取行胸腔镜下肺切除术的病人为研究对象,随机分成联合组和对照组,各30例,对照组采用术前手术室常规护理方案,联合组采取术前强化信息支持联合PMRT对病人进行干预,比较2组干预前后焦虑水平、镇静-躁动情况、血压、心率的变化和麻醉恢复室时长及住院时间。结果2组病人术前1 d常规访视时焦虑水平、心率、收缩压和舒张压差异均无统计学意义(P>0.05),联合组在手术室等候间和出手术室时焦虑水平、心率、收缩压和舒张压均低于对照组(P < 0.01)。2组手术前后各时间点焦虑水平、心率值、收缩压和舒张压间差异均有统计学意义(P < 0.05~P < 0.01),其中联合组各指标均呈现在手术室等候间升高,出手术室时下降的趋势(P < 0.05~P < 0.01),而对照组在手术室等候间和出手术室时各指标均高于术前1 d(P < 0.01),手术室等候间和出手术室时差异均无统计学意义(P>0.05)。2组躁动发生情况及住院时间差异均无统计学意义(P>0.05),而在麻醉恢复室停留时间上,联合组低于对照组(P < 0.01)。结论术前实施强化信息支持联合PMRT护理干预可以有效缓解胸腔镜下肺切除术病人术前和术后焦虑情绪。     

护理干预对COPD患者家庭使用无创呼吸机的作用

目的：探讨护理干预对慢性阻塞性肺疾病（COPD）患者家庭使用无创呼吸机的作用。方法选择14例有家庭使用无创呼吸机指征的慢性阻塞性肺疾病患者,住院治疗期间对患者及家属进行有关无创呼吸机使用方法及注意事项的指导,随访并观察患者家庭使用无创呼吸机的疗效。结果患者家属均能正确掌握无创呼吸机的使用方法和使用过程中的注意事项,有效改善了症状,减少了急性加重住院治疗的次数,改善了患者的生活质量。结论通过护理人员对COPD患者及家属的指导,可以有效提高其在家庭中使用呼吸机的操作技能及依从性,确保患者在家中得到较好的治疗和护理。     

Admission of nursing home patients to geriatric medical wards.

Comparison was made between patients admitted from a nursing home and all other patients admitted to a geriatric medical unit in 1990 and 1993. The number of nursing home patient admissions rose from 26 in 1990 to 106 in 1993. Nursing home patients were frailer both physically and mentally with a dementia rate of 78% (in those who survived, 1993) and a mortality rate of 19.8% (1993), compared with a dementia rate of 19% and a mortality rate of 11.3% in all other admissions in 1993. Male patients admitted from a nursing home were more likely to die than females (33% versus 14.5%, 1993). Lengths of stay of nursing home patients were shorter, largely due to the availability of a 'safe environment' when discharged, but also related to shorter survival times. 61% of patient admissions from nursing homes in 1993 were considered 'unnecessary' and could have been avoided if specialist advice had been available before admission.     

Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma

OBJECTIVE: To change standard practice from using nebulisers to metered dose inhalers and holding chambers (spacers) in children presenting with mild to moderate acute asthma. DESIGN: A before-after comparison of children with acute asthma presenting to the emergency department (ED) between August and October 1999 with those presenting between June and August 1997. SETTING: A tertiary care metropolitan children's hospital. INTERVENTIONS: Evidence-based clinical practice guidelines for using spacers were developed by a local multidisciplinary consensus process. A multifaceted guideline implementation program was used in 1999. MAIN OUTCOME MEASURES: Physician prescribing practices (spacer use); clinical outcomes (need for hospitalisation, admission to intensive care unit, and length of stay [LOS]). RESULTS: 75 of 247 children (30%; 95% CI, 25%-36%) required hospital admission in 1999. This was similar to the 1997 study period, when 95 of 326 (29%; 95% CI, 24%-34%) children were admitted. Of those with mild to moderate asthma, 160 (68%) received bronchodilators in the ED; 151 (94%) were initially treated with a spacer device in 1999. In 1997, no children were initially treated with spacers in the ED. The median (range) LOS in hospital for children with asthma of all severities was 1.7 (0.5-19.8) days in 1999 and 1.7 (0.2-7.6) days in 1997 (P=0.85). CONCLUSIONS: We successfully changed standard practice from using nebulisers to spacers for bronchodilator delivery in children with mild to moderate acute asthma, with no difference in the need for or duration of hospitalisation.     

A review of burns patients admitted to the Burns Unit of Hospital Universiti Kebangsaan Malaysia

This is a retrospective review of 110 patients admitted to the Burns Units between October 1999 and November 2001. The aim was to determine the burns pattern of patients admitted to hospital UKM. There was an increasing trend for patients admitted. Female to male ratio was 1:2. Children consisted 34% of the total admission. Children had significant higher number of scald burns as compare to adult (p < 0.01). Domestic burns were consist of 75% overall admission. Mean percentage of TBSA (total body surface area) burns was 19%. Thirty percent of patients sustained more than 20% of TBSA. Sixty percent of patients had scald burns. Ninety percents of patients with second degree burns that were treated with biologic membrane dressing or split skin graft. Mean duration of hospital stay was 10 days. Over 70% of patients were discharged within 15 days. Overall mortality rate was 6.3%. The patients who died had significantly larger area of burns of more than 20% TBSA (p < 0.05) and a higher incidence of inhalation injury (p < 0.02). Hence, this study suggests a need for better preventive measures by the authority to prevent burns related accident and the expansion of the service provided by the Burns Unit.