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Abstract

Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.
63
Copyright © 2016 The Korean Society of Emergency Medicine
Improving emergency department
patient flow
Paul Richard Edwin Jarvis
Emergency Department, Calderdale & Huddersfield NHS Foundation Trust, West Yorkshire, UK
Emergency departments (ED) face significant challenges in delivering high quality and timely
patient care on an ever-present background of increasing patient numbers and limited hospital
resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads
to poor patient flow and departmental crowding. These are associated with reduction in the
quality of the care delivered and poor patient outcomes. A literature review was performed to
identify evidence-based strategies to reduce the amount of time patients spend in the ED in or-
der to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid as-
sessment, streaming and the co-location of a primary care clinician in the ED have all been
shown to improve patient flow. In addition, when used effectively point of care testing has been
shown to reduce patient time in the ED. Patient flow and departmental crowding can be im-
proved by implementing new patterns of working and introducing new technologies such as
point of care testing in the ED.
Keywords Emergency department; Patient flow; Improvement
Clin Exp Emerg Med 2016;3(2):63-68
http://dx.doi.org/10.15441/ceem.16.127
eISSN: 2383-4625
Review Article
Received: 15 February 2016
Revised: 2 March 2016
Accepted: 2 March 2016
Correspondence to:
Paul Richard Edwin Jarvis
Emergency Department, Calderdale
Royal Hospital, Dryclough Lane, Halifax,
West Yorkshire HX3 0PW, UK
E-mail: paul.jarvis@cht.nhs.uk
How to cite this article:
Jarvis RE. Improving emergency department
patient flow. Clin Exp Emerg Med
2016;3(2):63-68.
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/4.0/).
What is already known
Published literature on improving patient flow in the emergency department is
often contradictory.
What is new in the current study
This study identifies those factors that have been shown to improve patient
flow within the emergency department.
64 www.ceemjournal.org
Improving emergency department patient flow
INTRODUCTION
Across the world emergency departments (EDs) are facing incre-
asing challenges due to growing patient numbers and an inability
to flex capacity to meet demand. This is on a background of de-
creasing hospital resources. Consequently, ED crowding has be-
come an ubiquitous, international phenomenon. Approximately
half of all EDs report operating near or above maximum capacity.1
Several studies have presented evidence that ED crowding con-
tributes to a reduction in the quality of patient care,2-8 delays in
commencement of treatment9,10 and that adherence with recog-
nised guidelines worsens.11 The link between ED crowding and
mortality is increasingly being recognised.12,13 Another symptom
of overcrowding is patients leaving without their care being com-
pleted. In the United States this accounts for 2% of all ED visits.14
Crowding occurs when demands placed on the ED are greater
than the entire hospitals capacity to ensure timely care in the ED.
The factors that contribute to poor ED performance can be classi-
fied as being either intrinsic or extrinsic to the ED.3 Departmental
layout and staffing levels are examples of intrinsic factors that
influence patient flow, whereas exit block related to the lack of
inpatient bed availability and surges in patient demand are fac-
tors extrinsic to the ED that influence patient flow. The impact
that the wider hospital system has on patient flow in the ED should
not be underestimated. Blom et al.15 showed that the probability
of a patient being admitted from the ED is negatively correlated
to inpatient bed occupancy.
Improving patient flow within the ED is ultimately achieved by
reducing the amount of time patients spend in the ED, thereby
reducing departmental crowding. Shorter patient journey times
are associated with improved patient satisfaction16 and reduc-
tions in mortality and morbidity.17,18
The aim of this article is to review the evidence relating to strat-
egies to reduce the amount of time patients spend in the ED in
order to improve patient throughput in the ED.
DOCTOR TRIAGE
Triage is a brief intervention that should occur ideally within 15
minutes of the patient’s arrival in the ED.4,19 The aim of triage is
to risk stratify patient presentations and prioritise them accord-
ingly as a way of allocating limited resources, such as staff and
physical space based on their clinical need.5 Nurse-led triage is
currently the international standard triage model throughout the
world20,21 and there is insufficient evidence of any one triage scale
being more effective than another.6 Utilising the triage nurse to
request investigations, such as blood tests and X-rays, has been
shown to be associated with earlier diagnosis, shorter waiting
times and faster patient throughput in the ED.22-24 For this system
to be effective there has to be a robust training programme, pro-
tocols and a standardised approach to investigation.
Doctor-led triage is often cited as a possible solution to poor
ED flow.5 It is important to differentiate having a doctor embed-
ded in the triage process from other models of ED working such
as ‘see and treat’ (or ‘fast-track’). Triage is the initial assessment
of undifferentiated patients, whereas see and treat identifies pa-
tients without serious illness or injury who are likely to have the
potential for prompt discharge.
Rowe et al.5 evaluated the impact of having a doctor, of any
grade, assisting the triage process. They demonstrated that a phy-
sician in triage is an effective intervention to alleviate the effects
of ED crowding. Triage performed specifically by a senior doctor
has been proposed as a way of accelerating patient flow through
the ED, reducing admissions and improving the time to key deci-
sion making.2 This is done by initiating prompt patient assessment,
appropriate diagnostic testing and initiating treatment earlier in
the patient’s journey. This includes the identification of definite
admissions and expediting swifter and safer discharge of patients
not requiring further investigation or treatment.
A review confirmed that having a senior doctor in triage im-
pacted positively upon many ED metrics and concluded that it
offers a valuable solution to ED crowding.25 Another systematic
review found senior doctors, working individually at the front door
of the ED or as part of a wider triage team is associated with a
reduction in overall ED patient journey time and the length of
time from the patient arriving to them being assessed by a doc-
tor.5 Although it appears, as a model of working, doctor triage is
beneficial to patient flow in the ED, the heterogeneous nature of
the role of the doctor in these studies means it is difficult to de-
termine the most efficient and effective model for senior doctor
triage.
RAPID ASSESSMENT MODELS
Rapid assessment is the assessment, investigation, and initial treat-
ment of patients as soon as they arrive in the ED. This model uti-
lises the principle of single piece flow more commonly found in
the automotive manufacturing industry.26 Essentially early assess-
ment and investigation coupled with prompt initiation of treat-
ment aims to reduce the amount of waiting time that occurs be-
tween each of these steps in the traditional model. Typically these
are patients that do not require resuscitation room or high de-
pendency unit treatment.27
A review article demonstrated that utilising a rapid assessment
65
Clin Exp Emerg Med 2016;3(2):63-68
Paul Richard Edwin Jarvis
model reduces the overall journey time of patients in the ED. This
review article also demonstrated that the length of time it takes
for patients to be seen by a doctor is reduced when a rapid as-
sessment model is utilised.27
The costs of implementing such system is often cited as a bar-
rier to its introduction. However there is evidence that altering
the existing work pattern within the ED and introducing a rapid
assessment model within the confines of existing departmental
resources is associated with improved patient flow.28
STREAMING
Streaming is the process of allocating similar patients (with re-
gards to disease severity or nature of complaint) to a particular
work stream. Typically, patients in each work stream are assessed
by dedicated staff in a specific geographical area within the ED.
For example, ‘see and treat’ is a form of streaming where patients
with less severe illnesses are allocated to a dedicated clinical area
and receive assessment and treatment from a clinical team only
seeing ‘see and treat’ patients. By its nature, triage leads to a build
up of relatively well patients in the ED as critically ill patients are
seen preferentially. However, streaming ensures less urgent pa-
tients continue to be seen in a timely manner. The individual pa-
tient work streams in the ED can be staffed by senior doctors,
nurse practitioners, physician’s assistants or a combination of all
of these.22
There is little evidence to support the use of streaming patients
according to their triage categories as a means of redirecting pa-
tients from hospital EDs to other clinical settings outside of the
hospital, such as primary care.3
There is evidence that dividing ED patients into work streams
results in reduced waiting times and shorter ED journey times
when compared with a non-streamed ED model.22 The effective-
ness of this strategy is likely to be dependent upon how patients
are signposted towards the different streams within the ED and
whether there is appropriate staffing and physical space to meet
the patient demand of each individual work stream.29
There is limited evidence that dividing patients entirely based
upon whether they are likely to be admitted or not has any bene-
fit on ED patient flow.22
PRIMARY CARE CO-LOCATED IN THE ED
Two reviews have evaluated the effectiveness of utilising primary
care clinicians within the ED setting for patients with less urgent
clinical problems.30,31 There was insufficient evidence comparing
the safety of care provided by general practitioners in the ED com-
pared with emergency physicians. However, there is some evidence
to suggest there is a potential for cost savings as general practi-
tioners tend to order fewer tests and fewer admissions31,32 whilst
patient satisfaction was increased.32 The waiting time for ED pa-
tients in hospitals with a co located general practitioner service
was on average 19% less than patients attending EDs without a
primary care service.33
POINT-OF-CARE TESTING
Point-of-care testing (POCT) provides clinicians with rapid results
for commonly ordered investigations. Moving laboratory standard
testing into the ED could increase the speed of diagnosis. Numer-
ous reports have highlighted a reduction in turnaround times for
investigation results utilising POCT in an emergency setting.22,34-37
A systematic review performed in 2011 showed that the introduc-
tion of POCT in the ED may reduce the total patient journey time
in the ED.22 More recent studies have demonstrated a similar mod-
est reduction in the amount of time a patient spends in the ED
before a disposition decision is reached when POCT is utilised.36,37
Norgaard and Mogensen38 compared laboratory turnaround
times when utilising POCT in the ED with centralised laboratory
testing with an air-tube transport system for the rapid transport
of blood samples. They showed that in this setting POCT yielded
results on average 46 minutes earlier than from the central labo-
ratory.
A multicentre randomised controlled study performed in the
United Kingdom evaluated the performance of POCT in the ED
examining cardiac biomarkers in patients with suspected myo-
cardial infarction.39 This study demonstrated a discharge rate
which was 20% greater in patients who had blood analysed by
POCT. Interestingly, this study demonstrated a greater effect in
district general hospitals rather when compared with large uni-
versity-affiliated teaching hospitals. This phenomenon has been
demonstrated by other authors.40 Interestingly, recent evidence
suggests that POCT can add value when used in the prehospital
setting and may reduce the number of patients brought to the
ED.41-43
Blood sample POCT is most commonly performed by nursing
staff in the ED.44 To ensure quality assurance there needs to be a
robust training programme in place reinforced with regular recer-
tification. This places an additional burden on members of staff
who already have heavy workloads. However, improvements in
patient flow seen within the ED as a result of the introduction of
POCT are likely to reduce staff workload.44
The cost of a single test performed utilising POCT is higher than
the cost of a similar test performed in a centralised laboratory.36
66 www.ceemjournal.org
Improving emergency department patient flow
However, Rooney and Schilling44 state that the time saved elimi-
nating steps when POCT is introduced, such as the sample trans-
portation, registration of the sample in the laboratory and time
spent retrieving results, means the cost of utilising POCT seldom
exceeds those of analysis in a centralised laboratory. An Austra-
lian study performed in 2014 concluded that each hour of patient
time saved by utilising POCT costs approximately 120 Australian
dollars (84.69 US dollars).36
Jarvis et al.45 combined POCT with consultant-led rapid assess-
ment in the ED and demonstrated a 40% reduction in disposition
decision time. This would support the idea that the overall effec-
tiveness is dependent upon the processes within the ED.
The actual impact of implementing POCT in a specific ED varies
greatly. Presumably, the overall effect POCT has on patient jour-
ney times is dependent on the effectiveness and productivity in
the rest of the ED. Consequently, ED working patterns may require
substantial modification to maximise the benefits of POCT. When
used effectively, POCT has been shown to reduce delays to the
initiation of treatment, increase patient discharge rates and de-
crease total ED journey time.45
CONCLUSION
Poor patient flow, and the resulting crowding, represents a signif-
icant restriction on the ED’s ability to deliver high quality emer-
gency and urgent care. Excessive patient waiting, slow investiga-
tion turnaround times and delays in making disposition decisions
are key factors intrinsic to the ED which affect patient flow.
The association between increased ED mortality rates and de-
partmental crowding12,13 suggest that crowding should be treated
as a significant public health concern. It is influenced by factors
in the pre-hospital, wider hospital setting, community and social
care and should not be considered as a problem based entirely in
the ED. Nevertheless, the significance of these extrinsic factors
should not disempower EDs from improving their processes and
work patterns to assist patient flow.
The use of doctor triage, rapid assessment, streaming and the
co-location of a primary care clinician in the ED have all been
shown to improve patient flow. In addition, when used effectively
POCT has been shown to reduce delays in disposition decisions
being made and increase timely patient discharge rates with an
associated reduction in the overall total patient journey time. There
is an elevated cost when compared with laboratory testing on a
test for test basis.36 However, these increased costs may be out-
weighed by improvements in patient flow.44
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was re-
ported.
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... At an operational level, this has resulted in bottlenecks [5,14,22] adding to longer waiting times [23] and inefficient care [24]. These factors are also associated with overcrowding in EDs, a problem that has raised global concern [3,6,15,[25][26][27][28][29][30][31][32][33][34], patients who have left the department before being seen by a clinician, and excessive patient flow time [35]. ...
... To date, several approaches have been trialled to address ED bottlenecks [18,23,34,35,[56][57][58]. Some of these have involved real-world interventions such as doctor-led triage, rapid assessment, fast tracking, streaming, alternative admission options during periods of access block, expansion of nursing scope of practice, the co-location of a primary care clinician in the ED, and Point-of-Care Testing (POCT), which have yielded varying degrees of success [34,56,58]. ...
... To date, several approaches have been trialled to address ED bottlenecks [18,23,34,35,[56][57][58]. Some of these have involved real-world interventions such as doctor-led triage, rapid assessment, fast tracking, streaming, alternative admission options during periods of access block, expansion of nursing scope of practice, the co-location of a primary care clinician in the ED, and Point-of-Care Testing (POCT), which have yielded varying degrees of success [34,56,58]. Other solutions broadly classified under lean, Six Sigma, and continuous quality improvement have also been applied to examine healthcare processes [17,35] including those related to ED bottlenecks [25,59]. ...
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... An essential role of a hospital emergency department (ED) is to prioritize treatment for patients according to urgency and symptom severity [1]. This role is related to the nature of ED work, where unpredictable situations often occur, and resources are limited owing to crowding [2,3]. Because emergency care demands higher efficacy to manage growing patient volumes, a prompt and evidence-based triage system is required to provide safe and optimal care [4]. ...
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Background Natural language processing has been established as an important tool when using unstructured text data; however, most studies in the medical field have been limited to a retrospective analysis of text entered manually by humans. Little research has focused on applying natural language processing to the conversion of raw voice data generated in the clinical field into text using speech-to-text algorithms. Objective In this study, we investigated the promptness and reliability of a real-time medical record input assistance system with voice artificial intelligence (RMIS-AI) and compared it to the manual method for triage tasks in the emergency department. Methods From June 4, 2021, to September 12, 2021, RMIS-AI, using a machine learning engine trained with 1717 triage cases over 6 months, was prospectively applied in clinical practice in a triage unit. We analyzed a total of 1063 triage tasks performed by 19 triage nurses who agreed to participate. The primary outcome was the time for participants to perform the triage task. Results The median time for participants to perform the triage task was 204 (IQR 155, 277) seconds by RMIS-AI and 231 (IQR 180, 313) seconds using manual method; this difference was statistically significant (P<.001). Most variables required for entry in the triage note showed a higher record completion rate by the manual method, but in the recording of additional chief concerns and past medical history, RMIS-AI showed a higher record completion rate than the manual method. Categorical variables entered by RMIS-AI showed less accuracy compared with continuous variables, such as vital signs. Conclusions RMIS-AI improves the promptness in performing triage tasks as compared to using the manual input method. However, to make it a reliable alternative to the conventional method, technical supplementation and additional research should be pursued.
... One possible strategy for reducing crowding in emergency departments is co-location of primary care services in the emergency department [16]. However, recent reviews suggest that evidence regarding effectiveness and safety of patient streaming to primary care services is limited and outdated [17,18]. ...
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Background Patient numbers in emergency departments are on the rise. The DEMAND intervention aims to improve the efficacy of emergency services by computer-assisted structured initial assessment assigning patients to emergency departments or primary care practices. The aims of our study were to evaluate patient satisfaction with this intervention and to analyse if reduced patient satisfaction is predicted by sociodemographic data, health status or health literacy. Methods We conducted a cross-sectional patient survey in emergency departments and co-located primary care practices. Each intervention site was planned to participate for two observation periods, each with a duration of one full week. Study participants were recruited by the local staff. The patients filled out a written questionnaire during their waiting time. Patient satisfaction was assessed by agreement to four statements on a four point Likert scale. Predictors of patient satisfaction were identified by multilevel, multivariable logistic regression models adjusted for random effects at the intervention site level. Results The sample included 677 patients from 10 intervention sites. The patients had a mean age of 38.9 years and 59.0% were women. Between 67.5% and 55.0% were fully satisfied with aspects of the intervention. The most criticised aspect was that the staff showed too little interest in the patients’ personal situation. Full satisfaction (“clearly yes” to all items) was reported by 44.2%. Reduced patient satisfaction (at least one item rated as “rather yes”, “rather no”, “clearly no”) was predicted by lower age (odds ratio 0.79 for ten years difference, 95% confidence interval 0.67/0.95, p = 0.009), presenting with infections (3.08,1.18/8.05, p = 0.022) or injuries (3.46,1.01/11.82, p = 0.048), a higher natural logarithm of the symptom duration (1.23,1.07/1.30, p = 0.003) and a lower health literacy (0.71 for four points difference, 0.53/0.94, p = 0.019). Conclusions The patients were for the most part satisfied with the intervention. Assessment procedures should be evaluated a) regarding if all relevant patient-related aspects are included; and whether patient information can be improved b) for patients with strong opinions about cause, consequences and treatment options for their health problem; and c) for patients who have problems in the handling of information relevant to health and healthcare. Trial registration German Clinical Trials Register ( https://www.drks.de/drks_web/setLocale_EN.do ) no. DRKS00017014.
... Absenteeism would likely correlate with hospital length of stay, which is a driver of cost savings in the PSP diagnostic arm. The rapidity and diagnostic accuracy of a point-of-care PSP test would improve ED efficiency, reduce crowding, and avoid costs associated with misdiagnosis, delay to treatment and decline in procedural accuracy [44][45][46]. It would also prevent many missed diagnoses due to improved sensitivity, thereby potentially limiting the number of severity-related deaths from delayed treatment. ...
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Background Sepsis is a life-threatening organ dysfunction in response to infection. Early recognition and rapid treatment are critical to patient outcomes and cost savings, but sepsis is difficult to diagnose because of its non-specific symptoms. Biomarkers such as pancreatic stone protein (PSP) offer rapid results with greater sensitivity and specificity than standard laboratory tests. Methods This study developed a decision tree model to compare a rapid PSP test to standard of care in the emergency department (ED) and intensive care unit (ICU) to diagnose patients with suspected sepsis. Key model parameters included length of hospital and ICU stay, readmission due to infection, cost of sepsis testing, length of antibiotic treatment, antibiotic resistance, and clostridium difficile infections. Model inputs were determined by review of sepsis literature. Results The rapid PSP test was found to reduce costs by $1688 per patient in the ED and $3315 per patient in the ICU compared to standard of care. Cost reductions were primarily driven by the specificity of PSP in the ED and the sensitivity of PSP in the ICU. Conclusions The results of the model indicate that PSP testing is cost saving compared to standard of care in diagnosis of sepsis. The abundance of sepsis cases in the ED and ICU make these findings important in the clinical field and further support the potential of sensitive and specific markers of sepsis to not only improve patient outcomes but also reduce healthcare expenditures.
... The Newfoundland and Labrador provincial government and the province's 4 regional health authorities (RHAs) have the option of expanding the health care workforce [11,12] at a time of historic fiscal restraint or finding effective interventions to improve the efficiency of their current ED service [13]. Overtime [14][15][16], expanding the ED [17,18] and redirecting patients to primary care [19,20] have not been shown to be effective. ...
... Other hospitals with limited data may adopt a similar approach of discovering useful variables that may differ from variables/characteristics used in this and previous research to develop a prediction model.Although the output of this prediction model could be used as a binary score, the output as a probability would have far more use in practice. For ED clinician use, instead of limiting the predictive capabilities to admission or discharge, the probability output could be used for streaming into "assessment for admission," "fast track for discharge," and "senior review." 3 Compared to a non-streamed approach, evidence has shown that grouping ED patients into work streams results in a reduction in wait times and a shorter length of stay in the ED, with limited evidence that grouping patients solely based on whether or not they are going to be hospitalized improves ED patient flow.38,39 Sun et al37 proposed the model threshold should be adjusted based on the intended use in practice (clinician or bed manager). ...
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Objectives: This study aims to develop and internally validate a low-dimensional model to predict outcomes (admission or discharge) using commonly entered data up to the post-triage process to improve patient flow in the pediatric emergency department (ED). In hospital settings where electronic data are limited, a low-dimensional model with fewer variables may be easier to implement. Methods: This prognostic study included ED attendances in 2017 and 2018. The Cross Industry Standard Process for Data Mining methodology was followed. Eligibility criteria was applied to the data set, splitting into 70% train and 30% test. Sampling techniques were compared. Gradient boosting machine (GBM), logistic regression, and naïve Bayes models were created. Variables of importance were obtained from the model with the highest area under the curve (AUC) and used to create a low-dimensional model. Results: Eligible attendances totaled 72,229 (15% admission rate). The AUC was 0.853 (95% confidence interval [CI], 0.846-0.859) for GBM, 0.845 (95% CI, 0.838-0.852) for logistic regression and 0.813 (95% CI, 0.806-0.821) for naïve Bayes. Important predictors in the GBM model used to create a low-dimensional model were presenting complaint, triage category, referral source, registration month, location type (resuscitation/other), distance traveled, admission history, and weekday (AUC 0.835 [95% CI, 0.829-0.842]). Conclusions: Admission and discharge probability can be predicted early in a pediatric ED using 8 variables. Future work could analyze the false positives and false negatives to gain an understanding of the implementation of these predictions.
... Overcrowding in emergency departments (ED) is a widely recognized problem that negatively impacts patient care [1,2]. Given that up to 70% of medical decisions are based on laboratory testing [3], faster turn-around times (TAT) with point-of-care testing (POCT) appears to be a promising way to improve both clinical decision making and clinical effectiveness [4,5]. However, better patient outcomes [6,7] can only be achieved if the POC diagnostic is performed by a trained healthcare professional and if the results obtained are accurate and reliable [8]. ...
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Background: Point-of-care testing (POCT) provides shorter turn-around times and, in many cases, potentially improves medical decision making. The AQT90 FLEX® benchtop immunoanalyzer (Radiometer Medical ApS, Copenhagen, Denmark) allows for the determination of beta-human chorionic gonadotropin (βhCG) in 18 min. The main aim of this study was to evaluate the impact of measuring βhCG using the AQT90 analyzer in the gynecology emergency department (ED) compared to the standard practice of using central laboratory blood testing on the patient length of stay (LOS). Methods: The evaluation consisted of two parts. The first one, conducted in the central laboratory, focused on the analytical performances of the AQT βhCG assay. The second one, conducted in the ED, aimed at determining the impact of POCT βhCG implementation on the timeframe in which ED patients require βhCG assessment. Results: The within-lab imprecisions at the mean values of 17 and 287 IU/L were 2.7% and 3.7%, respectively. Using Deming regression (n = 60), the following equation was obtained in the central lab: AQT90 βhCG = 1.1 Roche βhCG-12.9 (r = 0.997). The implementation of POCT βhCG in the ED significantly reduced patient LOS (145 (90-212) min vs. 205 (155-265) with and without AQT90, respectively, p < 0.001). At the 2 IU/L decision level, a 99.7% agreement with the Roche assay was reported (kappa statistics, 0.99). Conclusions: We confirm that the analytical qualities of the AQT 90 were in line with those obtained in the central lab. The implementation of the POCT βhCG is associated with a shorter LOS in the ED due to the faster availability of the results and the faster decision-making possibilities.
... Internationally, the EDs are confronted with a growing demand for their services as the number of unplanned contacts increases [1][2][3][4]. ...
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Background Emergency departments (EDs) experience an increasing number of patients. High patient flow are incentives for short duration of ED stay which may pose a challenge for patient diagnostics and care implying risk of ED revisits or increased mortality. Four hours are often used as a target time to decide whether to admit or discharge a patient. Objective To investigate and compare the diagnostic pattern, risk of revisits and short-term mortality for ED patients with a length of stay of less than 4 h (visits) with 4–24 h stay (short stay visits). Methods Population-based cohort study of patients contacting three EDs in the North Denmark Region during 2014–2016, excluding injured patients. Main diagnoses, number of revisits within 72 h of the initial contact and mortality were outcomes. Data on age, sex, mortality, time of admission and ICD-10 diagnostic chapter were obtained from the Danish Civil Registration System and the regional patient administrative system. Descriptive statistics were applied and Kaplan Meier mortality estimates with 95% CI were calculated. Results Seventy-nine thousand three hundred forty-one short-term ED contacts were included, visits constituted 60%. Non-specific diagnoses (i.e. symptoms and signs and other factors) were the most frequent diagnoses among both visits and short stay visits groups (67% vs 49%). Revisits were more frequent for visits compared to short stay visits (5.8% vs 4.2%). Circulatory diseases displayed the highest 0–48-h mortality within the visits and infections in the short stay visits (11.8% (95%CI: 10.4–13.5) and (3.5% (95%CI: 2.6–4.7)). 30-day mortality were 1.3% (95%CI: 1.2–1.5) for visits and 1.8% (95%CI: 1.7–2.0) for short stay visits. The 30-day mortality of the ED revisits with an initial visit was 1.0% (0.8–1.3), vs 0.7% (0.7–0.8) for no revisits, while 30-day mortality nearly doubled for ED revisits with an initial short stay visit (2.5% (1.9–3.2)). Conclusions Most patients were within the visit group. Non-specific diagnoses constituted the majority of diagnoses given. Mortality was higher among patients with short stay visits but increased for both groups with ED revisits. This suggest that diagnostics are challenged by short time targets.
Background In comparison to general trauma patients, loss of skin barrier amongst the burns cohort predisposes them to a higher risk of nosocomial infections and sepsis, and this often leads to unfavourable morbidity and mortality outcomes. Purpose This integrative review aimed to explore existing literature to identify risk factors related to nosocomial infections and/or sepsis in adult burns patients following hospital admission. Methods Electronic searches for journals published between 2007 and 2021 were performed in CINAHL, Scopus and Medline, and key journals were hand-searched. Inclusion criteria was: (1) peer-reviewed, primary studies; (2) qualitative, quantitative or mixed-methods studies; (3) study participants had sustained burns-related injury and developed nosocomial infections and/or sepsis during the course of hospitalisation. Studies were appraised using the Critical Appraisal Skill Program checklists. Results 15 studies ranging from ‘poor’ to ‘fair’ to ‘moderate’ quality were included in the final review. Patient factors that contributed to the development of nosocomial infections and/ or sepsis included: (1) Full thickness burns; (2) age; (3) % Total Burns Surface Area; and (4) Herpes Simplex Virus activation. Several provider-system risk factors were identified by ‘poor’ quality studies and further research is required to substantiate those findings. Discussion Findings remained inconclusive due to the lack of ‘good’ quality studies however, there was an overemphasis on patient-related risk factors instead of healthcare workers or the system. Future research may focus on activation of the latest infection prevention strategies and early enforcement of care bundles. Through identification of related risk factors, it may reduce the incidence of nosocomial infection and/or sepsis post-burns.
Article
Objective The goal of this quality improvement project was to improve timing, communication, and continued care for pediatric patients who present to the emergency department at a Level I pediatric trauma center and require inpatient admission. Methods Using continuous improvement methodology, a patient flow process was created to improve the throughput of pediatric patients requiring inpatient admission from the emergency department, aimed at decreasing the time from decision to admit to actual admission. The new workflow included ED and inpatient nursing collaboration, with nursing leaders coordinating patient transfer. Results Baseline data indicated that, in 2019, patients admitted to a short-stay pediatric unit from the emergency department had an average time of 106.8 minutes from decision to admit to the actual admission. After the implementation of a new admission process, time from decision to admit to actual admission decreased from a mean of 106.8 minutes to 82.84 minutes for patients admitted to a short-stay unit. This illustrates an improvement from 59.75% to 68.75% of patients admitted within 60 minutes from ED admission to arrival on a short-stay unit. This model was then replicated throughout other units in the hospital. Conclusion There are no known benchmark data to guide practice for rapid admission from the pediatric emergency department to inpatient units and continuing care. This quality improvement project demonstrates a model that has been successful admitting patients in an efficient, time-controlled manner. Additional research is needed to document benchmarks for admission timing and to demonstrate other measurable outcomes in patient care.
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To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators. Systematic review. Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies. Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data. Narrative synthesis and meta-analysis of homogenous data were performed. Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified. This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Emergency departments (EDs) face several challenges in maintaining consistent quality care in the face of steadily increasing public demand. Improvements in the survival rate of critically ill patients in the ED are directly related to the advancement of early recognition and treatment. Frequent episodes of overcrowding and prolonged waiting times force EDs to operate beyond their capacity and threaten to impact upon patient care. The objectives of this review are as follows: (a) to establish overcrowding as a threat to patient outcomes, person-centered care, and public safety in the ED; (b) to describe scenarios in which point-of-care testing (POCT) has been found to ameliorate factors thought to contribute to overcrowding; and (c) to discuss how POCT can be used directly, and indirectly, to expedite patient care and improve outcomes. Various studies have shown that overcrowding in the ED has profound effects on operational efficiency and patient care. Several reports have quantified overcrowding in the ED and have described a relationship between heightened periods of overcrowding and delays in treatment, increased incidence of adverse events, and an even greater probability of mortality. In certain scenarios, POCT has been found to increase the number of patients discharged in a timely manner, expedite triage of urgent but non-emergency patients, and decrease delays to treatment initiation. This review concludes that POCT, when used effectively, may alleviate the negative impacts of overcrowding on the safety, effectiveness, and person-centeredness of care in the ED.
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The association between emergency department (ED) overcrowding and poor patient outcomes is well described, with recent work suggesting that the phenomenon causes delays in time-sensitive interventions, such as resuscitation. Even though most researchers agree on the fact that admitted patients boarding in the ED is a major contributing factor to ED overcrowding, little work explicitly addresses whether in-hospital occupancy is associated to the probability of patients being admitted from the ED. The objective of the present study is to investigate whether such an association exists. Retrospective analysis of data on all ED visits to Helsingborg General Hospital in southern Sweden between January 1, 2011, and December 31, 2012, was undertaken. The fraction of admitted patients was calculated separately for strata of in-hospital occupancy <95%, 95-100%, 100-105%, and >105%. Multivariate models were constructed in an attempt to take confounding factors, e.g., presenting complaints, age, referral status, triage priority, and sex into account. Subgroup analysis was performed for each specialty unit within the ED. Overall, 118,668 visits were included. The total admitted fraction was 30.9%. For levels of in-hospital occupancy <95%, 95-100%, 100-105%, and >105% the admitted fractions were 31.5%, 30.9%, 29.9%, and 28.7%, respectively. After taking confounding factors into account, the odds ratio for admission were 0.88 (CI 0.84-0.93, P >0.001) for occupancy level 95-100%, 0.82 (CI 0.78-0.87, P >0.001) for occupancy level 100-105%, and 0.74 (CI 0.67-0.81, P >0.001) for occupancy level >105%, relative to the odds ratio for admission at occupancy level <95%. A similar pattern was observed upon subgroup analysis. In-hospital occupancy was significantly associated with a decreased odds ratio for admission in the study population. One interpretation is that patients who would benefit from inpatient care instead received suboptimal care in outpatient settings at times of high in-hospital occupancy. A second interpretation is that physicians admit patients who could be managed safely in the outpatient setting, in times of good in-hospital bed availability. Physicians thereby expose patients to healthcare-associated infections and other hazards, in addition to consuming resources better needed by others.
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Objective To determine if time to disposition decisions for emergency department (ED) patients can be reduced when blood tests are processed using point-of-care (POC) devices and to conduct a cost-effectiveness analysis of POC compared with laboratory testing. Methods This randomised trial enrolled adults suspected of an acute coronary syndrome or presenting with conditions considered to only require blood tests available by POC. Participants were randomised to have blood tests processed by POC or laboratory. Outcomes measured were time to disposition decision and ED length-of-stay (LOS). The cost-effectiveness analysis calculated the total and mean costs per ED presentation, as well as total and mean benefits in time saved to disposition decision. Results There were 410 POC participants and 401 controls. The mean times to a disposition decision for POC versus controls were 3.24 and 3.50 h respectively, a difference of 7.6% (95% CI 0.4% to 14.3%, p=0.04), and 4.32 and 4.52 h respectively for ED LOS, a difference of 4.4% (95% CI −2.7% to 11.0%, p=0.21). Improved processing time was greatest for participants enrolled by senior staff with a reduction in time to disposition decision of 19.1% (95% CI 7.3% to 29.4%, p<0.01) and ED LOS of 15.6% (95% CI 4.9% to 25.2%, p=0.01). Mean pathology costs were $12 higher in the POC group (95% CI $7 to $18) and the incremental cost-effectiveness ratio was $113 per hour saved in time to disposition decision for POC compared with standard laboratory testing. Conclusions Small improvements in disposition decision time were achieved with POC testing for a moderate increase in cost. Greatest benefit may be achieved when POC is targeted to senior medical staff.
Article
Background: Overcrowding in the emergency department (ED) is a common phenomenon. The aim of this study was to quantify the impact introducing point-of-care testing (POCT) for renal function has on the length of time patients spend in the ED. Methods: A prospective, observational cohort study was conducted in an ED in the United Kingdom. The study consisted of 2 consecutive phases. Patients that attended the ED during phase 1 had their renal function investigated using the hospital’s centralized laboratory analyzer. Phase 2 patients requiring renal function analysis were investigated in the ED using a bedside POCT analyzer. The time from patient arrival in the ED to the time the patient was ready to move onto the next destination of care was recorded. Results: Twenty-five thousand seven hundred nine patients attended the ED during the whole study period. Ten thousand eight hundred sixty-eight patients were eligible for the study. Phase 1 contained 3835 patients, and phase 2 had 7033 patients. A 15.5% reduction in the median time for patients to be declared ready to leave the ED was demonstrated. The median time for phase 1 was 129 minutes compared with 109 minutes for phase 2 (P = 0.0025). Conclusions: This study demonstrates that using POCT for renal function in the ED was significantly quicker than using a centralized hospital laboratory. The use of a bedside POCT device enables clinicians to make informed clinical decisions in a timelier manner. This research was supported by a grant from Abbott Point of Care.
Article
Background: Overcrowding in the emergency department is a common phenomenon. This study assessed the impact of introducing a consultant-supported rapid assessment model, known as EDIT, and point of care testing upon the length of time patients spend in the emergency department. Methods: A prospective, observational cohort study was conducted in an emergency department in a district general hospital in the UK. The study consisted of two phases. Patients who attended the emergency department during phase 1 were assessed using a nurse-led triage model with blood samples being analysed in a centralized hospital laboratory. Phase 2 patients were assessed by a consultant-supported rapid assessment model with blood tests being analysed using point of care testing. The time from patient arrival in the emergency department to the time that care was complete and the patient was ready to move on to the next destination of care was recorded. These times from the two phases were compared using the Wilcoxon rank sum test. Results: A total of 11 213 patients attended the emergency department during the whole study period, of whom 4622 patients were eligible for the study. Phase 1 contained 3835 patients and phase 2 had 787 patients. The median time for patients to be declared ready to leave the emergency department in phase 1 was 129 minutes compared to 76 minutes for phase 2 (P=0.0025). This was a reduction in the median of 53 minutes or 41.1% (95% confidence interval 39.7-42.3%). Conclusions: This study demonstrates that a consultant-supported rapid assessment model using point of care testing significantly shortens the time patients spend in the emergency department.
Article
Background Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known. Methods We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared. Results 6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85 days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30 day mortality. Conclusions Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.
Article
To conduct a systematic review to check the level of validity and reliability of the Manchester Triage System and the quality of reporting of literature on this topic. This is a systematic review based on the PRISMA guideline on reporting systematic reviews. The systematic search of the international literature published from 1997 through 30 November 2012 in the PubMed, Embase, Cochrane Library, Cinahl, Web of Knowledge, and Scopus databases. This review included quantitative and qualitative research investigating the reliability and validity of the Manchester Triage System for the broad population of adults and children visiting the emergency department. After a systematic selection process, included studies were assessed on their quality by three researchers using the STARD guidelines. Twelve studies were included in the review. The studies investigated the inter- and intra-rater reliability using the "kappa" statistic; the validity was tested with many measures: validity in predicting mortality, hospital admission, under- and overtriage, used resources, and length of stay in the emergency department, as well as a reference standard rating. In this review, the Manchester Triage System shows a wide inter-rater agreement range with a prevalence of good and very good agreement. Its safety was low because of the high rate of undertriage and the low sensitivity in predicting higher urgency levels. The high rate of overtriage could cause unnecessarily high use of resources in the emergency department. The quality of the reporting in studies of the reliability and validity of the Manchester Triage System is good.
Article
Prehospital point of care testing (POCT) of biomarkers may be a valuable tool for optimizing prehospital diagnosis. We report the status of prehospital POCT in relation to acute myocardial infarction (AMI). No randomized studies have been performed. Eight observational studies collectively show added diagnostic value of prehospital POCT in relation to AMI. The revised European NSTEMI guidelines focus on early risk assessment in relevant timing of reperfusion strategy. We anticipate that prehospital POCT will be central in NSTEMI care in the near future.