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Push-Alert Notification of Troponin Results to Physician Smartphones Reduces the Time to Discharge Emergency Department Patients: A Randomized Controlled Trial
Abstract
Study objective:
For emergency department (ED) patients with chest pain, discharge decisions often hinge on troponin results. Push-alert notifications deliver results immediately to physician smartphones. Our objective is to determine whether troponin push alerts improve the time to discharge decisions for ED patients with chest pain.
Methods:
In an academic ED, we assessed the effect of a quality improvement initiative using troponin push alerts to physician smartphones, with a cluster-randomized evaluation. Participating physicians were randomized to receive troponin push alerts (intervention) or not receive them (control). We retrospectively identified patients treated by participating physicians during the study period who were discharged from the ED with chest pain. The primary outcome was the time from final troponin result to discharge decision. Secondary outcomes included length of stay. A linear mixed model was used to adjust for physician clustering.
Results:
During the study, 1,554 patients were discharged from the ED with chest pain. There were 551 patients in the control group and 554 in the intervention group who met inclusion criteria. The overall median interval from final troponin result to discharge decision was 79.7 minutes (interquartile range [IQR] 33.6 to 167.8 minutes); it was 94.3 minutes (IQR 36.2 to 177.8 minutes) in the control group and 68.5 minutes (IQR 30.5 to 157.2 minutes) in the intervention group. This 25.8-minute difference in medians (95% confidence interval 24.6 to 28.0 minutes) was statistically significant. Total ED length of stay was 345 minutes (IQR 261 to 419 minutes) in the control group and 328 minutes (IQR 250 to 408 minutes) in the intervention group.
Conclusion:
Physicians who received troponin push alerts discharged their patients with chest pain 26 minutes faster than those without troponin notifications. Total ED length of stay did not significantly improve for these patients.
... Where possible, reported outcomes were grouped by similarity and summarized using descriptive statistics. [37][38][39], result availability alerts [18,40], health information exchange systems [41], and computerized provider order entry tools [21]. Included studies compared interventions with relevant comparator groups, such as prior versions of an EMIS, absence of an EMIS, pen-and-paper documentation, and/or communication via telephone and fax. ...
... Two studies reported on the time from result to disposition [18,40]. Both concluded that there was a decrease in median time from result availability to physician decision-making owing to the implementation of an alert system within an EMIS. ...
... For example, median time from basic metabolic panel, urinalysis, and respiratory pathogen panel results to disposition decreased by 12, 10, and 43 min, respectively. Moreover, Verma et al. [40] reported that the median time from last troponin result to discharge was decreased from 94.3 to 68.5 min when push notifications for all troponin results were added to an existing EMIS. ...
Background
Although many emergency department (ED) settings have implemented an electronic medical information system (EMIS) and EMIS tools in an effort to improve timeliness of care outcomes, there remains a paucity of scientific information on this topic. We therefore performed a scoping review to describe the range of EMIS interventions and their impacts on time-based outcomes in the ED.
Methods
We searched four bibliographic databases to identify potentially relevant records published after 2014 in English. Two reviewers assessed records for eligibility using a two-step screening process. We then extracted data on the type of EMIS, outcomes assessed, and reported results. Findings were summarized in tabular form and grouped by time-based outcome.
Results
Twenty-five studies met the eligibility criteria, with approximately half being retrospective studies. Interventions varied among studies; they generally included a new or updated EMIS, EMIS tools related to disease diagnosis and/or management, triage tools, or health information exchange platforms. Included studies compared interventions with relevant comparator groups, such as prior versions of an EMIS, absence of an EMIS, pen-and-paper documentation, and/or communication via telephone and fax. The most common outcomes reported were length of stay (n = 17 studies) and time to medication (n = 6 studies), followed by time to order, time to provider, and time from result to disposition. Reported effects of the interventions were generally inconsistent, showing either improvements, delays, or no change in examined outcomes.
Conclusions
Additional research is needed to determine how electronic medical information may be used in the ED to improve timeliness of care. Findings from this review can be used to inform future systematic reviews that evaluate the impact of these systems and tools on specific quality of care measures.
... [4][5][6] There is 1 recent study that evaluated push alert notifications of troponin results to physician smartphones for emergency room patients with chest pain. 10 The authors found that the push alert led to quicker discharge without impacting the ED length of stay. A recent literature review in the area showed that while evidence exists on laboratory notification systems, there are very few studies since the advent of EHRs. 1 There is potential for patient harm when clinicians fail to respond to laboratory results in a timely manner. ...
... In the study by Verma et al, 10 researchers used a clusterrandomization approach to study push notification of troponin values to smartphones. In the study, they found that physicians who received troponin push alerts discharged patients faster than those without notifications. ...
Objective
We developed a push notification allowing for an electronic acknowledgment of critical lab results to providers in the intensive care unit.
Materials and Methods
This project was conducted over a 3-month period at a large academic safety net hospital. A push notification and acknowledgment system were created to comply with the existing critical results notification requirements. We monitored the number of acknowledged results, time to acknowledgment, and lab type.
Results
Prior to the push notification, lab services paged the provider. This resulted in many critical lab results relayed to the clinician beyond the expected 10-minute window. With the push notification workflow, we found that, during the 3-month period, 82, or 5.8%, of the 1414 results were acknowledged. This represented 82 less pages/calls lab services had to make.
Discussion
The push notification alert was easy to use and there was quicker results notification when acknowledged. There were limitations due to hand-offs for clinicians and some were not familiar with the mobile technology and the electronic acknowledgment.
Conclusions
Although the acknowledgment rate was low, every electronic acknowledgment saved lab service technicians an average of 10 minutes compared to the existing workflow. As familiarity with the technology and workflow increases, this novel form of communication has the potential to have significant cost savings for lab services, in addition to efficiency gains for lab, clinicians, and more timely care. The integration of health information technology and push notification of critical labs should be the focus of investigation for further future research.
... 9,10 Electronic systems that wirelessly alert providers about timed events have been shown to improve throughput in ED patients evaluated for chest pain. 11,12 These alerts also increase the likelihood of the result reaching the provider and help avoid potential errors in communication of test results. 13 At our institution we implemented the ability for providers to receive an electronic alert when the result of any selected test has been entered in the system. ...
... The overall magnitude of improvements observed in our study is similar to a trial of smartphone, troponin-result push notifications, in which Verma et al. found a 26-minute improvement in lag time from troponin result to patient disposition. 11 Our institution almost exclusively uses a pointof-care troponin test in the ED and thus we could not study the specific clinical scenario of troponin to disposition in our study. A study of radiologic critical test results reported via text message to physicians similarly showed improved response time in ED patients. ...
Introduction: Emergency department (ED) patient care often hinges on the result of a diagnostic test. Frequently there is a lag time between a test result becoming available for review and physician decision-making or disposition based on that result. We implemented a system that electronically alerts ED providers when test results are available for review via a smartphone- and smartwatch-push notification. We hypothesized this would reduce the time from result to clinical decision-making. Methods: We retrospectively assessed the impact of the implementation of a push notification system at three EDs on time-to-disposition or time-to-follow-up order in six clinical scenarios of interest: chest radiograph (CXR) to disposition, basic metabolic panel (BMP) to disposition, urinalysis (UA) to disposition, respiratory pathogen panel (RPP) to disposition, hemoglobin (Hb) to blood transfusion order, and abnormal D-dimer to computed tomography pulmonary angiography (CTPA) order. All ED patients during a one-year period of push-notification availability were included in the study. The primary outcome was median time in each scenario from result availability to either disposition order or defined follow-up order. The secondary outcome was the overall usage rate of the opt-in push notification system by providers. Results: During the study period there were 6115 push notifications from 4183 ED encounters (2.7% of all encounters). Of the six clinical scenarios examined in this study, five were associated with a decrease in median time from test result availability to patient disposition or follow-up order when push notifications were employed: CXR to disposition, 80 minutes (interquartile range [IQR] 32–162 minutes) vs 56 minutes (IQR 18–141 minutes), difference 24 minutes (p
... Many scholarly publications have also looked into how warning signals alter key laboratory outcomes. The majority of these warnings have a beneficial influence on patient care and a significant decrease in the time gap between the availability of laboratory data and clinician decision-making [30][31][32]. ...
The purpose of this study is to investigate health care consumers' perceptions of the presence of a smartphone application that provides: (a) information on the waiting time in the Emergency Department (ED), (b) the available medical specializations per hospital, and (c) guidance in emergency instances.The study's sample included 121 people who used health services in the Attica region, regardless of age or gender. The poll was carried out during January and February 2023. The data was analyzed using the statistical application SPSS 26.0. Most participants believe that the suggested smartphone application offers considerable benefits and helps to cut waiting times and give them with better treatment, depending on the condition and specialization of the doctor.
... The extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use [10,[31][32][33][34][35][36] Usability Multidisciplinary communication and tools for communicating with external care providers after a visit to the emergency department EHR a features that impact patient flow through the ED [37][38][39][40][41][42] Clinical workflow Artificial intelligence and machine learning algorithms or adherence to interoperability standards EHR features that allow for the ability to investigate research questions or conduct quality improvement studies [43][44][45] Research and data analytics a EHR: electronic health record. Innovations below each category are informed by Delphi outputs and offer a nonexhaustive view of proposed innovations across usage categories, affecting each step of care. ...
Background:
The needs of the emergency department (ED) pose unique challenges to modern electronic health record (EHR) systems. A diverse case load of high-acuity, high-complexity presentations, and ambulatory patients, all requiring multiple transitions of care, creates a rich environment through which to critically examine EHRs.
Objective:
This investigation aims to capture and analyze the perspective of end users of EHR about the strengths, limitations, and future priorities for EHR in the setting of the ED.
Methods:
In the first phase of this investigation, a literature search was conducted to identify 5 key usage categories of ED EHRs. Using key usage categories in the first phase, a modified Delphi study was conducted with a group of 12 panelists with expertise in both emergency medicine and health informatics. Across 3 rounds of surveys, panelists generated and refined a list of strengths, limitations, and key priorities.
Results:
The findings from this investigation highlighted the preference of panelists for features maximizing functionality of basic clinical features relative to features of disruptive innovation.
Conclusions:
By capturing the perspectives of end users in the ED, this investigation highlights areas for the improvement or development of future EHRs in acute care settings.
... An extensive number of publications have also examined the impact of alert notifications on critical laboratory results. Although sometimes contradictory or pointing out the risk of alert fatigue potentially slowing the response to these alerts and harmful to the patient [43][44][45], they mostly show a significant reduction in time lag between laboratory result availability and decision making, a high degree of clinician approval, and a beneficial impact on patient care [25,[46][47][48][49]. During 2018, there were an estimated 130 million ED visits in the USA. ...
For maintaining collaboration and coordination among emergency department (ED) caregivers, it is essential to effectively share patient-centered information. Indirect activities on patients, such as searching for laboratory results and sharing information with scattered colleagues, waste resources to the detriment of patients and staff. Therefore, we conducted a pilot study to evaluate the initial efficacy of a mobile app to facilitate rapid mobile access to central laboratory results and remote interprofessional communication. A total of 10 ED residents and registered nurses were randomized regarding the use of the app versus conventional methods during semi-simulated scenarios in a pediatric ED (PED). The primary outcome was the elapsed time in minutes in each group from the availability of laboratory results to their consideration by participants. The secondary outcome was the elapsed time to find a colleague upon request. Time to consider laboratory results was significantly reduced from 23 min (IQR 10.5–49.0) to 1 min (IQR 0–5.0) with the use of the app compared to conventional methods (92.2% reduction in mean times, p = 0.0079). Time to find a colleague was reduced from 24 min to 1 min (i.e., 93.0% reduction). Dedicated mobile apps have the potential to improve information sharing and remote communication in emergency care.
... Research staff reviewed the ED information system daily to identify consecutive eligible hip fracture patients and matched this list to data sheets completed by the ED physician to identify whether POCUS-GRA was performed. 29 Research staff sent collegial email reminders to participating ED physicians if POCUS-GRA was not performed on eligible patients, and inquired as to the reason for not performing POCUS-GRA. ...
Objectives
Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium.
Design
Open-label feasibility study.
Setting
An academic tertiary care Canadian ED (annual visits 60 000).
Participants
Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year.
Intervention
A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders.
Primary and secondary outcome measures
The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT ( NCT02892968 ).
Results
Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1–20 blocks per physician). The median (IQR) time to perform blocks was 15 (10–20) min, and reduction in pain was 6/10 (3–7) following POCUS-GRA. There were no reported complications.
Conclusion
Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT.
Trial registration number
Clinicaltrials.gov #02892968
... However, neither the use of the DL-algorithm nor the use of the ENS led to a statistically significant reduction of RCT and TAT. Other studies have shown positive effects of ENS on interdisciplinary communication [12,26], documentation [27] and patient flow in the ED [28,29]. ...
Objectives
Rapid communication of CT exams positive for pulmonary embolism (PE) is crucial for timely initiation of anticoagulation and patient outcome. It is unknown if deep learning automated detection of PE on CT Pulmonary Angiograms (CTPA) in combination with worklist prioritization and an electronic notification system (ENS) can improve communication times and patient turnaround in the Emergency Department (ED).
Methods
In 01/2019, an ENS allowing direct communication between radiology and ED was installed. Starting in 10/2019, CTPAs were processed by a deep learning (DL)-powered algorithm for detection of PE. CTPAs acquired between 04/2018 and 06/2020 (n = 1808) were analysed. To assess the impact of the ENS and the DL-algorithm, radiology report reading times (RRT), radiology report communication time (RCT), time to anticoagulation (TTA), and patient turnaround times (TAT) in the ED were compared for three consecutive time periods. Performance measures of the algorithm were calculated on a per exam level (sensitivity, specificity, PPV, NPV, F1-score), with written reports and exam review as ground truth.
Results
Sensitivity of the algorithm was 79.6% (95%CI:70.8-87.2%), specificity 95.0% (95%CI:92.0-97.1%), PPV 82.2% (95%CI:73.9-88.3), and NPV 94.1% (95%CI:91.4-96%). There was no statistically significant shortening of any of the observed times (RRT, RCT, TTA, TAT).
Conclusion
DL-assisted detection of PE in CTPAs and ENS-assisted communication of results to referring physicians technically work. However, the mere clinical introduction of these tools, even if they exhibit a good performance, is not sufficient to achieve significant effects on clinical performance measures in the clinical process chain.
... Critical result notifications create their own challenge of "alert fatigue", although there is evidence that alert-based decision support systems can meaningfully improve patient care [8,13]. Push notifications of troponin results to emergency department (ED) physicians, for example, have reduced the time to discharge among patients presenting with chest pain [14]. ...
Healthcare providers make time-sensitive care decisions based on EHR data. As systems of record, the EHR is often not configured to optimally surface timely information. For patients awaiting admission, infection control concerns that potentially require private rooms can prolong stays in the Emergency Department. We aim to determine if an event-based notification platform connected with a commercial EHR can help prioritize timely information and improve patient flow in the emergency department. We undertook a pre-post analysis for patients being admitted from the emergency room who were tested for influenza. We used a primary outcome of mean time from negative test result to inpatient transfer. The median time decreased by 27%, from 4.1 hours to 3.0 hours. The distribution of transfer times pre and post-intervention were significantly different with a p-value of <0.001. Our findings support the use of event-based notification systems to improve patient flow in the emergency department.
... La molteplicità delle soluzioni per abbreviare i TAT, presente in letteratura da diversi decenni, può essere riassunta in alcune linee d'intervento [38]: potenziamento periferico delle prestazioni di laboratorio, con Laboratori satellite e strumentazione POCT; potenzialità informatiche del LIS e del CPOE; trasporto meccanico; riorganizzazione dei processi intra-laboratorio ed extra-laboratorio, secondo metodologie conosciute di miglioramento della qualità. È proprio verso questi ultimi punti che pare si focalizzi l'attenzione negli ultimi 5 anni, ancora verso l'impianto di POCT ma maggiormente alla revisione dei processi con Total Laboratory Automation (TLA) e all'applicazione di metodiche Lean e/o 6 sigma, anche perché l'impatto prevalente della fase preanalitica sul TAT totale è messo in discussione [27,37]. Appare chiaro, d'altro canto, che le misure d'intervento devono essere interdisciplinari, multiprofessionali e interconnesse per dare un efficace risultato finale [30,36,38]. ...
Background
The timeliness, measured as turnaround time (TAT), of troponin (cTn) is a critical factor in the diagnosis and rule in / rule out of Emergency Department (ED) patients suspected of acute coronary syndromes (ACS). Nevertheless, in the past the required serial sampling could diminish the need for a very rapid TAT on any single sample.
Methods
A bibliographic research was conducted on PubMed and several institutional and Scientific Societies websites for clinical and laboratory guidelines (GLs) with a recommended cTn TAT and for evidences of effects of TAT on clinical and/or organizational outcomes of ED patients with suspected NSTEMI (non-ST elevation myocardial infarction), produced in the last 5 years.
Results
Three of eight clinical GLs and five of five Laboratory GLs recommend a cTn TAT ≤ 1 h, but this quality goal is not evidence-based: TAT has a clear effect only on ED length-of-stay (LOS), that could affect patients’ outcomes. Nevertheless, the use of high-sensitivity troponin (hs-cTn) quick algorithms at 1 h, 30 min or at presentation (T0) and accelerated diagnostic pathways that combine hs-cTn, ECG and risk scores (ADP) allow a rapid and safe rule in / rule out for over two/thirds in 1 hour and for over one/third at T0 of ED patients suspected of NSTEMI (NPV for MACE 98.7–100% and 95.5–100%, respectively). The definition of cTn TAT and of its beginning (order, blood collection, laboratory receipt) is still uncertain.
Conclusions
The hs-cTn TAT should be ≤1 h or less, for an effective use in new algorithms at 1 h or T0 and in new ADPs, suggested by clinical GLs and literature evidences. The TAT should measure the time from blood collection to the availability of results.
Background Automated electronic result notifications can alert health care providers of important clinical results. In contrast to historical notification systems, which were predominantly focused on critical laboratory abnormalities and often not very customizable, modern electronic health records provide capabilities for subscription-based electronic notification. This capability has not been well studied.
Objectives The purpose of this study was to develop an understanding of when and how a provider decides to use a subscription-based electronic notification. Better appreciation for the factors that contribute to selecting such notifications could aid in improving the functionality of these tools.
Methods We performed an 8-month quantitative assessment of 3,291 notifications and a qualitative survey assessment of 73 providers who utilized an elective notification tool in our electronic health record.
Results We found that most notifications were requested by attending physicians (∼60%) and from internal medicine specialty (∼25%). Most providers requested only a few notifications while a small minority (nearly 5%) requested 10 or more in the study period. The majority (nearly 30%) of requests were for chemistry laboratories. Survey respondents reported using the tool predominantly for important or time-sensitive laboratories. Overall opinions of the tool were positive (median = 7 out of 10, 95% confidence interval: 6–9), with 40% of eligible respondents reporting the tool improved quality of care. Reported examples included time to result review, monitoring of heparin drips, and reviewing pathology results.
Conclusion Developing an understanding for when and how providers decide to be notified of clinical results can help aid in the design and improvement of clinical tools, such as improved elective notifications. These tools may lead to reduced time to result review which could in turn improve clinical care quality.
Information management in the emergency department (ED) is a challenge for all providers. The volume of information required to care for each patient and to keep the ED functioning is immense. It must be managed through varying means of communication and in connection with ED information systems. Management of information in the ED is imperfect; different modes and methods of identification, interpretation, action, and communication can be beneficial or harmful to providers, patients, and departmental flow. This article reviews the state of information management in the ED and proposes recommendations to improve the management of information in the future.
To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events.
Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7.
All emergency department patients who were not admitted (seen and discharged; left without being seen).
Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital.
13,934,542 patients were seen and discharged and 617,011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥ 6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital.
Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.
A qualitative study performed with a cross-sectional survey to report staff perceptions on emergency department (ED) communication while trialling a personal hands-free wireless communication device (WCD) between August and October 2008 in a busy inner city ED.
A survey of all Royal London Hospital ED staff was conducted pre and post-implementation of a personal WCD. The survey included responses to occupation, experience, communication modes, communication wait times, perceived interruptions at the bedside and general perceptions of communication efficiency.
No appreciable change in communication modes or perceived waiting times was reported No increase in bedside interruptions were reported. An overwhelming number of respondents considered the system had contributed significantly to improving the quality of the work environment, patient safety and care.
This study correlated with others showing a very strong perception of improved communication and working environment: less noise, better handovers and improved staff resource use. The study adds to the limited number of published trials examining WCD in health care. Observational reports post-implementation were overwhelmingly positive. Quantitative studies measuring the impact on patient flow, safety and cost benefits should be considered.
Failure to adequately communicate a critical laboratory value is a potential cause of adverse events. Accreditation requirements specify that clinical laboratories must undertake assessments and appropriate measures to improve the timeliness of critical value reporting and prompt receipt by the responsible caregiver. Documentation and communication processes must be regularly monitored and implemented under ongoing systems for quality monitoring. Critical value reporting is an important phase of the clinical laboratory testing process, and notifications of results outside the target time can indicate ineffectiveness of the process. In the present study, we report data obtained in a 12-month period of critical values analysis and describe a computerized communication system conducive to improving the quality of critical value reporting at a university hospital. Automated communication improves the timeliness of notification and avoids the potential errors for which accreditation programs require read-back of the result. The communication also improves the likelihood of reaching the physician on call and may provide important decision support.
Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.
Background:
Overcrowding diminishes Emergency Department (ED) care delivery capabilities.
Objectives:
We developed a generic methodology to investigate the causes of overcrowding and to identify strategies to resolve them, and applied it in the ED of a hospital participating in the study.
Methods:
We utilized Discrete Event Simulation (DES) to capture the complex ED operations. Using DES results, we developed parametric models for checking the effectiveness and quantifying the potential gains from various improvement alternatives. We performed a follow-up study to compare the outcomes before and after the model recommendations were put into effect at the hospital participating in the study.
Results:
Insufficient physicians during peak hours, the slow process of admitting patients to inpatient floors, and laboratory and radiology test turnaround times were identified as the causes of reduced ED throughput. Addition of a physician resulted in an almost 18% reduction in the ED Main discharged patient length of stay.
Conclusion:
The case study results demonstrated the effectiveness of the generic methodology. The research contributions were validated through statistically significant improvements seen in patient throughput and waiting time at the hospital participating in the study.
we examined the diagnostic performance of high sensitivity cardiac troponin T (cTnThs) measurement and its ability to predict risk in unselected patients presenting to the emergency department with acute chest pain.
we conducted a retrospective analysis of 137 consecutive patients with chest pain (age range, 66 ± 16 years; 64% male). A final diagnosis of acute myocardial infarction was made using the "old" (cTnT fourth-generation assay, ≥ 0.04 microg/L) or the "new" cutpoint (cTnThs ≥ 0.014 microg/L).
the adjudicated final diagnosis of acute myocardial infarction significantly increased from 20 to 35 patients (a 75% increase) and troponin-positive nonvascular cardiac chest pain from 10 to 30 (a 200% increase) using cTnThs. The number of patients with unstable angina or troponin-negative nonvascular cardiac chest pain significantly decreased (P <.05). Diagnostic performance of cTnThs levels at admission was significantly higher compared to cTnT levels (area under the curve [AUC] 0.85 vs AUC 0.70; P <.05). cTnThs levels below the detection limit (<0.003 microg/L) had a negative predictive value of 100% to exclude acute myocardial infarction. The event rate during 6 months of follow-up was low in patients with cTnThs levels <0.014 microg/L, while patients with cTnT levels ≥ 0.04 μg/L were at increased, and patients with cTnThs ≥ 0.014 μg/L and cTnT <0.04 microg/L at intermediate risk of death or recurrent myocardial infarction (P = .002). Risk was highest in chest pain patients with dynamic changes of cTnThs levels >30%.
the introduction of cTnThs assay displays an excellent diagnostic performance for the workup of patients with chest pain at the time of their initial presentation. Even small increases of cTnThs indicate increased risk for death or myocardial infarction during follow-up.
Sample size requirements are given for intervention trials in which the unit of randomization is the cluster. Cases dealt with include the comparison of two means and the comparison of two proportions. Required modifications to the standard statistical analyses are also discussed.
The aim of many research investigations is to compare the proportion of individuals in each of several groups that have a certain characteristic. The unit of allocation for such investigations is often an intact social unit, as in randomizing families, medical practices, schools, or entire communities, to different intervention groups. Standard statistical methods are not appropriate for these designs, since they do not take into account the dependencies among individuals within the same cluster. The authors review the strengths and weaknesses of several approaches for dealing with this problem, using data from a school-based smoking cessation trial. A principal conclusion is that the choice of method should depend on whether or not random allocation is used in the assignment of interventions.
Emergency department (ED) overcrowding is a common problem. Despite a widespread belief that low hospital bed availability contributes to ED overcrowding, there are few data demonstrating this effect.
To identify the effect of hospital occupancy on ED length of stay for admitted patients and patient disposition.
This was an observational study design using administrative data at a 500-bed acute care teaching hospital. All patients presenting to the ED between April 1993 and June 1999 were included in the study. The predictor variable was daily hospital occupancy. Outcome measures included daily ED length of stay for admitted patients, daily consultation rate, and daily admission rate. The models controlled for the average daily age of ED patients and the average daily "arrival density" index, which adjusts for patient volume and clustering of patient arrivals.
The average hospital occupancy was 89.7%. On average 155 patients visited the ED daily; 21% were referred to hospital physicians and 19% were admitted. The median ED length of stay for admitted patients was 5 hours 54 minutes (interquartile range 5 hr 12 min to 6 hr 42 min). Daily ED length of stay for admitted patients increased 18 minutes (95% CI = 12 to 24) when there was an absolute increase in occupancy of 10%. The ED length of stay appeared to increase extensively when hospital occupancy exceeded a threshold of 90%. Consultation and admission rates were not influenced by hospital occupancy.
Increased hospital occupancy is strongly associated with ED length of stay for admitted patients. Increasing hospital bed availability might reduce ED overcrowding.
Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Time studies that assess key ED processes will help clarify the causes of patient care delays and prolonged LOS. The objectives of this study were to identify and quantify the principal ED patient care time intervals, and to measure the impact of important service processes (laboratory testing, imaging and consultation) on LOS for patients in different triage levels.
In this retrospective review, conducted at a large urban tertiary care teaching hospital and trauma centre, investigators reviewed the records of 1047 consecutive patients treated during a continuous 7-day period in January 1999. Key data were recorded, including patient characteristics, ED process times, tests performed, consultations and overall ED LOS. Of the 1047 patient records, 153 (14.6%) were excluded from detailed analysis because of incomplete documentation. Process times were determined and stratified by triage level, using the Canadian Emergency Department Triage and Acuity Scale (CTAS). Multiple linear regression analysis was performed to determine which factors were most strongly associated with prolonged LOS.
Patients in intermediate triage Levels III and IV generally had the longest waiting times to nurse and physician assessment, and the longest ED lengths of stay. CTAS triage levels predicted laboratory and imaging utilization as well as consultation rate. The use of diagnostic imaging and laboratory tests was associated with longer LOS, varying with the specific tests ordered. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service consulted.
Triage level, investigations and consultations are important independent variables that influence ED LOS. Future research is necessary to determine how these and other factors can be incorporated into a model for predicting LOS. Improved information systems will facilitate similar ED time studies to assess key processes, lengths of stay and clinical efficiency.