Article

Emergency department visits by patients with an internal medicine specialist: understanding the role of specialists in reducing ED crowding

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Abstract

As emergency department (ED) crowding continues to worsen, many visits are at academic referral hospitals. As a result, engaging specialty services will be essential to decompressing the ED. To do this, it will be important to understand which specialties to focus interventions on for the greatest impact. To characterize the ED utilization of non-surgical adult patients with an ambulatory specialist who were seen and discharged from the ED. Retrospective cohort study of all consecutive patients currently under the care from a specialist presenting to an urban, university affiliated hospital between 01 January 2015 and 31 December 2016. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. Only patients who were discharged directly from the ED were included in the analysis. There were 29,853 ED visits by patients currently under the care of a specialist during the study period. 17.76% of these visits were related to the medical specialty of the specialist. Of these visits, 41.73% occurred during office hours, and 24.81% occurred during weekends. The specialties with the largest proportion of ED visits related to their specialty was cardiology, gastroenterology, and pulmonary, respectively. Nearly 18% of all patients that have a specialist and are treated and discharged from the ED present with a diagnosis related to their specialist’s practice. This may indicate that there is a role for specialty service to play in decreasing some ED utilization that may be appropriate for the out-patient clinical setting. By focusing attention on specific specialties and interventions targeted during office hours, there may be an opportunity to decrease ED utilization.

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... Specialty-related ED visits during all hours.based on the primary discharge diagnosis from the ED and grouped based on the Clinical Classifications Software (CCS) for International Classification of Diseases (ICD), 9th Revision[4,7,11]. ...
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Objective: There have been various interventions to reduce ED utilization. Little is known about the sustainability of outcomes of interventions to reduce ED overcrowding. We sought to investigate whether the outcomes from one of successful interventions to reduce ED utilization, specialist physician level reporting were sustained over time and how this practice change was sustained over time. Method: This study is a longitudinal analysis of the pre and post intervention ED utilization data collected on ED pediatric patients who were followed by pediatric gastroenterologists in an urban, academic hospital. The primary outcome was the mean rate of ED visits per 1000 office visits from January, 2013 to June, 2017 using a u control chart with three sigma limits. Results: There were continuous leadership's support, physicians' engagement and communications among different members involved in the intervention. The rate of gastrointestinal (GI)-related ED visits after an intervention decreased by 54% from 4.89 to 2.23 during all hours and by 59% from 2.19 to 0.91 during office hours. Discussion: Physician-level reporting reduced ED utilization over a four year period. The outcomes could be sustained over time with sustained leadership and physicians' engagement.
... It may provide the starting point for an expanded concept of patient care which relies on telemedicine and involves multiple specialisms. The home treatment of acute deep vein thrombosis and pulmonary embolism [20,21] has proved effective in optimizing the overall use of resources and enhance patients' quality of life and engagement [22][23][24]. A similar transition has been observed in the field of hemophilia and other chronic bleeding disorders, with increasing interactions between central hubs and multiple specialists at different geographic locations, often achieved via telemedicine and videoconferencing [25]. ...
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Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.
The effect of emergency department crowding on clinically oriented outcomes
  • S L Bernstein
  • D Aronsky
  • R Duseja
  • SL Bernstein
Evaluation of a fast track unit: alignment of resources and demand results in improved satisfaction and decreased length of stay for emergency department patients
  • S W Rodi
  • M Grau
  • C M Orsini
  • SW Rodi
Singer AJ Use of a comprehensive metabolic panel point-of-care test to reduce length of stay in the Emergency Department: a randomized controlled trial
  • J Y Jang
  • S S Do
  • E J Lee
  • C B Park
  • K J Song
  • JY Jang