Extreme heat and emergency department workload: Toward a climate-resilient health care system.

Background: In order to determine the impact of alcohol-related problems (ARPs) on the emergency department (ED) workload, we conducted a prospective investigation to demonstrate the clinical presentations and outcomes of patients with ARPs, and to evaluate which factors influenced the impacts of ARPs on the ED. Methods: Emergency patients were included if the clinical diagnosis or injury was attributed to an acute alcohol effect, due to an acute illness or acute complication of a chronic disease related to chronic alcohol abuse, or due to alcohol-related violence. Results: Among the 196 emergency patients with ARPs, 105 (53.6%) were for alcohol-related injuries (ARIs), and 91 (46.4%) for alcohol-related non-injuries (ARNIs). Fifty-nine patients (30.1%) were intoxicated, with a blood alcohol concentration (BAC) exceeding 100 mg/dl, and 73.2% of patients who responded to questions on drinking behaviors admitted drinking at least once a week. Over 1/2 of the patients visited the ED during 00:00 to 08:00, and 1/3 were admitted. Patients with ARPs had a 2-fold higher rate of hospital admission (32.1% vs. 16.1%, p＜0.0l) and rate of admission to the intensive care unit (8.4% vs. 3.8%, p＜0.0l). Of all patients, 13 (6.6%) interfered with the ED work. Intoxicated patients were 15 times more likely to interfere with the ED work, and the average ED stay was longer for intoxicated patients (247.3 vs. 138.2 mi p＜0.0l). Conclusion: ARPs pose a major burden on the ED, especially on night shift personnel, and among intoxicated patients. Caution should be exercised, and patients highly likely to cause trouble in the ED should be identified, such as those with a BAC exceeding 100 mg/dl.

The primary objective of this study was to create a methodology for measuring transient levels of physician workload in a live emergency department (ED) environment. Characterizing, defining, and measuring aspects of this interrupt-driven work environment represent the preliminary steps in addressing impending issues concerning ED overcrowding, efficiency, and patient and provider safety. A time-motion task analysis was conducted. Twenty emergency medicine (EM) physicians were observed for 180-min intervals in an ED of an academic medical center. Near continuous workload measures were developed and used to track changing workload levels in time. These measures were taken from subjective, objective, and physiological perspectives. The NASA-Task Load Index was administered to each physician after observational sessions to measure subjective workload. Physiological measurements were taken throughout the duration of the observation to measure stress response. Additional information concerning physicians' patient quantity and patient complexity was extracted from the ED information system. Graphical workload profiles were created by combining observational and subjective data with system state data. Methodologies behind the creation of workload profiles are discussed, the workload profiles are compared, and quantitative and qualitative analyses are conducted. Using human factors methods to measure workload in a setting such as the ED proves to be challenging but has relevant application in improving the efficiency and safety of EM. Techniques implemented in this research are applicable in managing ED staff and real-time monitoring of physician workload.

141 Frequency and Effect of Interruptions on Resident Workload in the Emergency Department

BackgroundExcessive workload in emergency departments (ED) negatively affects patient safety, often leading to missed critical tasks due to time constraints. The Workload Assessment of Nurses on Emergency (WANE) scale developed...

To measure the association between overall workload and patient and family experience (PFE) in a pediatric emergency department (ED). Our secondary objective was to assess the construct validity of total ED Relative Value Units (RVUs) as an overall ED workload measure. We performed a retrospective study from January 2022 to August 2023 using data from a large, urban, academic pediatric ED with approximately 85,000 patient visits annually. PFE was measured by surveys distributed to all patients discharged from ED. The association of overall ED workload with PFE was assessed using multivariate ordinal logistic regression. We examined the construct validity of total ED RVUs by replacing this measure with National Emergency Department Overcrowding Scale (NEDOCS) in the logistic regression model. Of 126,336 discharged visits, 7128 (5.6%) completed surveys. We found a statistically significant association between ED workload and PFE. For each 10 RVUs added to ED workload, the odds of more positive PFE decreased by 9% (95% CI: 8%-9%). The adjusted odds ratio of NEDOCS demonstrated a less pronounced association in the same direction; an increase of 10 points in NEDOCS was associated with 6% (95% CI: 5%-6%) decrease in the likelihood of higher PFE ratings. High ED workload, as measured by overall RVUs, was significantly associated with negative PFE. Similar results were found when we substituted NEDOCS for overall RVUs. Our findings suggest that overall RVUs may be a useful measure of ED workload and might provide a quantitative target for quality improvement.

The primary goal of introducing digital information systems in healthcare organisations is to improve care processes and outcomes, however, studies that investigate the impact of digital information systems on the day-to-day operations management from the perspective of workflow and consumer satisfaction in emergency departments are scarce. Therefore, this study aimed to explore the impact of a digital clinical logistics system on the duration of patient care, consumer satisfaction and shift leaders' experience of workload in emergency departments. A longitudinal prospective design was used. Three units participated in the study; an intervention unit, a control unit A (no implemented system) and a control unit B (system already in use). We collected data on care duration, consumer satisfaction and shift leaders' experience of workload for four weeks at five time points both before system implementation (summer 2015, spring 2016) and after system implementation (summer 2016, autumn 2016, winter 2016). The average care duration time increased in the postimplementation period in the intervention and control B units (p < 0.001). Duration of care was higher in the intervention unit than control unit B in summer 2016 (p < 0.001) and winter 2016 (p = 0.009). Similarly, duration of care in control unit A was higher than control unit B in spring 2016 (p < 0.001). Consumer satisfaction decreased in the intervention unit, in winter 2016 (p < 0.001) and the experience of workload increased in the intervention unit, in summer 2016 and autumn 2016 (p < 0.05). However, the patients-to-nurses ratio was doubled in the intervention unit in the last time point postimplementation when compared to the first timepoint, while it remained similar in the control units throughout the study period. This work demonstrated that a digital care logistics system may support in increasing the number of patients treated with the same nursing resources. However, this seems to connect to other outcome variables such as increased care duration, increased experience of workload and decreased consumer satisfaction in some postimplementation time points.

A transparent and easily replicated method of estimating the number of, and costs associated with, low acuity presentations to an emergency department is required to assist evaluation of the utilization of emergency department services. This study presents two independent estimates of the number of, and costs associated with, low acuity presentations to an emergency department. A retrospective analysis was conducted using emergency department information system data from a metropolitan mixed paediatric/adult teaching hospital emergency department/trauma centre. Low acuity patient presentation estimates were calculated by: Method one: The product of (A) total self-referred presentations for triage categories three, four and five and (B) the difference between the self-referred and general practitioner-referred discharge rates from the emergency department. Total low acuity patient presentations = (A x B). Method two: Summing the number of self-referrals with presenting problems never referred by general practitioners. Costs were calculated using Commonwealth cost weights. Method one gave a low acuity patient estimate of 12.5% (95% CI 12.0-13.0%) and method two 10.6% (95% CI 10.2-11.0%) of total presentations. Costs were 10.5% (method one) and 8.5% (method two) of total costs. Adjusted for assessment time, costs were 6.8% (method one) and 5.5% (method two) of total costs. Low acuity patients were more common outside of normal working hours, method one: 14.4% (95% CI 13.5-15.2%) versus 10.0% (95% CI 9.4-10.6%), P < 0.001; method two: 11.4% (95% CI 10.9-12.0%) versus 8.5% (95% CI 7.8-9.2%), P < 0.001. Provision of alternative daily 0900-2400 general practice services would change low acuity patients by no more than 2-3% of total presentations and change low acuity patient costs by no more than 2% of total costs. Low acuity patients form a small, relatively constant part of the emergency department workload. The provision of alternative after-hours services for low acuity patients would be unlikely to significantly reduce the overall work load of this metropolitan emergency department.

Given the known downstream implications of choice of respiratory support on patient outcomes, all factors influencing these decisions, even those not limited to the patient, warrant close consideration. We examined the effect of emergency department (ED)-specific system factors, such as work load and census, on the use of noninvasive versus invasive respiratory support. We conducted a multi-center retrospective cohort study of all adult subjects with severe COVID-19 requiring an ICU admission from 5 EDs within a single urban health care system. Subject demographics, severity of illness, and the type of respiratory support used were obtained. Using continuous measures of ED census, boarding, and active management, we estimated ED work load for each subjects' ED stay. The subjects were categorized by type(s) of respiratory support used: low-flow oxygen, noninvasive respiratory support (eg, noninvasive ventilation [NIV] and/or high-flow nasal cannula [HFNC]), invasive mechanical ventilation, or invasive mechanical ventilation after trial of NIV/HFNC. We used multivariable logistic regression to examine system factors associated with the type of respiratory support used in the ED. A total of 634 subjects were included. Of these, 431 (70.0%) were managed on low-flow oxygen alone, 108 (17.0%) on NIV/HFNC, 54 (8.5%) on invasive mechanical ventilation directly, and 41 (6.5%) on NIV/HFNC prior to invasive mechanical ventilation in the ED. Higher severity of illness and underlying lung disease increased the odds of requiring invasive mechanical ventilation compared to low-flow oxygen (odds ratio 1.05 [95% CI 1.03-1.07] and odds ratio 3.47 [95% CI 1.37-8.78], respectively). Older age decreased odds of being on invasive mechanical ventilation compared to low-flow oxygen (odds ratio 0.96 [95% CI 0.94-0.99]). As ED work load increased, the odds for subjects to be managed initially with NIV/HFNC prior to invasive mechanical ventilation increased 6-8-fold. High ED work load was associated with higher odds on HFNC/NIV prior to invasive mechanical ventilation.

Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

The primary objective of this study was to investigate the impact of interrupting nurses on mental workload in emergency departments by using a Natural Goals Operators Methods and Selection rules Language (NGOMSL) simulation model. The model advanced our understanding of how interrupting nurses influenced their mental workload. A time study was conducted to collect emergency nurses’ behaviors related to clinical activities at the Mayo Clinic in Minnesota. After that, the NGOMSL simulation model was developed based on the time study data. Compared to the non-interruption scenario, the result showed that the nurse’s mental workload was 2.04 times higher during patient care activities and 4.72 times higher during EMR charting in the interruption scenario. The simulation results indicated that the NGOMSL model could demonstrate the impact on mental workload caused by interruptions in emergency departments. The findings of this study will contribute to developing a new way to measure nursing mental workload caused by the interruptions.

Emergency management of corneal injuries

The Role of Cooling Centers in Protecting Vulnerable Individuals from Extreme Heat.

Emergency department workload — A transatlantic comparison

The lived experiences of patients and ambulance ramping in a regional Australian emergency department: An interpretive phenomenology study

Extreme heat events are a global public health threat, and the frequency of these events are projected to increase significantly in the coming decades. Responding to extreme heat requires that municipalities communicate with public audiences. Generally speaking, risk communication and public engagement efforts are more effective when they are responsive to current risk perception trends. This social scientific study examines extreme heat risk perceptions, emergency response needs, and level of trust in first responders among residents of the Portland (OR) Metro Area. Using quantitative survey data, it demonstrates the compounding influence of three previously identified vulnerability indicators–poverty, disability, and race–on public perception surrounding extreme heat and environmental emergencies. Results show these vulnerability indicators have a significant compounding effect on public perception, such that an increased number of vulnerability indicators is associated with greater anticipated harm from extreme heat, higher anticipated need in the event of an environmental emergency, and lower trust in first responders. Firefighters and medical providers were the most trusted first responders across all vulnerability groups. Guidelines for public engagement and recommendations for future social scientific research are discussed.