Improving Standardization and Access to Care via Seizure Pathways in the Emergency Department

159 Modified Early Warning Score (MEWS)-Enhanced Emergency Department Flow Process

Background Ketamine is gaining acceptance as an agent for prehospital pain control, but the associated risks of agitation, hallucinations and sedation have raised concern about its potential to prolong emergency department (ED) length of stay (LOS). This study compared ED LOS among EMS patients who received prehospital ketamine, fentanyl or morphine specifically for pain control. We hypothesized ED LOS would not differ between patients receiving the three medications. Methods This retrospective observational study utilized the 2018 ESO Research Database, which includes more than 7.5 million EMS events attended by more than 1,200 agencies. Inclusion criteria were a 9-1-1 scene response; age ≥ 18 years; a recorded pain score greater than 4; an initial complaint or use of a treatment protocol indicating a painful condition; prehospital administration of ketamine, fentanyl or morphine; and ED LOS data available. Patients were excluded if they received a combination of the medications, or if there were indications that medication administration could have been for airway management (i.e., altered mental status, head injury, respiratory distress/depression) or agitation control (e.g., behavioral complaints). Kruskal-Wallis test was used to compare ED LOS among patients receiving each of the three medications. Post-hoc evaluations of between-group differences were conducted using Wilcoxon Rank Sum test and a Bonferroni-corrected alpha value of 0.017. Results Of 9,548 patients who met the inclusion criteria, 119 received ketamine, 1,359 received morphine, and 8,070 received fentanyl. Patient and event characteristics did not significantly differ between the three groups. Median (IQR) ED LOS was 3.5 (2.5–6.1) hours for patients who received ketamine, 4.0 (2.7–6.1) hours for patients who received morphine, and 3.7 (2.6–5.4) hours for patients who received fentanyl (p = 0.002). In post-hoc pairwise comparisons, patients who received morphine had significantly longer ED LOS than patients who received fentanyl (p < 0.001); there was no significant difference in ED LOS for patients who received ketamine vs. morphine (p = 0.161) or for patients who received ketamine vs. fentanyl (p = 0.809). Conclusion ED LOS is not longer for patients who receive prehospital ketamine, versus morphine or fentanyl, for management of isolated painful non-cardiorespiratory conditions.

AimStudies reporting factors associated with paediatric/adolescent acute behavioural disturbance (ABD) in the Emergency Department (ED) are lacking. The aim of this study is to describe paediatric/adolescent ED presentations involving ABD events.MethodsA retrospective chart review of presentations involving ABD events, identified via hospital security log, to a tertiary referral paediatric ED during the 2017 calendar year. Data reported included: cause of presentation, use of sedation/physical restraint, ED/inpatient length of stay (LOS) and time requiring security staff presence.ResultsFrom 280 reported ABD episodes 26 were excluded leaving 254 events involving 150 patients across 233 presentations of whom 38 (25.3%) presented on multiple occasions. Median age was 14 years (interquartile range (IQR): 13–16), 132/233 (56.7%) were female, 167/233 (71.7%) primary mental health complaints, 30/233 (12.9%) deliberate self‐harm, 18/233 (7.7%) deliberate self‐poisoning, 11/233 (4.7%) acute intoxication and 7/233 (3.0%) other.Transport to hospital involved police and ambulance in 124/233 (53.2%), ambulance only 71/233 (30.5%), police only 16/233 (6.9%), relative or carer 20/233 (8.6%), with self‐presentation in 2/233 (0.9%).Sedation or physical restraint was used in 81/233 (34.8%), both 38/233 (16.3%), restraint only 26/233 (11.2%) and sedation only 17/234 (7.3%). Intra‐muscular droperidol accounted for 57/96 (59.4%) sedations, IM/IV benzodiazepines 15/96 (15.6%), IM/IV ketamine 5/96 (5.2%) and 19/96 (19.8%) other.Discharge from ED occurred in 171/233 (73.1%) with median ED LOS 5.1 h (IQR: 3.5–7.7) and median hospital LOS 92.4 h (IQR: 47.5–273.4) for those admitted. The Mental Health Act was utilised in 183/233 (78.5%) presentations.Median security staff time requirement per presentation was 2.4 h (IQR: 1.0–3.9).ConclusionsPaediatric/adolescent ED presentations involving ABD are primarily due to mental health complaints. Less than half require the use of sedation/physical restraint. Time requiring security staff involvement is a significant resource consumption.

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

While recent studies have demonstrated an overall increase in psychiatric visits in the emergency department (ED), none have focused on a nationally representative pediatric population. Understanding trends in pediatric psychiatric ED visits is important because of limited outpatient availability of pediatric specialists, as well as long wait times for psychiatric appointments. The study aim was to evaluate the trends in ED psychiatric visits for children between 2001 and 2010 with comparison by sociodemographic characteristics. This was a retrospective, cross-sectional analysis of ED psychiatric visits for children<18years of age using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes. Outcome measures included frequency of visits for children with psychiatric diagnosis codes and odds and adjusted odds of psychiatric visits controlling for temporal, demographic, and geographic factors. From 2001 to 2010, an average of 28.3 million pediatric visits to EDs occurred annually. Among those, an approximately 560,000 (2% of ED visits) were psychiatric visits each year. Pediatric psychiatric ED visits increased from an estimated 491,000 in 2001 to 619,000 in 2010 (p=0.01). Teenagers (adjusted odds ratio [AOR]= 3.92, 95% confidence interval [CI]=3.37 to 4.57) and publicly insured patient visits (AOR= 1.47, 95% CI=1.25 to 1.74) had increased odds of psychiatric ED visits. Pediatric ED psychiatric visits are increasing. Teenagers and children with public insurance appear to be at increased risk. Further investigation is needed to determine what the causative factors are.

Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour. This was a before-and-after study conducted at an academic suburban ED with 75,000 annual patient visits. All patients presenting to the ED during the months of August and October 2006 were considered. A Stat lab located within the central laboratory was introduced in September 2006 to reduce laboratory TAT. The test TATs and ED LOS before (August 2006) and after (October 2006) implementing the Stat lab for all ED patients were the data of interest. ED LOS before and after the Stat lab was introduced was compared with the Mann-Whitney U-test. A sample size of 5,000 patients in each group had 99% power to detect a 1-hour difference in ED LOS. There were 5,631 ED visits before and 5,635 visits after implementing the Stat lab. Groups were similar in age (34 years vs. 36 years) and gender (51% males in both). The percentages of patients with laboratory tests before and after Stat lab implementation were 68.7 and 71.3%, respectively. Test TATs for admitted patients were significantly improved after the Stat lab introduction. Implementation of the Stat lab was associated with a significant reduction in the median ED LOS from 466 (interquartile range [IQR] = minutes before to 402 (IQR = 296-553) minutes after implementing the Stat lab. The effects of the Stat lab on ED LOS were less marked for discharged patients. Introduction of a Stat lab dedicated to the ED within the central laboratory was associated with shorter laboratory TATs and shorter ED LOS for admitted patients, by approximately 1 hour.

Emergency department (ED) length of stay (LOS) is a quality of care measure and, when prolonged, contributes to ED crowding. Bronchiolitis, a common seasonal illness of infants, provides an opportunity to examine factors affecting ED LOS. We analyzed data from a 30-center prospective cohort study of ED patients younger than 2 years with an attending physician diagnosis of bronchiolitis to determine what factors affect LOS. Researchers conducted a structured interview and chart review. Among 1459 children enrolled, ED LOS was available for 1416 children (97%). The median ED LOS was 3.3 hours (interquartile range, 2.3-4.8 hours). Multivariate analysis demonstrated that factors significantly (P < 0.05) associated with ED LOS were larger annual ED visit volume (reference, lowest tertile [< 44,134 visits], 44,134-62,420 [β = 0.74], and ≥ 62,421 [β = 0.63]), Hispanic race/ethnicity (reference, white race, β = 1.43), lack of primary care provider (β = 1.28), duration of symptoms of 4 to 7 days (reference, < 1 day; β = 0.58), presentation of midnight to 7 AM (reference, 4:00-11:59 PM; β = 1.07), decreasing lowest oxygen saturation in ED (β = 0.07), fewer number of A-agonists during the first hour (β = 0.74), unknown oral intake (reference, adequate; β = 0.69), performance of chest x-ray (β = 0.62), and hospital admission (β = 1.11). In this prospective multicenter study of children younger than 2 years with bronchiolitis, multiple factors were associated with longer ED LOS. These factors suggest the following steps to help shorten ED LOS: optimizing translation services, improving primary care provider rates, enhancing overnight patient flow, forgoing chest x-rays, and developing evidence-based admission criteria.

OBJECTIVES/SPECIFIC AIMS: Emergency department (ED) length of stay (LOS) is one of the important indicators of quality and efficiency of ED service delivery and is reported to be both cause and result of ED crowding. Increased ED LOS is associated with ED crowding, increases service cost and sometimes poor patient outcome. Substance abuse is one of the major determinants of morbidity, mortality and healthcare needs. Substance abuse may confound the healthcare and service needs of patients in the ED irrespective of primary purpose of their ED visit and may lengthen the ED LOS. The aim of this study was to evaluate the effect of patients’ demographic and clinical characteristics and of different patient-related activities such as screening brief intervention and referral to treatment (SBIRT) on the ED LOS of patients discharged from the ED with a diagnosis of substance abuse. METHODS/STUDY POPULATION: We conducted a retrospective data analysis of electronic health records. The study population included 26971 patients who visited our hospital ED between 2013 and 2017, had a history of substance abuse and were discharged from the ED. An accelerated failure time (AFT) model was used to analyze the influence of covariates on patient ED LOS. The predictor factors in the model included age, gender, ED arrival shift and weekday, diagnosis history of mental health and drug use, acuity triage level from 1 to 5, with 1 being worse severity, and whether any lab tests were ordered, SBIRT intervention and whether patient was homeless. The AFT model is an alternative to the Cox Proportional Hazard Ratio model, which directly models the log of ED LOS as a function of a vector of covariates. The model defines the increase or decrease in LOS with the changes in the covariate levels as an acceleration factor or time ratio (TR). RESULTS/ANTICIPATED RESULTS: The overall median ED LOS was 4 hours with IQR of 4.2 hours. The average age of the study population was 39.3 years, 58.6% of the patients were male and 57% where White; 63.4% had a history of drug use; 43% had a history of mental health issue, and 0.4% were homeless. In the analysis using the AFT model, increased age (a year increase, TR =1.01, p =0.008), female sex (TR=1.044, P&lt;0.001), SBIRT (TR=1.525, P &lt;0.001), history of mental health issue (TR=1.117, P&lt;0.00), evening arrival (evening vs night, TR=1.04, p=0.006), history of drug use (drug vs alcohol only, TR=1.04, p=0.001), higher acuity (triage level 1 vs 5, TR=2.795, p &lt;0.001) and homelessness (TR=1.073, P = 0.021) lengthened the ED LOS. In contrast, weekend arrival (TR=0.956, p=0.004) and day shift arrival (day vs night, TR=0.958, p=0.004) shortened the ED LOS. DISCUSSION/SIGNIFICANCE OF IMPACT: We identified gender, age, SBIRT, arrival shift, weekend arrival, mental health status, substance abuse, acuity level and homelessness to be significant predictor of ED LOS. The fact that SBIRT increased the LOS should be balanced with the advantages of engaging patients into substance use disorder treatment. Understanding the determinants of ED LOS in this population may provide useful information for physicians or patients to better anticipate an individual’s LOS and to help administrators plan the ED staffing and other resources mobilization.

Rapid influenza diagnostic test at triage can decrease emergency department length of stay.

Background:Emergency department (ED) visits for acute gout increased by approximately 20% between 2006 and 2014 in the United States. (1) Reducing ED length of stay (LOS) can help improve health outcomes, and reduce ED crowding and cost of care for patients with gout.Objectives:The aim of our study was to assess ED LOS and to identify factors associated with prolonged ED LOS in patients with acute gout.Methods:In this retrospective analysis, we included the first ED visit of adult patients (&gt;18years) with acute gout who presented to the 3 EDs affiliated with Lifespan Health Systems, the largest healthcare provider in Rhode Island. Our study period was 3/30/2015 to 9/30/2017.We calculated ED LOS as the time spent by patients in the ED until they were discharged. Patients presenting to the ED and subsequently admitted to the hospital were excluded given the differential effect of systems factors in these patients. We assessed the following factors’ association with being in the upper quartile of ED LOS: (a) Patient factors – demographics, comorbidities and clinical presentation of gout (number of joints involved, severity as gauged by an ED triage nurse on a scale of 1 to 5; 1 being the worst) and (b) systems factors – time of day, day of the week, and time of year at presentation to the ED, teaching versus non-teaching hospital setting, and performing an arthrocentesis. We performed univariate and multivariable analyses to identify factors associated with prolonged ED LOS in patients with acute gout.Results:A total of 355 patients (mean age 56.6 ± 16.03 years, 81.3% males) were included. The median ED LOS was 2.65 hours (1.75, 4.3 hours). A quarter of the patients spent more than 4.3 hours in the ED; the national average across all medical illnesses being 3.7 hours (2). In the univariate analysis, older age (&gt; 65 years), comorbidities (hypertension, congestive heart failure), worse ED severity score, procedural delays, and teaching hospital setting were associated with being in the upper quartile of ED LOS. In a multivariable analysis, age &gt;65 years, procedural delays, and worse ED acuity score continued to be associated with longer ED LOS.Conclusion:In our study settings, patients with acute gout spent a longer time in the ED than the national median of 120-150 minutes. (2) We noted that older age and higher acuity score in addition to procedural delays led to longer length of stay in the ED. The results of our study should guide future interventions to reduce ED LOS for patients with acute gout.

This study used a nationwide database to identify and analyze factors that influence emergency department (ED) length of stay (LOS) and improve the efficiency of emergency care. This retrospective study analyzed data from the National Emergency Department Information System (NEDIS) database in Korea: 25,578,263 ED visits from 2018 to 2022. Patient demographics, clinical characteristics, and ED operational variables were examined. Univariate and multivariate logistic regression analyses were used to assess the associations between the variables and prolonged ED LOS, defined as 6 hours or more. Among the 25,578,263 patients, the median ED LOS was 2.1 hours (interquartile range, 1.050-3.830 hours), with 12.6% experiencing a prolonged ED LOS. Elderly patients (aged ≥65 years) were significantly more likely than younger patients to experience prolonged ED LOS (adjusted odds ratio [aOR], 1.415; 95% confidence interval [CI]: 1.411-1.419). Patients transferred from other hospitals (aOR, 1.469; 95% CI, 1.463-1.474) and those arriving by emergency medical services (aOR, 1.093; 95% CI, 1.077-1.108) also had high odds of prolonged LOS. Conversely, pediatric patients had a low likelihood of extended stay (aOR, 0.682; 95% CI, 0.678-0.686). Severe illness, including sepsis (aOR, 1.324; 95% CI, 1.311-1.340) and COVID-19 infection (aOR, 1.413; 95% CI, 1.399-1.427), was strongly associated with prolonged LOS. Prolonged ED LOS is influenced by a combination of patient demographics, clinical severity, and systemic factors. Targeted interventions for older adults, severe illness, and operational inefficiencies such as hospital transfers are essential for reducing ED LOS and improving overall emergency care delivery.

109 Provider in Triage Does Not Improve Patient-Centered Metrics in a Crowded Academic Emergency Department

BackgroundWe sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario...

Emergency Departments (EDs) are increasingly managing elderly patients with chronic diseases and complex comorbidities. While the association between chronic conditions and poor clinical outcomes is well established, their impact on ED operational performance, particularly on length of stay (LOS), remains underexplored. We conducted a retrospective, single-center observational study at Merano Hospital (Italy), analyzing a random sample of adults ED visits in 2023. Patients were classified as having chronic conditions if they had ≥ 2 pre-existing chronic conditions. Demographic, clinical, and access-related variables were extracted from electronic health records. The primary outcome was ED LOS, defined as the time from registration to ED chart closure, excluding boarding time. Univariate and multivariable logistic regression analyses were used to identify predictors of prolonged LOS (≥ 75th percentile). Among 4172 patients, 12.9% were classified as having chronic conditions. These patients were significantly older and more likely to present with prolonged symptoms and acute exacerbations of chronic illnesses. Median ED LOS was significantly longer among chronic patients (127.6 vs. 97.0min, p < 0.001). Chronic status emerged as an independent predictor of prolonged LOS (OR 1.537, 95% CI 1.223-1.932). In patients with low triage priority, the presence of chronic conditions was associated with a 54-min increase in LOS and a 52% increase in log-transformed LOS (p < 0.001). Chronic conditions are associated with significantly longer ED management times, irrespective of clinical urgency. These findings highlight the need for targeted strategies to enhance care integration and alleviate the burden on ED services.

ObjectiveTo investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).Materials and MethodsThis retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.ResultsAccording to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).ConclusionQIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.