Decreased Emergency Department Length Of Stay Research Articles

Outcomes associated with prehospital epinephrine in adult and pediatric patients with anaphylaxis

BackgroundPrompt epinephrine administration is important to improve outcomes in anaphylaxis. ObjectiveTo assess the impact of prehospital epinephrine on clinical outcomes of hospital admission, biphasic reactions, and emergency department (ED) length of stay (LOS) in a cohort of ED patients who had anaphylaxis including both children and adults. MethodsWe conducted a single-center prospective and retrospective cohort study of patients who had anaphylaxis from April 2008 to December 2022. Associations between prehospital epinephrine administration with biphasic reactions and ED LOS were assessed with univariable models and the association with ED disposition was assessed with both univariable and multivariable logistic regression. ResultsA total of 1107 patient visits were included for analysis. The median patient age was 29 (IQR: 14-50), 593 (53.6%) patients were of female sex, and 366 (33.1%) were younger than 18 years of age. Patients in the prehospital epinephrine group were also less likely to experience a biphasic reaction (5.4% vs 9.3%; odds ratio [OR] 0.56, 95% CI: 0.34-0.92) and had a decreased ED LOS (median 4.0 hours vs 4.7 hours). There was no difference in hospital admission between patients with and without prehospital epinephrine in both the univariable (19.5% vs 15.7%; OR 1.30, 95% CI: 0.94-1.79) and multivariable (adjusted OR 1.08, 95% CI: 0.71-1.64) models. ConclusionPrehospital epinephrine administration reduced the odds of a biphasic reaction and decreased ED LOS but did not reduce hospitalization in this cohort of ED patients who had anaphylaxis. Our findings suggest that timely administration of prehospital epinephrine is associated with improved patient outcomes.

Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.

During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7-July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including "abdominal pain." We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7-May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6-July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes, P = <0.001) declined by 16.5 minutes (95% confidence interval -10, -22). Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.

Emergency Department Management of Chest Pain With a High-Sensitivity Troponin-Enabled 0/1-Hour Rule-Out Algorithm.

The analytical sensitivity of high-sensitivity cardiac troponin T (hsTnT) assays has enabled rapid myocardial infarction rule-out algorithms for emergency department (ED) presentations. Few studies have analyzed the real-world impact of hsTnT algorithms on outcomes and operations. Comparison of ED length of stay (LOS) and 30-day outcomes (return to ED, inpatient admission, and mortality) for patients presenting with chest pain during 2 separate 208-day periods using a 0/1-hour hsTnT-enabled algorithm or fourth-generation TnT. Discharge, 30-day readmission, and 30-day mortality rates were not significantly different with fourth-generation TnT vs hsTnT. Thirty-day return rates were significantly decreased with hsTnT (17.4% vs 14.9%; P < .01). For encounters with TnT measured at least twice and resulting in discharge, median ED LOS decreased by 61 minutes with the use of hsTnT (488 vs 427 minutes; P < .0001). Median time between first and second TnT results decreased by 82 minutes with hsTnT (202 vs 120 minutes; P < .0001), suggesting that the 0/1-hour algorithm was incompletely adopted. Implementation of the hsTnT algorithm was associated with decreased 30-day return rates and decreased ED LOS for a subset of patients, despite incomplete adoption of the 0/1-hour algorithm.

102 Detection of Acute Coronary Syndrome by Magnetocardiography

To evaluate the use of magnetocardiography (MCG) for early identification or rule out of acute coronary syndromes (ACS) in emergency department (ED) patients with chest pain. Magnetocardiography is a noninvasive imaging method that measures the electromagnetic fields generated by the heart’s activity. MCG is rapid, easy to perform, and provides a radiation-free imaging assessment for patients with suspected ACS. This is a prospective, observational, multicenter trial comparing the accuracy and time to disposition of ED standard of care (SOC) vs. MCG. Patients were enrolled at 3 sites from January to May 2021. Inclusion criteria were ED patients with chest pain, age ≥ 18 years, modified heart score > 2, and signs/symptoms of ACS in the ED. Exclusion criteria were STEMI, unable to fit into the device, non-ambulatory, hemodynamically unstable, and unable to lie supine for up to 5 minutes. Additional exclusion criteria were patients with pacemakers, AICD, other active devices, or any ferromagnetic metal above the costal margins. Patients underwent a MCG scan in addition to ED SOC. MCG was performed within 4 hours of ED triage. We hypothesize that the use of MCG will lead to shorter ED length of stay (LOS), with equal or improved diagnosis of suspected ACS patients. Of 58 scans, 32 were available for evaluation. 26 were unevaluable due to either insufficient data or uninterpretable. Patients with any artifacts were considered unevaluable. With technical improvements, the arttifact on current scans may be decreased which will result in fewer unevaluable scans. Mean age was 51.3 (SD± 1 .9) years, 50% female, 59.4% Black, 37.5% White, 3.1% other. Mean HEART score was 4.2 (SD± 1.1). Mean number of cardiovascular risk factors was 3.0 (SD± 1.6). Mean LOS (minutes) for MCG was 187 (SD ± 122) vs. SOC 812 (SD ± 73) (P < 0.0001 by paired t-test) (95% CI difference: -882.0, - 368.1). Thus, when compared with standard of care evaluation alone, the mean length-of-stay could have been reduced by 10.6 hours without any significant change in diagnostic accuracy. MCG and SOC based on troponins were both negative in 28 patients.There were 2 false positives by SOC (6.2%, 2/32). In these two patients presumed to have ACS by SOC, both went to cardiac catheterization, which revealed no ACS. MCG correctly identified the patients to have no ACS. There were two false negatives by MCG. In these two patients, MCG was positive and SOC rule out by troponins was negative. No stress test or cardiac catheterization was done in these two patients. Eleven patients (34%) were placed in the observation unit (OU). The MCG done in the ED and the rule out in the OU were both negative for ACS. Furthermore, early MCG done in the ED as compared with standard of care evaluation alone, would potentially eliminate overnight observation unit stays in 34% of the study population. Magnetocardiography results in a significantly lower LOS for chest pain in the ED which could lead to decreased ED LOS, improved ED turnaround times and better ED efficiency. MCG may avoid an OU stay with resultant cost savings in about one-third of ED chest pain patients. More importantly, MCG detected patients who were false positive by SOC and could have avoided a cardiac catheterization. MCG had two false positives which were negative by troponins but no cardiac catheterization or stress test were done in these two patients.

Improving Quality With Emergency Department Throughput in a Critical Access Hospital.

The study objective was to determine the impact of specific measures to reduce the length of stay (LOS) in an emergency department (ED) in a critical access hospital (CAH). Despite mandates to reduce bottlenecks by increasing throughput, many EDs are not successful. Strategies available to larger hospitals may not be feasible for resource-limited CAHs. Interventions were implemented to decrease ED LOS in a rural CAH. Through retrospective chart reviews from time periods both preimplementation and postimplementation, the LOS was determined and compared using 2-sample t tests. Significant decreases were found between the groups in mean LOS times, as well as specific time intervals within the overall LOS time for nursing-centric activities and incidence of patients leaving prior to treatment completion. A significant decrease in LOS resulted from numerous actions taken to improve patient flow. Results may be used to enhance patient flow and decrease LOS in other CAHs, improving quality and access to care.

Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients

BackgroundDelayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. MethodsThe Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. Results412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). ConclusionsED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.

A Protocol to Evaluate Low Risk Pregnancies of Unknown Location Reduces Emergency Department Length of Stay [17H

INTRODUCTION: Women are frequently diagnosed with pregnancy of unknown location (PUL) in the emergency department (ED). These patients often receive a gynecology consult and then must be followed closely to finalize diagnosis. In 2017, our hospital implemented a protocol allowing low-risk patients diagnosed with PUL in the ED to have a telephone consult with gynecology rather than in-person evaluation. We investigated impact of this protocol on ED length of stay (LOS) for these patients. METHODS: Retrospective chart review of patients entered into the beta book from January 2017 to November 2017. All patients entered into the beta book after an ED visit were included, while those diagnosed outpatient were excluded. Primary outcome was ED LOS; secondary outcomes included provider adherence to the protocol and patients' completeness of follow up. RESULTS: 120 subjects were included. LOS was significantly shorter in the telephone consult group (Median 270 min, IQR 223-346 min) than in the standard consult group (Median 345 min, IQR 276-434 min), P=.009. In-person gynecology consult was more likely when: a resident provided the initial evaluation (P=.017), patients presented with pain or nausea (P=.006), and ultrasound demonstrated free fluid (P=.007), adnexal mass (P=.001), or ectopic pregnancy (P<.001). Patient compliance with follow-up care was similar in both groups, and no adverse events were noted during study time frame. CONCLUSION: Patients with PUL not required to have an in-person gynecology consult have a significantly decreased ED LOS without compromising adherence to outpatient care. Such protocols may be safely adopted in tertiary care centers.

Impact of Rapid Molecular Respiratory Virus Testing on Real-Time Decision Making in a Pediatric Emergency Department

Acute respiratory illnesses (ARIs) are usually viral [influenza, respiratory syncytial virus (RSV)] and account for 25% of emergency department (ED) peak-season visits. Laboratory PCR testing is accurate albeit slow, whereas rapid antigen testing is inaccurate. We determined the impact of bedside PCR (molecular point-of-care test; mPOCT) on pediatric ARI management. This was a prospective cohort study of consecutive pediatric patients with ED-ordered respiratory PCR test, enrolled over 9 weeks during peak flu season. On ordering, ED physicians were interviewed to ascertain real-time plans if given immediate influenza/RSV PCR results for the current patient. Two groups were compared: actual management and management adjusted for mPOCT results. We compared ED length of stay (LOS), tests ordered, and antibiotic/antiviral ordering. One-hundred thirty-six respiratory PCR panels were ordered, 71 by admitting team, 61 for ED management. Of 61 ED-initiated tests, physicians indicated in 39 cases (64%) they would change patient management were bedside viral results available. Physicians would have decreased ED LOS by 33 minutes, ordered fewer tests (18%; P<0.001) with average patient charge savings of $669, fewer antibiotics among discharged patients (17%; P=0.043), and increased appropriate antiviral use (13%; P=0.023). Rapid bedside ARI mPOCT PCR has the potential to decrease ED LOS, reduce diagnostic tests and patient charges, and increase appropriate use of antibiotics and antiviral agents.

Influences on emergency department length of stay for older people.

The aim of this study was to examine the influences on emergency department (ED) length of stay (LOS) for older people and develop a predictive model for an ED LOS more than 4 h. This retrospective cohort study used organizational data linkage at the patient level from a major Australian health service. The study population was aged 65 years or older, attending an ED during the 2013/2014 financial year. We developed and internally validated a clinical prediction rule. Discriminatory performance of the model was evaluated by receiver operating characteristic (ROC) curve analysis. An integer-based risk score was developed using multivariate logistic regression. The risk score was evaluated using ROC analysis. There were 33 926 ED attendances: 57.5% (n=19 517) had an ED LOS more than 4 h. The area under ROC for age, usual accommodation, triage category, arrival by ambulance, arrival overnight, imaging, laboratory investigations, overcrowding, time to be seen by doctor, ED visits with admission and access block relating to ED LOS more than 4 h was 0.796, indicating good performance. In the validation set, area under ROC was 0.80, P-value was 0.36 and prediction mean square error was 0.18, indicating good calibration. The risk score value attributed to each risk factor ranged from 2 to 68 points. The clinical prediction rule stratified patients into five levels of risk on the basis of the total risk score. Objective identification of older people at intermediate and high risk of an ED LOS more than 4 h early in ED care enables targeted approaches to streamline the patient journey, decrease ED LOS and optimize emergency care for older people.

Adjunct Analgesic Use for Acute Pain in the Emergency Department.

Purpose: Multimodal analgesia is common practice in the postoperative setting, but the utility of adjunctive analgesia in the emergency department (ED) is less understood. The primary objective of this study was to analyze ED prescriber ordering habits for adjunct nonopioid pain medication for opioid-naïve patients who require intravenous (IV) morphine or hydromorphone for acute pain. Secondary objectives were to assess initial and total opioid consumption in morphine equivalent units (MEU), pain scores, and ED length of stay (LOS) between groups. Methods: A retrospective chart review of adult patients who presented to the ED at a large academic medical center and received IV morphine or hydromorphone for acute pain was conducted. Patients were analyzed according to initial opioid received and presence or absence of adjunct nonopioid analgesics. Results: A total of 102 patient charts were analyzed. Adjunctive nonopioid analgesics were ordered on 38% of patients. Patients who received an adjunct nonopioid analgesic received a smaller mean initial opioid dose than those who did not (4.73 vs 5.48 MEU, p = .08). Initial pain score reduction on the 11-point Numeric Rating Scale (NRS) did not differ between patients who received adjunct analgesics versus those who did not (3 vs 4, p = .75). Patients who received adjunct analgesics were associated with a decreased ED LOS (294 vs 342 minutes, p = .04). Conclusion: A small proportion of patients with acute pain received a nonopioid analgesic in conjunction to IV opioids. Further studies are warranted to assess the impact of adjunct analgesics for patients with acute pain.

Improving geriatric trauma outcomes: A small step toward a big problem.

Because of the unique physiology and comorbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an American College of Surgeons Level I trauma center. As of October 1, 2013, all injured patients 70 years or older were mandated to have the highest-level trauma activation upon emergency department (ED) arrival regardless of physiology or mechanism of injury. Patients admitted before that date were designated as PRE; those admitted after were designated as POST. The study period was from October 1, 2011, through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), ED length of stay (LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p < 0.05 was considered significant). χ or Fisher's exact test was used as appropriate for bivariate analyses of categorical variables; patients' ages were compared using the Wilcoxon rank-sum test. A total of 2,269 patients (mean, 80.63 years; mean ISS, 12.2; PRE, 1,271; POST, 933) were included in the study. On multivariable analysis, increasing age, higher ISS, and hypotension were associated with higher mortality. POST patients were more likely to have an ED LOS of 2 hours or shorter (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) after controlling for hypotension, ISS, and comorbidities. POST mortality significantly decreased (odds ratio, 0.689; 95% confidence interval, 0.484-0.979). Based on age alone, the focused intervention of a higher level of trauma activation decreased ED LOS and mortality in injured geriatric patients. Therapeutic/care management study, level IV.

Identifying disparity in emergency department length of stay and admission likelihood.

To assess whether insurance status has an effect on emergency department (ED) length of stay (LOS) and likelihood for admission or transfer to an operating room. This was a retrospective cross-sectional study of all encounters from January 2011 through October 2013 at an urban, academic trauma center. Analysis included multi-variable linear regression for ED LOS and logistic regression for the likelihood of admission. Overall, 201 535 patients met the inclusion criteria, for which the mean age was 43.8 years, 55.9% were female, 23.4% were uninsured and 8% were of non-black race. Admission rate was 24.5% and operative rate was 1.4%. After adjusting for age, sex, triage acuity and race, the presence of insurance coverage was associated with an increased ED LOS of 575 (95%CI 552-598) vs. 567 (95%CI 543-591) minutes (P<0.01) among admitted patients and a decreased ED LOS of 456 (95%CI 381-531) vs. 499 (95%CI 423-575) minutes (P<0.01) among those transferred to an operating room. Adjusting for these same predictors, insured status remained a predictor for admission (odds ratio 1.24, 95%CI 1.20-1.28, P<0.01) and a negative predictor for transfer to the operating room (odds ratio 0.84, 95%CI 0.77-0.92, P<0.01). The insured experienced a clinically insignificant increase in ED LOS when admitted and a 43-minute decrease in ED LOS when being transferred to the operating room. The insured were more likely to be admitted and less likely to be transferred to an operating room.

The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers

ObjectiveHigh-sensitivity troponin T (hs-TnT) assays detect myocardial injury sooner, possibly improving throughput times for emergency department (ED) assessment of suspected acute myocardial infarction (AMI). This study evaluates the influence of hs-TnT implementation on ED length of stay (LOS), consultations and admissions, as well as ED revisits with cardiology admissions for patients undergoing testing for suspected AMI. MethodsThis control pre-post design analysis included patients evaluated using hs-TnT or conventional troponin T. Data were collected from 3 ED databases for patients who had a troponin assay for suspected AMI for the periods February 12, 2011-April 22, 2011 (Ctrl); November 20, 2011-January 28, 2012 (Pre); and February 12, 2012-April 21, 2012 (Post). The primary outcome was ED LOS; secondary outcomes included the proportions of patients who received ED cardiology consultations, patients who were admitted to hospital, and discharged patients who revisited the ED within 30 days. ResultsData were analyzed from 6650 (Ctrl), 6866 (Pre), and 5754 (Post) patients. Median ED LOS decreased following hs-TnT implementation (6.60 hours in Ctrl and Pre vs 6.10 hours in Post, P < .001). There was no change in cardiology consultations or admissions following hs-TnT implementation. Fewer ED revisits occurred within 30 days in Post (16.0% Ctrl, 16.5% Pre vs 14.9% Post; P < .01). These results were preserved after adjusting for age and Canadian Triage Acuity Score. ConclusionsThis hs-TnT implementation strategy, using an equivalent cutoff for the conventional troponin T and hs-TnT assays, decreased ED LOS for patients with suspected AMI and did not increase cardiology resource utilization or ED revisits.

Rapid Emergency Department Medical Clearance Protocol for Psychiatric Patients

Over the recent years, interest in emergency department (ED) length of stay (LOS) has become an important performance measure. In 2008, the National Quality Forum approved two quality measures related to ED length of stay: the median time from arrival to ED departure for both admitted and discharged patients. Additionally, increasing LOS is inversely related to patient satisfaction. If pay for performance becomes tied to ED LOS, this criterion will become even more important. The objective of this study was to see if implementation of a rapid medical clearance protocol for ambulatory, “low-risk” psychiatric patients presenting to the ED resulted in a lower ED LOS. This was a prospective cohort study. A protocol was developed to identify low-risk, ambulatory psychiatric patients who were unlikely to need extensive ED evaluation and move them rapidly from the ED to the psychiatric evaluation unit (PEU). The criteria for low-risk patients were based on vital signs, past medical history, presence of ingestion and alcohol history. The following times were compared for the month prior and the month following protocol implementation: ED arrival to arrival at PU (total time in ED) and time seen by ED provider to arrival at PEU. Data was analyzed using R 2.15 software (Vienna, Austria) and the two-sample Kolmogorov-Smirnov (KS) test. A total of 654 records (post n=290, pre n=364) had complete data for analysis of ED arrival time to arrival at PEU. Four hundred thirty-one records (post n=184, pre n=247) had complete data for analysis of time seen by provider to arrival at PEU. The median total time in ED dropped from 90 minutes to 62 minutes after protocol implementation. The median time from seen by provider to PEU arrival dropped from 106 minutes to 77 minutes after protocol implementation. Missing data led to two different patient samples; thus, the time difference between the two time-stamp groups appears incongruous. Post-implementation time from seen by provider to PEU arrival was statistically smaller than pre-implementation time (KS test, p=.0005). Lastly, the percentage of patients with seen by provider to PEU arrival times within 60 minutes increased from 23% to 36% after protocol implementation. Implementation of a protocol to expedite medical clearance in ambulatory, “low-risk” psychiatric patients can decrease ED LOS to a meaningful degree. Further evaluation of the protocol must be done to ensure that this does not lead to expedited clearance of those who needed more extensive evaluation. Similarly, the success of the protocol to date suggests we may want to look for other patients who would fit the ambulatory, “low-risk” category.

The impact of implementing a 24/7 open trauma bed protocol in the surgical intensive care unit on throughput and outcomes

Increased emergency department (ED) length of stay (LOS) has been associated with increased mortality in trauma patients. In 2010, we implemented a 24/7 open trauma bed protocol in our designated trauma intensive care units (TICUs) to facilitate rapid admission from the ED. This required maintenance of a daily bump list and timely transferring of patients out of the TICU. We hypothesized that ED LOS and mortality would decrease after implementation. The following data from patients admitted directly from the ED to any ICU were retrospectively compared before (2009) and after (2011) the implementation of a trauma bed protocol at a Level I trauma center: age, sex, Glasgow Coma Scale (GCS) score, shock on admission (systolic blood pressure < 90 mm Hg), mechanism, injury severity scores (Injury Severity Score [ISS] and Abbreviated Injury Scale [AIS] score), ED LOS, ICU readmission rates, and mortality. Of the patients, 267 (17%) of 1,611 before and 262 (21%) of 1,266 (p < 0.01) after the protocol were admitted directly to the ICU, despite similar characteristics. ED LOS decreased from 4.2 ± 4.0 hours to 3.1 ± 2.1 hours (p < 0.01) in all patients as well as patients with an ISS of greater than 24 (3.1 ± 2.5 vs. 2.2 ± 1.6, p < 0.05) and a head AIS score of greater than 2 (4.2 ± 4.9 vs. 3.1 ± 2.0, p = 0.01). Mortality was unchanged for all patients (9% vs. 8%, p = 0.58) but trends toward improved mortality were found after protocol implementation inpatients with an ISS of greater than 24 (30% vs. 13%, p = 0.07) and in patients with a head AIS score of greater than 2 (12% vs. 6%, p = 0.08). A greater proportion of total patients were admitted to a designated TICU after implementation (83% vs. 93%, p < 0.01). ICU readmissions were unchanged (0.3% vs. 1.5%, p = 0.21). The implementation of a 24/7 open trauma bed protocol in the surgery ICU was associated with a decreased ED LOS and increased admissions to designated TICUs in all patients. Improved throughput was achieved without increases in ICU readmissions. Therapeutic study, level IV.

122 The Effect of Implementing High-Sensitivity Troponin Testing on Operational Efficiency in Three Large Urban Emergency Departments

New highly sensitive cardiac Troponin T (hsTnT) assays are becoming widely adopted in Canadian hospitals, raising the possibility of improved throughput times for emergency department (ED) assessment. Few studies have addressed the effects of introducing the hsTnT assay on ED and hospital resource consumption. In this study, we evaluate the impact of hsTnT implementation on ED length of stay (LOS), consultation and admission rates for patients with suspected AMI. This time-series analysis involved a cohort of all patients presenting to three Calgary adult EDs evaluated using hsTnT or its predecessor, conventional TnT (cTnT). The hsTnT assay was implemented on January 31, 2012. An educational intervention for ordering physicians and nurses preceded the implementation of hsTnT testing. The cutoff value used for diagnosis of AMI was 50 ng/ml. Data was collected for February 12, 2011-April 22, 2011: control period one year prior to hsTnT implementation (Ctrl1yrPre); November 20, 2011-January 28, 2012: immediately pre-hsTnT implementation (Immed-pre); February 12, 2012- April 21, 2012: immediately post-hsTnT implementation (Post). Subjects included all ED patients, excluding physician-confirmed STEMIs, who had at least one cTnT or hsTnT drawn as a marker for symptoms suspicious of AMI. The ED information system database was used to collect outcome data. Categorical variables were analyzed using Pearson's Chi-squared test. The Mann-Whitney U test was used to compare median values between the three study periods. We analyzed data from 6742 patients Ctrl1yrPre, 6952 Immed-pre and 5822 Post; demographic characteristics between the groups were similar. A smaller proportion of patients had troponin assays performed in the Post period, compared to the Ctrl1yrPre and Immed-pre periods (12.5% Post vs. 15.8% Ctrl1yrPre and 15.4% Immed-pre). A significant reduction in median ED LOS was observed following hsTnT implementation: 6.53 hours (h) in Ctrl1yrPre, 6.52 h in Immed-pre, and 6.04 h in Post (p<0.001). The proportion of patients with third troponins ordered decreased from 7.9% in Ctrl1yrpre and 7.2% in Immed-pre to 5.9% in Post (p<0.001). There was no statistically significant change in the number of Cardiology consultations or admissions following hsTnT implementation. Implementing hsTnT testing at three centers with an equivalent cutoff value and a change in nurse-initiated TnT ordering resulted in a decreased ED LOS for patients with suspected AMI and no increase in cardiology resource utilization. This finding may be attributable to a carefully considered hsTnT assay implementation strategy that reduced the number of unnecessary TnT assays performed.

Does Limiting Oral Contrast Decrease Emergency Department Length of Stay?

Introduction:The purpose of this study was to examine the impact on emergency department (ED) length of stay (LOS) of a new protocol for intravenous (IV)-contrast only abdominal/pelvic computed tomography (ABCT) compared to historical controls.Methods:This was a retrospective case-controlled study performed at a single academic medical center. Patients ≥ 18 undergoing ABCT imaging for non-traumatic abdominal pain were included in the study. We compared ED LOS between historical controls undergoing ABCT imaging with PO/IV contrast and study patients undergoing an IV-contrast-only protocol. Imaging indications were the same for both groups and included patients with clinical suspicion for appendicitis, diverticulitis, small bowel obstruction, or perforation. We identified all patients from the hospital’s electronic storehouse (imaging code, ordering department, imaging times), and we abstracted ED LOS and disposition from electronic medical records.Results:Two hundred and eleven patients who underwent PO/IV ABCT prep were compared to 184 patients undergoing IV-contrast only ABCT prep. ED LOS was shorter for patients imaged with the IV-contrast only protocol (4:35 hrs vs. 6:39 hrs, p < 0.0001).Conclusion:Implementation of an IV-contrast only ABCT prep for select ED patients presenting for evaluation of acute abdominal pain significantly decreased ED LOS.

Decreased Emergency Department Length of Stay by Application of a Computerized Consultation Management System

Consultation difficulty occurs in hospitals located in many countries, and it is understood that strategies to improve the emergency department (ED) consultation process are needed. The authors constructed a computerized consultation management system in the ED of a tertiary care teaching hospital to improve the consultation process and evaluate the influence of the consultation management system on ED length of stay (LOS) and the throughput process. Consultation management system software was developed and integrated into the hospital information system. The development process took place between June 2008 and May 2009. Before the development of the consultation system, ED personnel contacted on-call physicians of the specialty department, who are usually residents, by cellular phones. After the system had been developed, ED personnel selected the department and on-call physician in the specialty department using the consultation management software and activated the automatic consultation process when specialty consultation was necessary. If the treatment plan had not been registered for 3 hours, all of the residents in the specific department are notified of the delay in the treatment plan with a short message service (SMS) message. If an admission or discharge order had not been made in 6 hours, all of the residents and faculty staff in the specific department receive SMS messages stating the delay in disposition. ED patient data were collected from the hospital information system for 40 days before the system was developed (June 1, 2008, to July 10, 2008) and 40 days after the system was implemented (June 1, 2009, to July 10, 2009). The median ED LOS decreased significantly, from 417.5 minutes (interquartile range [IQR] = 178.8-1,247.5 minutes) in the presystem period to 311.0 minutes (IQR = 128.0-817.3 minutes) in the postsystem period (p < 0.001). Also, the median time to disposition order decreased significantly, from 336.0 minutes (IQR = 145.0-943.0 minutes) to 235.0 minutes (IQR = 103.0-21.5; p = 0.001). No significant reduction was observed in the interval between the time of disposition decision and the time when the patients left the ED. Significant reductions of ED LOS were observed after implementing the system (p < 0.001) regardless of whether the visit occurred during the weekday daytime (09:00-17:00 hours), holiday and weekend daytime (09:00-17:00 hours), or nighttime (17:00-09:00 hours next day). This study found decreased ED LOS by implementation of a computerized consultation management system in a tertiary care teaching hospital. The automated consultation and monitoring process formalized communication between physicians providing ED patient care in the academic ED with high consultation and admission rates.

Effect of emergency department fast track on emergency department length of stay: a case–control study

Objective:To examine the effect of fast track on emergency department (ED) length of stay (LOS).Design and setting:Pair-matched case–control design in a public teaching hospital in metropolitan Melbourne, Australia.Participants:Patients treated by...

Analysis of Emergency Department Test Ordering Patterns in an Urban Academic Medical Center

Emergency department (ED) overcrowding and prolonged patient length of stay (LOS) is an increasing problem in most American hospitals. Some reports in the literature have suggested that point-of-care (POC) testing may help alleviate ED overcrowding by providing rapid test results to aid in triage decisions and administration of appropriate therapy. In our hospital, a limited menu of POC tests was shown to decrease ED LOS and reduce the number of hours the ED was on divert status. In recent years, the menu of tests available in POC formats has continued to expand raising the possibility that more patients could receive rapid POC results and potentially have a greater impact on ED operations. We analyzed ED laboratory test ordering patterns to determine what impact an expansion of the ED POC menu might achieve using a selected group of instruments. The ED at Massachusetts General Hospital evaluated approximately 76,000 patients in 2005, of which 25% are admitted. Of these, approximately 76% received laboratory testing. The average number of tests per patient for those that received testing was 7.7 assuming scoring of standard medicare panels as one test for the panel, and 75% of patients had 5 or more tests/panels ordered. Of tests performed in our ED, 9% are now performed at the POC in our satellite laboratory (blood glucose, cardiac markers, dipstick urinalysis, urine pregnancy testing, and rapid Strep A and influenza testing) and 66% of patients that receive testing have some test performed at the POC. Overall, the most common laboratory tests requested are the basic metabolic panel (15.0% of tests), complete blood count (13.2%), calcium/phosphate/magnesium (9.7%), hepatic panel (6.7%), urinalysis (6.2%), cardiac markers (5.2%), prothrombin time (5.1%), amylase/lipase (4.8%), urine pregnancy (4.1%), toxicology (2.9%), and partial thromboplastin time (2.8%), respectively. Of patients that received testing, 88% had a complete blood count; 86%, a basic metabolic panel; 68%, a calcium/phosphate/magnesium; 58%, a hepatic panel; 47%, a urinalysis; 39%, a prothrombin time; 36%, an amylase/lipase; 32%, a urine pregnancy; 28%, cardiac markers; and 2.1%, a toxicology analysis. Of all tests, 71.6% were chemistries, 23.4% were hematology tests, and 5% were microbiology tests. Using a hypothetical combination of a rapid chemistry analyzer, a conventional hematology cell counter, and other true POC testing devices, 75.6% of the tests requested by our ED could be performed in our satellite laboratory. With this menu, all requested testing could be performed on 62% of patients that receive testing. The remaining 38% would require some other additional test(s) to complete the laboratory evaluation. Point-of-care testing in an ED satellite laboratory at the Massachusetts General Hospital performs a significant number of selected tests. Expanding the menu to include routine chemistry and hematology would permit 62% of all patients that receive testing to be fully accommodated. Unlike previously reported benefits of POC testing, such as cardiac markers, the potential benefits of doing this in terms of improving patient care or ED operations is not yet clear.