Differences In Emergency Department Length Research Articles

Radiologists predict differential resource utilization but not clinical outcome in emergency department patients imaged with ultrasound for right upper quadrant pain.

Radiologists with diverse training, specialization, and habits interpret imaging in the Emergency Department. It is necessary to understand if their variation predicts differential value. The purpose of this study was to determine whether attending radiologist variation predicts major clinical outcomes in adult Emergency Department patients imaged with ultrasound for right upper quadrant pain. Consecutive ED patients imaged with ultrasound for RUQ pain from 10/8/2016 to 8/10/2022 were included (N = 7097). The primary outcome was prediction of hospital admission by signing attending radiologist. Secondary outcomes included: ED and hospital length of stay (LOS), 30-day mortality, 30-day re-presentation rate, subspecialty consultation, advanced imaging follow up (HIDA, MRI, CT), and intervention (ERCP, drainage or surgery). Sample size was determined a priori (detectable effect size: w = 0.06). Data were adjusted for demographic data, Elixhauser comorbidities, number of ED visits in prior year, clinical data, and system factors (38 covariates). P-values were corrected for multiple comparisons (false discovery rate-adjusted p-values). The included ultrasounds were read by 35 radiologists (median exams/radiologist: 145 [74.5-241.5]). Signing radiologist did not predict hospitalization (p = 0.85), abdominopelvic surgery or intervention within 30 days, re-presentation to the Emergency Department within 30 days, or subspecialty consultation. Radiologist did predict difference in Emergency Department length of stay (p < 0.001) although this difference was small and imprecise. HIDA was mentioned variably by radiologists (range 0-19%, p < 0.001), and mention of HIDA in the ultrasound report increased 10-fold the odds of HIDA being performed in the next 72h (odds ratio 10.4 [8.0-13.4], p < 0.001). Radiologist variability did not predict meaningful outcome differences for patients with right upper quadrant pain undergoing ultrasound in the Emergency Department, but when radiologists mention HIDA in their reports, it predicts a 10-fold increase in the odds a HIDA is performed. Radiologists are relied on for interpretation that shapes subsequent patient care, and it is important to consider how radiologist variability can influence both outcome and resource utilization.

Optimizing emergency department imaging utilization for pulmonary emboli: A study on the effects of IV contrast rationing

PurposeTo study the impact of a contrast mitigation protocol on imaging utilization for pulmonary embolism (PE) in the emergency department (ED). Material and methodsMedical records of ED patients with suspected PE who underwent CT pulmonary angiography (CTPA) or ventilation-perfusion (VQ) scans were analyzed in control (3/15/22–4/15/22) and test (5/15/22–6/15/22) periods. The test period included a contrast mitigation protocol due to a global iodinated contrast shortage (05/2022–06/2022). Out of 610 scans, 28 were excluded for non-PE indications. Patient demographics, time metrics, and imaging reports were recorded. ResultsAmong 11,019 ED visits, there were 582 imaging events for suspected PE. The test period exhibited a significantly lower imaging rate of 4.16 % compared to 6.54 % in the control period (p < 0.001). CTPA usage decreased by 47.73 %, while VQ scan usage increased by 775.00 % during the test period. Test period positivity rate was 0.82 %, with CTPA at 0.58 % (1/173) and VQ scan at 1.43 % (1/70). In the control period, the positivity rate was 0.29 %, with CTPA at 0.30 % (1/331) and VQ scan at 0.00 % (0/8). Previous hospitalization history was significantly higher in the test period (70/243 vs. 39/339, p < 0.001). The positivity rates between the two periods showed no significant difference (p = 0.57). There were no significant differences in ED length of stay and image acquisition times. ConclusionThe contrast mitigation protocol reduced CTPA use, increased VQ scans, and maintained positivity rates and image acquisition times. However, concerns persist about unnecessary imaging and low positivity rates, necessitating further research to optimize PE diagnostic algorithms.

2949. Emergency Department (ED) Discharge Antibiotic Prescription Review by Hospital Pharmacists at a Large Academic Medical Center

Abstract Background Direct patient discharge from the Emergency Department (ED) presents an ideal time to promote antimicrobial stewardship (AS). On March 1, 2021 we initiated a pilot program where ED pharmacists conduct a review of discharge antibiotic prescriptions (abx Rxs). The aim of this program is to ensure appropriate discharge abxs. Willow Pharmacy Epic Analysts, ED and AS pharmacists collaborated on this program which included Epic integration of Rx Discharge Track Board, ED Discharge InBasket, ED Discharge Rx iVent and AS-led education sessions. Methods Data for 2022 ED patients with discharge abx Rxs and iVents were extracted via Epic Reports. The first encounter per patient was included. We compared discharge abx Rxs and patient outcome data in Pharmacy vs No Pharmacy Review Groups (PRG, NPRG). Pharmacy iVents were used as a process measure. Results Among 5747 ED adult patients with discharge abx Rxs, 2638 (46%) were reviewed by pharmacy (PRG). PRG and NPRG had similar prevalence of chronic pulmonary disease (12% vs. 13%), diabetes mellitus (9% vs. 10%), malignancy (8% vs. 9%), peripheral vascular disease (6% vs. 8%), renal disease (4% vs. 5%), and HIV (1% vs. 2%) despite a difference in mean Charlson Comorbidity Index (0.64 vs 0.75, p&amp;lt; 0.01). The primary ED diagnosis was skin and soft tissue, urinary, intra-abdominal infections and pneumonia (25 vs 23%, 18 vs 17%, 8 vs 9%, 5 vs 6%, respectively all p=NS). In PRG, discharge abxs demonstrated an increase use of penicillin (26 vs 24%, p=0.017) and 2nd generation cephalosporin (17 vs 14%, p&amp;lt; 0.001). The PRG also decreased use of 3rd generation cephalosporin (11 vs 12%, p=NS), quinolones (6 vs 7%, p=NS) and clindamycin (1.7 vs 2.4%, p=NS). There was no difference in ED length of stay (LOS 4.8h in each group), C. difficile infection (CDI) within 8 weeks (0.1 vs 0.2%, p=NS), and 30 days repeat ED visit or inpatient admission with the same diagnosis as index ED encounter (2.8 vs 2.6%, p=NS). Pharmacists intervened in 10% (272/2638) of ED abx Rxs with 92% (249/272) acceptance rate. The top 3 pharmacy interventions were recommending alternative abx (42%), dose optimization (31%) and abx duration (6%). Conclusion Engaging pharmacists in ED discharge Rxs review resulted in use of narrower spectrum abx with lower CDI risk without any negative impact on ED LOS and clinical outcomes. Disclosures All Authors: No reported disclosures

BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation—a randomized multicenter clinical trial

BackgroundBiomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate.MethodsA randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications.ResultsThree hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( −). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques.ConclusionA combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate.Trial registrationNetherlands Trial Register NTR5839—1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15

343EMF Identifying and Addressing Barriers to Emergency Department Buprenorphine Use Across a Health Care System

343EMF Identifying and Addressing Barriers to Emergency Department Buprenorphine Use Across a Health Care System

A modified emergency severity index level is associated with outcomes in cancer patients with COVID-19

ObjectiveTo evaluate a modified emergency severity index (mESI)-based triage of cancer patients with coronavirus disease 2019 (COVID-19) in the emergency department (ED) and determine the associations between mESI level and ED disposition, hospital length of stay, and overall survival. MethodsMedical records were retrospectively reviewed for all patients who presented to our institution's ED between March 22, 2020, and March 12, 2021, and tested positive for SARS-CoV-2. ResultsA total of 306 cancer patients tested positive for SARS-CoV-2, with 45% of patients triaged to level 2 (emergent) and 55% to level 3 (urgent). Among all patients, 61.8% were admitted to the hospital, 15.7% were admitted to the intensive care unit, 2.9% were sent for observation, and 19.6% were discharged. Although demographic and clinical characteristics did not significantly vary by triage level, we observed significant differences in ED length of stay (urgent = 6.67 h, emergent = 5.97 h; p < 0.01). Hospital and intensive care unit admission rates were also significantly higher among emergent patients than among urgent patients (p < 0.05). There were 75 deaths (urgent = 32; emergent = 43), and the 30-day mortality rate was significantly higher among emergent patients (urgent = 8%, emergent = 15%; p < 0.05). The mESI level persisted as a significant factor associated with overall survival (hazard ratio = 1.7, 95% confidence interval = 1.09–2.81) in multivariable analysis. ConclusionThe mESI level is associated with ED disposition, ED length of stay, and overall survival in cancer patients presenting with COVID-19. These results indicate that the mESI triage tool can be effectively used in cancer patients with COVID-19, whose condition can rapidly deteriorate.

Effect of language interpretation modality on throughput and mortality for critical care patients: A retrospective observational study.

ObjectiveLimited data exist describing possible delays in patient transfer from the emergency department (ED) as a result of language barriers and the effects of interpretation services. We described the differences in ED length of stay (LOS) before intensive care unit (ICU) arrival and mortality based on availability of telephone or in‐person interpretation services.MethodsUsing an ICU database from an urban academic tertiary care hospital, ED patients entering the ICU were divided into groups based on primary language and available interpretation services (in‐person vs telephone). Non‐parametric tests were used to compare ED LOS and mortality between groups.ResultsAmong 22,422 included encounters, English was recorded as the primary language for 51% of patients (11,427), and 9% of patients (2042) had a primary language other than English. Language was not documented for 40% of patients (8953). Among encounters with patients with non‐English primary languages, in‐person interpretation was available for 63% (1278) and telephone interpretation was available for 37% (764). In the English‐language group, median ED LOS was 292 minutes (interquartile range [IQR], 205–412) compared with 309 minutes (IQR, 214–453) for patients speaking languages with in‐person interpretation available and 327 minutes (IQR, 225–463) for patients speaking languages with telephone interpretation available. Mortality was higher among patients with telephone (15%) or in‐person (11%) interpretation available compared with patients who primarily spoke English (9%).ConclusionsPatients with primary languages other than English who were critically ill spent a median of 17 to 35 more minutes in the ED before ICU arrival and experienced higher mortality rates compared with patients who spoke English as a primary language.

Intravenous insulin for the management of non-emergent hyperglycemia in the emergency department.

There is currently no consensus regarding the necessity of emergency department (ED) glucose reduction to manage hyperglycemia in patients presenting without a hyperglycemic emergency. Known consequences of intravenous (IV) insulin administration include hypoglycemia, hypokalemia, and increased ED length of stay. The primary objective of this study was to assess the impact of IV regular insulin on glucose reduction and ED length of stay in patients presenting to the ED with non-emergent hyperglycemia. Secondary objectives included the characterization of potential adverse events. This was a retrospective, observational study of patients ≥18years who received IV regular insulin and were discharged from the ED at a large academic Trauma Center. Univariate and multivariable regression analyses were utilized to determine if an association existed between IV insulin administration and blood glucose as well as ED length of stay. A total of 405 patients were included in the analysis. An insulin dose >5units was associated with a greater reduction in blood glucose (difference=37.4mg/dL; p<.001) but no difference in ED length of stay relative to ≤5units. Furthermore, 7.9% of patients developed hypokalemia and 0.4% developed hypoglycemia. The use of >5units of IV regular insulin for the management of isolated hyperglycemia in the ED was associated with a modest reduction in blood glucose and no difference in ED length of stay compared with those that received ≤5units. However, use of IV insulin for this purpose resulted in a 7.9% occurrence of hypokalemia.

Evaluating the impact of point-of-care ultrasonography on patients with suspected acute heart failure or chronic obstructive pulmonary disease exacerbation in the emergency department: A prospective observational study.

Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD. We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses. There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05-2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events. In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.

Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

Objective: The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only. Methods: We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury. Results: Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10–69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49–5.80, and OR =2.15, 95% CI, 1.07–4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate. Conclusions: This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.

Interphysician Differences in Emergency Department Length of Stay

BackgroundEmergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS). ObjectiveTo describe how ED LOS differs among physicians. MethodsWe performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOSO/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year. ResultsThree hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106–184 min), and the average longest observed LOS was 232 min (range 196–270 min); the average difference was 81 min (range 69–90 min). For LOSO/E, the average lowest LOSO/E was 0.801 (range 0.702–0.887), and the average highest LOSO/E was 1.210 (range 1.186–1.275); the average difference between the lowest LOSO/E and the highest LOSO/E was 0.409 (range 0.305–0.493). ConclusionThere are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOSO/E for physicians with the lowest LOSO/E at each site averaged approximately 20% less than predicted, and that the LOSO/E for physicians with the highest LOSO/E at each site averaged approximately 20% more than predicted.

249 Waiting for Care: Differences in Emergency Department Length of Stay and Disposition Between Medical and Psychiatric Patients

249 Waiting for Care: Differences in Emergency Department Length of Stay and Disposition Between Medical and Psychiatric Patients

52 Physician-level Differences in Emergency Department Length of Stay

52 Physician-level Differences in Emergency Department Length of Stay

No Difference in Emergency Department Length of Stay for Patients with Limited Proficiency in English

The population of the United States continues to diversify, with an increasing percentage of individuals who have limited English proficiency (LEP). A major concern facing emergency departments (EDs) around the country is increasing length of stay (LOS). Although multiple studies have shown racial and ethnic disparities in waiting time and LOS, no studies have examined specifically whether patients with LEP have a different LOS than English-speaking (ES) patients. In addition, no studies have examined whether the use of interpreters by patients with LEP has a significant impact on LOS. We hypothesized that there was a significant difference in LOS when comparing patients with LEP and ES patients and patients with LEP who used interpreters versus patients with LEP who did not. This was a prospective cohort study with LOS data collected from a level I ED patient tracking software program from October 2011 to December 2011. The primary language preferred by the patient was indicated at the time of triage and registration and the patient's use of an interpreter also was recorded. The patient's demographic data, ED visit information, and LOS were prospectively entered into an Excel spreadsheet. Percentages were compared using 95% confidence intervals and LOS was analyzed using the Student t test. With >100 subjects per group, our study had 80% power (ie, a power of 0.8) to determine a 15% difference in proportions between groups or a difference of 120 minutes (assuming a standard deviation of 300 minutes on both means). Data were collected from a total of 121 ES patients and 124 patients with LEP. In the LEP group were the languages of Spanish, Navajo, Vietnamese, Chinese, Arabic, and American Sign Language. Fifty-eight percent of patients with LEP used an interpreter. There were no differences between ES patients and patients with LEP in age, sex, mode of arrival, chief complaints, acuity, percentage admitted, percentage pediatric patients, or percentage of Medicaid/Medicare recipients. More patients with LEP were self-pay (36% vs 20%, diff 16, 95% confidence interval 2-31). There were no differences in mean LOS from time of arrival to time to being seen by a provider when comparing ES patients with patients with LEP or time of arrival to time to discharge or admission request. Comparing the patients with LEP who used interpreters with those who did not use interpreters, there was a significantly different LOS from time of arrival to time of discharge or admission request (958 ± 644 vs 628 ± 595 minutes, diff 330, 95% confidence interval 84-576). There was no difference in LOS for patients with LEP; however, patients with LEP who used interpreters had a significant increase in LOS compared with those who did not use interpreters.

199 No Difference in Emergency Department Length of Stay for Limited English Proficiency Patients With Language Disparities

Background: The population of the United States continues to diversify with an increasing percentage of homes with limited English proficiency (LEP). A major concern facing emergency departments (EDs) around the country is increasing length of stay (LOS). While multiple studies have shown racial and ethnic disparities in waiting time and length of stay (LOS), no studies have examined specifically if LEP patients have a different LOS than English-speaking (ES) patients. We hypothesized that there was a significant difference in LOS when comparing LEP and ES patients.

Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department

The objective was to compare intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of acute, anterior shoulder dislocations in the emergency department (ED) in terms of ED length of stay, rate of successful reductions, patient satisfaction, and complications. This was a prospective, randomized trial. Patients in the IAL group received 4 mg/kg (up to 200 mg) of 1% lidocaine injected into the glenohumeral joint using a lateral approach. Patients in the IVS group received medications for sedation as per the discretion of the treating physician. Follow-up was arranged within 2 weeks of the ED visit to assess for complications. Forty-four patients (25 IAL, 19 IVS) were included. This trial was stopped early owing to a combination of unexpected findings in success, resource limitations, and difficulty in patient enrolment. Median time from first physician assessment to patient discharge was not different between the IAL (170 minutes) group and the IVS (145 minutes) group (Δ -25 minutes; 95% CI -32, 70; p = 0.46). There was a significantly lower rate (p < 0.001) of successful closed reduction in the IAL group (48%) compared to the IVS group (100%). Patient satisfaction and physician ease of reduction were higher in the IVS group compared to the IAL group (p < 0.05). There were no reported complications in either group at time of reduction or follow-up. There was no difference in ED length of stay between groups. There was a lower rate of successful reductions and lower satisfaction scores in the IAL group.

Hospital Variability in Emergency Department Length of Stay for Adult Patients Receiving Psychiatric Consultation: A Prospective Study

We ascertain the components of emergency department (ED) length of stay for adult patients receiving psychiatric evaluation and to examine their variability across 5 hospitals within a health care system. This was a prospective study of 1,092 adults treated between June 2008 and May 2009. Research staff abstracted length of stay and clinical information from the medical records. Clinicians completed a time log for each patient contact. Main outcomes were median times for the overall ED length of stay and its 4 components, or time from triage to request for psychiatric evaluation, request to start of psychiatric evaluation, start to completion of psychiatric evaluation with a disposition decision, and disposition decision to discharge from the ED. The overall median length of stay was more than 8 hours. Median times for the components were 1.8 hours from triage to request, 15 minutes from request to start of psychiatric evaluation, 75 minutes from start of psychiatric evaluation to disposition decision, and nearly 3 hours from disposition decision to ED discharge. The median disposition decision to discharge time was substantially shorter for patients who went home (40 minutes) than for patients who were admitted (2.5 hours) or transferred for psychiatric admission at other facilities (6.3 hours). When adjustments for patient and clinical factors were made, differences in ED length of stay persisted between hospitals. ED length of stay for psychiatric patients varied greatly between hospitals, highlighting differences in the organization of psychiatric services and inpatient bed availability. Findings may not generalize to other settings or populations.

The Effect of Physician Triage on Emergency Department Length of Stay

Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist. We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion. This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period. We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month. Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.