ED Operations Research Articles

Factors influencing the classification accuracy of triage nurses in emergency department: analysis of triage nurses’ characteristics

BackgroundTriage nurses play a vital role in emergency departments (Eds), with the accuracy of the triage nurse significantly impacting patient care and departmental efficiency. However, there is a lack of exploration into whether the time it takes for triage nurses to triage patients affects accuracy.MethodThis study analyzed the electronic medical records of 787 patients and the characteristics of triage nurses, using statistical methods to determine factors affecting classification accuracy. Data were collected from a single general hospital between November 1 and November 30, 2023.ResultsFindings revealed an 84.9% accuracy rate. Longer clinical experience (p = .001, CI = 1.094–2.052), as well as extended classification time (p = .002, CI = 1.338–2.916), significantly improved accuracy. Age and gender had no notable effect.ConclusionEnhancing triage nurse experience and allowing adequate classification time can improve accuracy, optimizing patient care and ED operations.

Big data analytics and the effects of government restrictions and prohibitions in the COVID-19 pandemic on emergency department sustainable operations.

Grounded in dynamic capabilities, this study mainly aims to model emergency departments' (EDs) sustainable operations in the current situation caused by the COVID-19 pandemic by using emerging big data analytics (BDA) technologies. Since government may impose some restrictions and prohibitions in coping with emergencies to protect the functioning of EDs, it also aims to investigate how such policies affect ED operations. The proposed model is designed by collecting big data from multiple sources and implementing BDA to transform it into action for providing efficient responses to emergencies. The model is validated in modeling the daily number of patients, the average daily length of stay (LOS), and daily numbers of laboratory tests and radiologic imaging tests ordered. It is applied in a case study representing a large-scale ED. The data set covers a seven-month period which collectively means the periods before COVID-19 and during COVID-19, and includes data from 238,152 patients. Comparing statistics on daily patient volumes, average LOS, and resource usage, both before and during the COVID-19 pandemic, we found that patient characteristics and demographics changed in COVID-19. While 18.92% and 27.22% of the patients required laboratory and radiologic imaging tests before-COVID-19 study period, these percentages were increased to 31.52% and 39.46% during-COVID-19 study period. By analyzing the effects of policy-based variables in the model, we concluded that policies might cause sharp decreases in patient volumes. While the total number of patients arriving before-COVID-19 was 158,347, it decreased to 79,805 during-COVID-19. On the other hand, while the average daily LOS was 117.53 min before-COVID-19, this value was calculated to be 165,03 min during-COVID-19 study period. We finally showed that the model had a prediction accuracy of between 80 to 95%. While proposing an efficient model for sustainable operations management in EDs for dynamically changing environments caused by emergencies, it empirically investigates the impact of different policies on ED operations.

Characteristics and expectations among emergency department patients in India.

In India, and many low-middle income countries (LMICs), emergency medicine (EM) remains a poorly defined specialty and an unregulated field of clinical practice. Recognition of the attitudes, understanding, and expectations of patients presenting to Indian EDs will be crucial to the continued development of EM as a specialty. This is a multicenter, prospective, cross sectional study of adult and pediatric patients presenting to the ED in three geographically distinct regions of India. Participants were surveyed about their expectations regarding the type of care that they expected to receive, previous treatment options they have utilized, basic understanding of ED operations, factors contributing to their decision to seek ED care, and basic demographic information. 779 patients were approached to participate in the study, of which 698 (90%) completed the survey. Common ways that patients reported learning about the ED were referral from another healthcare provider (45%) and recommendation by a family member (61%). Participants chose the ED was because they thought they would be seen quickly (89%), would receive acute pain management (45%), their regular outpatient care was closed (45%), or were sent by another doctor (45%). Patients expected to wait 0.3 hours (18 minutes) on average to see a doctor in the ED. Over 75% or patients expected to see a specialist consultant in the ED and 12% expected to see their personal physician. Eighty-five percent of patients were triaged as moderate or high acuity, and 74% of patients were admitted. This study found that ED in India is utilized by a population with an extremely high acuity of medical illness that attempts to access healthcare through multiple avenues. Patients most frequently visit the ED due to a referral from another healthcare provider or family member. Most patients are aware of the existence of the ED, though understanding of available services may be lacking. Future research should focus on community outreach and education initiatives on ED services.

Resilient healthcare theory as a lens to research emergency department operations: a protocol for a scoping review

IntroductionEmergency departments (EDs) are complex systems that have constant fluctuations in demand, creating mismatches with planned capacity. Despite the complexity of ED operations, quality and safety improvement are often approached...

Smart hospitals and A&E departments in Hong Kong: Advantages, considerations and way forward

The concept of smart hospital is not new, but its development has unprecedentedly been accelerated by the COVID-19 pandemic. Throughput and performance dashboard on ED operation running in real-time manner would facilitate ED managers to maintain smooth ED operation or even predict and anticipate the service surge. The ED health big data would also have potential impact on the development of geriatric and ambulatory emergency medicine to accurately identify high-acuity patients and stratify low-risk patients for ambulatory care. [Extracted from the article] Copyright of Hong Kong Journal of Emergency Medicine is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Development and preliminary testing of an online software system to facilitate assessment of accuracy and consistency in applying the Australasian Triage Scale

PurposeThe aim of this project was to design and evaluate an online software system to facilitate the assessment of triage decision accuracy and consistency in applying the Australasian Triage Scale. BackgroundTriage is a critical component of emergency nursing practice, which affects patient access to emergency care. Accurate and consistent triage decisions are vital to ensuring patient safety, timely access to care and ED operation. Presently, there is no standard process to examine triage decisions, measure current performance and support department and individual performance development activities to improve patient safety and quality of emergency care. MethodAn iterative design guided by a human factors development approach was used to develop a retrospective, focus-based analysis system to evaluate triage decision accuracy and consistency, and enable the exploration of service gaps and opportunities for practice change and professional development. ResultsTriage decision accuracy and consistency, including areas for improvement are detectable and quantifiable. Findings generated may aid in departmental performance and professional development of triage nurses. ConclusionThis is the first system developed to assess decision accuracy and consistency in applying the Australasian Triage Scale. This paper has described the development and preliminary testing of a user-centred design process and implementation of a web-based system to evaluate triage decision accuracy and consistency.

Applying advanced analytics to guide emergency department operational decisions: A proof-of-concept study examining the effects of boarding

BackgroundEmergency Department (ED) leaders are increasingly confronted with large amounts of data with the potential to inform and guide operational decisions. Routine use of advanced analytic methods may provide additional insights. ObjectivesTo examine the practical application of available advanced analytic methods to guide operational decision making around patient boarding. MethodsRetrospective analysis of the effect of boarding on ED operational metrics from a single site between 1/2015 and 1/2017. Times series were visualized through decompositional techniques accounting for seasonal trends, to determine the effect of boarding on ED performance metrics and to determine the impact of boarding “shocks” to the system on operational metrics over several days. ResultsThere were 226,461 visits with the mean (IQR) number of visits per day was 273 (258–291). Decomposition of the boarding count time series illustrated an upward trend in the last 2–3 quarters as well as clear seasonal components. All performance metrics were significantly impacted (p<0.05) by boarding count, except for overall Press Ganey scores (p<0.65). For every additional increase in boarder count, overall length-of-stay (LOS) increased by 1.55min (0.68, 1.50). Smaller effects were seen for waiting room LOS and treat and release LOS. The impulse responses indicate that the boarding shocks are characterized by changes in the performance metrics within the first day that fade out after 4–5days. ConclusionIn this study regarding the use of advanced analytics in daily ED operations, time series analysis provided multiple useful insights into boarding and its impact on performance metrics.

Emergency medicine residencies structure of trainees' administrative experience: A cross-sectional survey.

While the Accreditation Council for Graduate Medical Education (ACGME) mandates that emergency medicine residencies provide an educational curriculum that includes administrative seminars and morbidity and mortality conference, there is significant variation as to how administrative topics are implemented into training programs. We seek to determine the prevalence of dedicated administrative rotations and details about the components of the curriculum. In this descriptive study, a 12-question survey was distributed via the CORD listserv; each member program was asked questions concerning the presence of an administrative rotation and details about its components. These responses were then analyzed with simple descriptive statistics. A total of 114 of the 168 programs responded, leading to a 68% response rate. Of responders, 73% have a dedicated administrative rotation (95% CI 64.0 to 80.4). The content areas covered by the majority of programs with a dedicated program include performance improvement (n=68), patient safety (n=64), ED operations (n=58), patient satisfaction (n=54), billing and coding (n=47), and inter-professional collaboration (n=43). Experiential learning activities include review of patient safety reports (n=66) and addressing patient complaints (n=45). Most of the teaching on the rotation is either in-person (n=65) and/or self-directed reading assignments (n=48). The most commonly attended meetings during the rotation include performance improvement (n=60), ED operations (n=59), and ED faculty (n=44). This paper provides an overview of the most commonly covered resident administrative experiences that can be a guide as we work to develop an ideal administrative curriculum for EM residents.

80 Grady Memorial Hospital Emergent Dialysis Program

The literature is scant on the existence of emergent dialysis programs that operate within the capacity of an emergency department. Notwithstanding, it is unclear what the demographics of these patients are who utilize these services and how to optimize their care. The primary objective of this research inquiry is to assess the impact of an emergent dialysis process redesign on the operational metrics of the emergency department and inpatient services. Secondary objectives include to identify the demographics of the patients served via the emergent dialysis program, to assess patient and provider satisfaction with the novel emergent dialysis program and finally to identify opportunities for workflow improvement. This is a before-after observational study derived from administratively collected data. The before period was from August 1, 2016 to October 30, 2016; the after period was from to June 23, 2017. In the before period, patients arrived in the ED, had an initial evaluation, then were admitted as an inpatient for dialysis. In the after period, patients arrived to the ED, were triaged to the Radiology Holding where they had labs, EKG, and an initial screening exam completed. Following this, they were either admitted to observation status where they would obtain dialysis or be discharged with anticipatory guidance and return precautions for emergent dialysis. Complications were captured from record review. Patient demographics and data was abstracted from electronic medical records (EPIC) and includes the following: ED arrival, first contact with doctor, ED LOS, Inpatient LOS, TDC. Over the study period there were 3036 ED visits. From this population there were 83 patients who presented to the emergency department for “emergent dialysis.” Patients were 57% male, 43% female, average age was 48 yrs, with approximately 97% undocumented citizens. Preceding the introduction of the program patients spent an average 342 minutes from ED arrival to dialysis in the ED. ED arrival to provider times was shortened and the overall ED LOS was also reduced to essentially zero. Inpatient LOS differed from 24-48 hours to zero. Following the initiation of the program patients spent an average of 379 minutes from ED arrival to dialysis, with 100% of the time spent outside of the ED. This represents a cumulative savings of 8,555 bed hours of ED time over the study period, or 102,668 hours when annualized. There were no reported complications. The average cost of each approach was approximately 3 million per process redesign vs 487,000 post the redesign. The “emergent dialysis process” has had a favorable impact on the ED and inpatient operations and resource utilization.

Transport characteristics and removal efficiency of copper ions in the electrodialysis process under electroconvection operation

Abstract Three distinct operational conditions, namely, ohmic, limiting current, and electroconvection region, respectively, can be created by applying different electric fields during ED operations. The fundamental of cation transport under ohmic and limiting current is well understood, however, the mechanism on cation transport under electroconvection is unclear. In order to clarify the feasibility of operating ED under electroconvection for the treatment of industrial wastewater (copper ion as the target pollutant), the methods of current–voltage profiling (C–V curve) and electrochemical impedance spectroscopy (EIS) were used to study the transport characteristics of Cu2+ through a cationic exchange membrane (CEM). The relevant operational parameters obtained above under electroconvection conditions were applied to a continuous ED system as to investigate the removal efficiency of Cu2+-containing wastewater. Results indicated that ED system operated under electroconvection conditions was able to achieve high Cu2+ removal efficiency (around 74% in 4-min treatment) at high electricity efficiency as the theoretical calculation (based on Cu2+ transport number close to 1.0). The pH of copper wastewater in the ED system decreased slightly from 4.7 to 4.0 under electroconvection operation. The interface at the membrane-water was perturbed by the electroconvection operation, which facilitated ions transport across the membrane. An equivalent circuit composed of the Rs, Cm and Rm (parallel circuit representing the CEM), and constant phase element described well the Cu2+ transport behavior in the membrane-solution system according to the p value is greater than 1.0.

Generating and evaluating simulation scenarios to improve emergency department operations

Overcrowding and long patient length of stay, staff shortage, arrival volume increases, and budget constraints are problems hampering ED operations (Sinreich and Marmor, 2005; Maull et al., 2009; NHS, 2010). This paper suggests a framework for schematic generation and evaluation of simulation scenarios to improve ED processes in real-life environments. We illustrate the application of our methodology in a specific ED. We contribute to the area of ED computer simulation by suggesting a methodology that offers the following advantages: (1) Simulation scenarios can be schematically formulated rather than based on trial-and-error experiments. (2) Scenario development can be integrated in the different stages of simulation model development to support designers and management in understanding ED problems, improvement goals, data that should be collected and operational changes that should be applied.

Does delay in appendectomy affect surgical site infection in children with appendicitis?

PurposeThe purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy. MethodsPediatric patients undergoing appendectomy in 2010–2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI. Results1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p=0.51; SA patients, p=0.91; CA patients, p=0.44) or with increased time from admission to operation (all patients, p=0.997; SA patients, p=0.69; CA patients, p=0.96). However, greater length of symptoms was associated with an increased risk of SSI (p<0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p<0.0001). ConclusionWe found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.

Entropy: A Conceptual Approach to Measuring Situation-level Workload Within Emergency Care and its Relationship to Emergency Department Crowding

BackgroundEmergency department (ED) crowding correlates with patient safety. Difficulties quantifying crowding and providing solutions were highlighted in the recent Institute of Medicine (IOM) report calling for the application of advanced industrial engineering (IE) research techniques to evaluate ED crowding. ED personnel workload is a related concept, with potential reciprocal effects between the two. Collaboration between emergency medicine and IE is needed to address crowding and ED personnel workload. ObjectiveWe review ED crowding and workload literature, relationships between workload and ED crowding, and the potential application of information theory as implemented in IE frameworks entitled “entropy” in evaluating both topics. DiscussionIE techniques have applications for emergency medicine and have been successful in helping improve ED operations. Lean and Six Sigma applications are some of these techniques. Existing ED workload measures don't account for all aspects of work in the ED (acuity, efficiency, tasks, etc.) Crowding scales, such as NEDOCS (National ED Overcrowding Study) and EDWIN (ED Work Index), fail to predict ED crowding. A new measurement “entropy” may provide a more comprehensive evaluation of ED workload and may predict work overload seen with crowding. Entropy measures task-based work and the information flow involved. By assigning an entropy value to patient type-specific tasks, we might predict when the ED is overwhelmed, and crowded. ConclusionsIE techniques provide solutions to the ED crowding problem and improve ED workload. We propose a technique novel to medicine: “Entropy,” derived from information theory, which may provide insight into ED personnel workload, its potential for measuring ED crowding, and possibly, in predicting an overwhelming situation.

A National Survey of Emergency Nurses and Avian Influenza Threat

The purpose of this study was to determine the perceived likelihood of emergency nurses reporting to work during an avian influenza outbreak, to consider options if nurses decided not to report work, and to explore Protection Motivation Theory constructs as predictors of reporting to work. A descriptive, nonexperimental, cross-sectional survey of emergency nurses within the United States. A total of 332 nurses (46%) responded. Most emergency nurses (84%) reported they would report to work (1 in 6 would not). The likelihood of reporting to work differed by education level, nurses' avian influenza information sources, and nurses who had family living with them. Of the nurses who decided not to report to work, the majority were willing to provide health information (90%), administer vaccinations (82%), and triage (74%) neighbors/friends from home. One third of nurses had not attended a disaster-preparedness drill within the past year. Only 20% identified formal training while on the job as a source of avian influenza information. A third of emergency nurses would be worried about getting an avian influenza vaccination because of potential adverse effects. Protection Motivation Theory accounted for almost 40% of the variance of likelihood to report to work, with response costs being the largest predictor. Disaster drills, avian influenza job training, and vaccination education are necessary to prepare emergency nurses for an outbreak. The findings support emergency nurses' willingness to work from home if they are unable to report to work. This finding is new and may have implications for disaster planning, staffing, and ED operations.

Satellite- and Epoch Differenced Precise Point Positioning Based on a Regional Augmentation Network

Precise Point Positioning (PPP) has been demonstrated as a simple and effective approach for user positioning. The key issue in PPP is how to shorten convergence time and improve positioning efficiency. Recent researches mainly focus on the ambiguity resolution by correcting residual phase errors at a single station. The success of this approach (referred to hereafter as NORM-PPP) is subject to how rapidly one can fix wide-lane and narrow-lane ambiguities to achieve the first ambiguity-fixed solution. The convergence time of NORM-PPP is receiver type dependent, and normally takes 15–20 min. Different from the general algorithm and theory by which the float ambiguities are estimated and the integer ambiguities are fixed, we concentrate on a differential PPP approach: the satellite- and epoch differenced (SDED) approach. In general, the SDED approach eliminates receiver clocks and ambiguity parameters and thus avoids the complicated residual phase modeling procedure. As a further development of the SDED approach, we use a regional augmentation network to derive tropospheric delay and remaining un-modeled errors at user sites. By adding these corrections and applying the Robust estimation, the weak mathematic properties due to the ED operation is much improved. Implementing this new approach, we need only two epochs of data to achieve PPP positioning converging to centimeter-positioning accuracy. Using seven days of GPS data at six CORS stations in Shanghai, we demonstrate the success rate, defined as the case when three directions converging to desired positioning accuracy of 10 cm, reaches 100% when the interval between the two epochs is longer than 15 min. Comparing the results of 15 min' interval to that of 10 min', it is observed that the position RMS improves from 2.47, 3.95, 5.78 cm to 2.21, 3.93, 4.90 cm in the North, East and Up directions, respectively. Combining the SDED coordinates at the starting point and the ED relative coordinates thereafter, we demonstrate the performance of RTK PPP with standard deviation of 0.80, 1.34, 0.97 cm in the North, East and Up directions.

Pandemic (H1N1) Influenza 2009 and Australian emergency departments: Implications for policy, practice and pandemic preparedness

To describe the reported impact of Pandemic (H(1)N(1) ) 2009 on EDs, so as to inform future pandemic policy, planning and response management. This study comprised an issue and theme analysis of publicly accessible literature, data from jurisdictional health departments, and data obtained from two electronic surveys of ED directors and ED staff. The issues identified formed the basis of policy analysis and evaluation. Pandemic (H(1)N(1) ) 2009 had a significant impact on EDs with presentation for patients with 'influenza-like illness' up to three times that of the same time in previous years. Staff reported a range of issues, including poor awareness of pandemic plans, patient and family aggression, chaotic information flow to themselves and the public, heightened stress related to increased workloads and lower levels of staffing due to illness, family care duties and redeployment of staff to flu clinics. Staff identified considerable discomfort associated with prolonged times wearing personal protective equipment. Staff believed that the care of non-flu patients was compromised during the pandemic as a result of overwork, distraction from core business and the difficulties associated with accommodating infectious patients in an environment that was not conducive. This paper describes the breadth of the impact of pandemics on ED operations. It identifies a need to address a range of industrial, management and procedural issues. In particular, there is a need for a single authoritative source of information, the re-engineering of EDs to accommodate infectious patients and organizational changes to enable rapid deployment of alternative sources of care.

Emergency department crowding: prioritising quantified crowding measures using a Delphi study

AimsEmergency department (ED) crowding has been associated with a number of negative health outcomes, including unnecessary deaths, increased waiting times and a decrease in care quality. Despite the seriousness of...

Interventions to Improve Patient-centered Care During Times of Emergency Department Crowding

Patient-centered care is defined by the Institute of Medicine (IOM) as care that is responsive to individual patient needs and values and that guides treatment decisions. This article is the result of a breakout session of the 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" and focuses on three broad domains of patient-centered care: patient satisfaction, patient involvement, and care related to patient needs.The working group provided background information and an overview of interventions that have been conducted in the domains of patient satisfaction, patient involvement (patients' preferences and values in decision-making), and patient needs (e.g., comfort, information, education). Participants in the breakout session discussed interventions reported in the medical literature as well as initiated at their institutions, discussed the effect of crowding on patient-centered care, and prioritized, in a two-step voting process, five areas of focus for establishing a research agenda for studying patient-centered care during times of crowding. The research priorities for enhancing patient-centered care in all three domains during periods of crowding are discussed. These include assessing the effect of other quality domains on patient satisfaction and determining the effects of changes in ED operations on patient satisfaction; enhancing patient involvement by determining the effect of digital records and health information technology (HIT); rapid assessment areas with focused patient-provider communication; and meeting patients' needs through flexible staffing, use of HIT to enhance patient communication, discharge instructions, and postdischarge telephone calls.

(A96) Process Improvement in Disaster Relief: Improvement of Disaster Resource Utilization through Systematic Organization

IntroductionUpon arrival of the SUNY Downstate Medical Center team for their disaster relief mission in Port au Prince, Haiti, it was observed that obstacles to patient care were directly related to difficulty in locating supplies and medications in a timely manner. In addition, staffing schedules had not been correlated to patient flow patterns.MethodsA survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center. The following variables were obtained to assess existing resources: number and types of providers available, provider staffing schedules, medication/supply inventories and management systems. Basic ED operation and supply system flow maps were created.ResultsThe assessment revealed a large volume of patients presenting in the early morning. Night shifts were inconsistently staffed with ED physicians. Although medications and supplies were reported to be available on-site, they were not tracked, inventoried, or centrally managed. As a result, this increased time to treatment and practitioner fatigue. Process improvements included: (1) Institution of swing and night shifts accommodated peak patient volumes, decreased waiting times, provided care for critical patients during off-peak hours, and decreased physician fatigue. (2) Identification and labeling of existing medications/supplies facilitated more accurate management of inventories and decreased time to treatment and disposition.ConclusionProcess improvement through systematic analysis led to better disaster resource utilization in this tent hospital.

Optimization of electrodialysis with bipolar membranes applied to cloudy apple juice: Minimization of malic acid and sugar losses

Abstract In previous studies, we demonstrated the feasibility of using electrodialysis with a bipolar–anionic configuration to quickly inactivate the enzyme polyphenol oxidases and prevent the enzymatic browning of cloudy apple juice. The approach consisted of reducing temporarily the pH of cloudy apple juice to 2.0 then adjusting back to its initial value. However, losses in malic acid (19.8%) and sugars (9.7%) were observed in apple juice, especially during the pH adjustment step. The purpose of this work was to study the effect of different methods used to reduce the losses of malic acid and sugars during the inactivation of the enzyme by electrodialysis with a bipolar–anionic configuration. Anionic membranes with improved permselectivity to monovalent ions were tested. The use of an apple juice containing 0.1 M HCl as an electrolyte instead of 0.1 M HCl alone was also considered. Finally, the combination of the acidification and pH adjustment steps in one operation using an acidified apple juice (pH 2.0) as the electrolyte that circulates on the anion side of the bipolar membranes and an apple juice to acidify as the electrolyte on the cation side of the bipolar membranes was tested. Selective membranes had no effect on reducing the juice's malic acid and sugar losses which amounted to 19.1 ± 2.1% and to 9.7 ± 1.5%, respectively. The use of an apple juice–HCl electrolyte resulted in juice's malic acid and sugar losses of approximately 10% and less than 5%, respectively. The combination of acidification and pH adjustment of apple juices in a single ED operation successfully reduced the malic acid (0.9%) and sugar (1.1%) losses and preserved the integrity of cloudy apple juice. However the process productivity was decreased by approximately 2 times, when compared to the former approach. Industrial Relevance Cloudy or unclarified apple juice is a natural food product with lots of pulp which enhances its sensory properties and it also provides fibre and nutrients that may be lacking in clarified juices. However, cloudy apple juice is very sensitive to enzymatic browning because it contains considerable quantities of polyphenols and polyphenol oxidases (PPO). Enzymatic browning reactions are catalyzed by PPO and result from the oxidation of phenolic compounds to o-quinones, which then polymerize to form dark pigments thereby changing the organoleptic and nutritional properties of the juice. In previous studies, we demonstrated the feasibility of using electrodialysis with a bipolar–anionic configuration to quickly inactivate the enzyme polyphenol oxidases and prevent the enzymatic browning of cloudy apple juice (Lam Quoc, Lamarche, & Makhlouf, 2000; Lam Quoc et al., 2006). The approach consisted of reducing temporarily the pH of cloudy apple juice to 2.0 then adjusting back to its initial value. However, losses in malic acid (19.8%) and sugars (9.7%) were observed in apple juice, especially during the pH readjustment step. In this work, we have studied the effect of different methods to reduce the losses of malic acid and sugars during the inactivation of the enzyme by electrodialysis with a bipolar–anionic configuration. The combination of acidification and pH readjustment of apple juices in a single ED operation successfully preserved the integrity of cloudy apple juice by reducing losses of malic acid and sugars to negligible level. As a result, the optimized process could be applied at industrial scale for the production of stable cloudy apple juice with good organoleptic and nutritional properties.