ED Service Research Articles

Optimising Emergency Care for Older Adults: A Case Study of the EDITH Service Following a Proximal Humerus Fracture

Abstract Background The Emergency Department in the Home (EDITH) service offers emergency Occupational Therapy and medical assessments to older adults at home, thus negating the need for hospital attendances. Mr X, an 86-year-old with vascular dementia and hypertension, sustained a left proximal humerus fracture from a fall. Following assessment in the ED, Mr X was deemed fit for discharge and was referred to EDITH for an acute functional assessment and clinical review. Methods Within 72 hours of discharge, Mr X was visited at home by an Occupational Therapist (OT) and an Advanced Nurse Practitioner (ANP). The OT conducted a home environment assessment, falls-risk screening, delirium screening, reviewed social supports, and performed a functional assessment. Education on one-handed dressing techniques and falls prevention was provided. The ANP conducted a clinical review, and reviewed Mr X’s medication and analgesia. Mr X had the support of his wife to assist with Activities of Daily Living (ADLs), functional mobility and medication management. Mr X’s son purchased assistive equipment recommended by the OT, to enhance home safety. Referrals were made to the local memory support service, a Physiotherapist, and his Public Health Nurse to organise formal care supports. Results Mr X remained at home with support from his wife, primary care services, and virtual EDITH follow-up. Mr X had a scheduled review at the fracture clinic following his ED attendance. Conclusion Emergency care practitioners play a crucial role in addressing acute functional and clinical changes in older adults attending the ED. Supported ED discharges and service integration during the acute phase can prevent hospital admissions. Collaboration between emergency medicine and primary care is essential for addressing acute medical needs and long-term functional outcomes. With adequate social support and timely services, older adults can recover successfully at home.

Evaluation of Staff Views of the Rapid Assistance with Frailty Team, It’s Perceived Clinical Effectiveness and Potential Areas for Development

Abstract Background The Rapid Assistance with Frailty Team (RAFT) has been operating within our local hospital since 2021. This novel multidisciplinary service aims to support frail older adults during hospital admission, by conducting focused comprehensive geriatric assessments, and providing bespoke support to their primary team. One method of evaluating the impact of the service has been to seek regular feedback from other staff, to guide continuous quality improvement regarding our approach. Methods This service evaluation was registered with the Quality and Patient Safety department locally in January 2024. An online questionnaire was developed to seek feedback from colleagues who would have experience of the service, with a link distributed via email to relevant staff members. Data collection took place over an eight-week period. Results In total, 69 responses from staff were received, and analysed thematically. They demonstrated high degrees of staff satisfaction, with over 76% either agreeing or strongly agreeing that ‘RAFT is a valuable service’. A further 69% of respondents felt that ‘RAFT is helpful in supporting discharge’. The most common expectations were for the team to assist with frailty assessment; support discharge planning; offer MDT input; provide follow-up care; and conduct education. Staff felt the service could be improved through refining the medical input role; provision of an ED service; increased staffing; expanding the discharge planning role; development of referral pathways; and improved communication. Conclusion Following presentation of these findings at our departmental teaching, a service development plan was agreed. This includes organising a focused internal rapid improvement event, with RAFT staff utilising the feedback from this service evaluation to identify how the service can be improved, as well as identifying key performance indicators to evaluate this progress. We will repeat this service evaluation in 6 months’ time, to assess if these interventions have made a meaningful impact.

Awareness of Urgent Care Services Among Primary Healthcare Center Patients in Al-Ahsa, Saudi Arabia.

Background Urgent care clinics (UCCs) provide services for patients without the need to book an appointment in advance to treat acute diseases and injuries that do not need ED service and provide care for chronic conditions. This study aimed to assess the patients's level of awareness regarding UCCs in the Al-Ahsa region and provide information contributing to decision-makers' support about the urgent care services and their patterns of use within primary healthcare. Methods A descriptive cross-sectional study was conducted in the Al-Ahsa region from August 2023 to December 2023. A validated questionnaire was used. Cluster sampling was used to select three primary healthcare centers from four health sectors (southern cluster, middle cluster, northern cluster, and eastern cluster), and then simple random sampling was used to select participants. sample size calculated by Cochran'ssample size formula, which estimated 377 participants. However, to accommodate a non-response rate of 10.0% and stronger statistical power and effect size, the final sample size was 469 participants. Data were analyzed by SPSS Statistics version 28 (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp.). Both descriptive and inferential statistics were used. A p-value ≤0.05 is considered statistically significant. Results Of the 469 participants in the study, more than half (54.8%) were aged between 18 and 38 years old, and more than half (54.8%) were male. More than half (67.4%) reported having no chronic diseases, whereas the most common chronic diseases reported were diabetes mellitus (11.9%) and hypertension (14.3%). Most of the participants (84.9%) weren't aware of UCCs. Among the participants who were aware of UCCs (n=71), 53.5% of them had visited a UCC in the last three months. The most common reasons for their visits were the common cold (40.8%), headaches (5.6%), and abdominal pain (5.6%). More than one-third of participants (38.6%) believed that UCCs provide services like those of the emergency center. According to patients' sex, there was a significant (0.031) difference in the awareness level; the highest was among females at 20.1% vs. 12.6%. Conclusion The study revealed that the majority of the participants were unaware of UCCs. Increasing patients' awareness of UCCs is necessary through different media to improve access to healthcare services and reduce overcrowding in the ED that is caused by non-urgent problems.

A-148 Thromboelastography Utilization in a Community Hospital Setting

Abstract Background Thromboelastography (TEG) applications have been gaining momentum in various clinical settings and service lines. However, the utilization of the technology varies among clinical establishments and requires additional assessment for TEG optimization among its user groups. Methods TEG (Haemonetics TEG6s) was applied in a community hospital based setting in SICU, OR and ED service lines to identify instrument prompted blood product support over a two month time period. Results Forty one measurement were obtained from twenty patients. SICU represented the majority of TEG use (78%) followed by OR (15%). Global TEG run assessments were completed on 27%, platelet mapping on 46%, and heparin assessment on 56% of samples. Global TEG recommendations included factor deficiency with suggested FFC or PCC use (12%) or no recommendations (10%). Platelet assessments recommended no product (19.5%), or ADP inhibition with platelet consideration if bleeding (14.6%). Heparin assessment indicated no treatment (44%) and above normal CK/R time with FFP or PCC if bleeding (10%). Conclusion TEG applications in various services suggested no need for blood product or factor application in the majority of platelet mapping and heparin assessments. Other assessments yielded about a half dozen suggestions from the instrument’s 150 suggestion options. TEG application appears to be easily implementable and suggests no treatment or a few repetitive treatment options for the majority of patients assessed thereby reducing onboarding educational and improving management requirements for select user groups.

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

BackgroundEmergency Departments (EDs) have become critical ‘touchpoints’ for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients’ ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients’ experiences with ED staff.MethodsThis qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants’ ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization.ResultsParticipants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care.ConclusionsWhile the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose.Trial registrationClinical trial registration: NCT03684681.

Snapshot of suspected acute coronary syndrome assessment processes in the emergency department: A national cross-sectional survey.

The Snapshot of Suspected ACS Assessment (SSAASY) study aims to describe the assessment processes for patients with suspected acute coronary syndrome (ACS) in Australian EDs, and to compare these processes with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (NHFA/CSANZ) guidelines. Between March and May 2021, a cross-sectional survey of Australian EDs was undertaken to investigate the assessment strategies used within the ED. All public and private hospitals identified as having dedicated EDs were invited to participate. Respondents provided data on hospital, ED and cardiac service characteristics. They also provided data on the risk stratification process recommended within their department (risk scores, troponin testing, objective testing for coronary artery disease). Awareness of the NHFA/CSANZ guidelines was assessed. Responses were received from 109/162 departments (67%). Most sites (n=100, 92%) reported using dedicated protocols developed by ED clinicians that included risk stratification scores. Highly sensitive troponin assays were used at 103 (94%) sites. Serial troponin testing was performed over 2h for low-risk patients in 53 (49%) sites and 2-3h for intermediate and high-risk patients in 74 (68%) sites. Further investigations included exercise stress tests (48%) and stress echocardiography (38%), with 45% of sites ordering outpatient investigations. The SSAASY study reported the strategies used to assess suspected ACS. In line with current NHFA/CSANZ guidelines, highly sensitive troponin assays are widely utilised. However, serial sampling intervals were longer than guideline recommendations, suggesting a translational gap between guidelines and clinical practice.

Structured evaluation of a virtual emergency department triage model of care: A study protocol.

A new virtual ED service was introduced into a hospital network in the northern suburbs of Melbourne in response to changing needs during the COVID-19 pandemic. The 'virtual ED' utilises a telehealth model as a means of assessment for appropriately selected patients to facilitate either complete care or navigation into streamlined pathways for ongoing care, in some cases bypassing the ED entirely where appropriate. The proposed study aims to evaluate the implementation of the model and identify future improvement opportunities, assess the impact on traditional health service delivery processes and patient experience, and determine the acceptability of the 'virtual ED' model of care. The present study will consist of a pre-post- implementation evaluation using the RE-AIM framework. Routine health service data will be collected for 6months post-implementation of the virtual ED model and compared to 24 months prior to implementation. Prospective data will be collected using routinely collected and survey data. Interviews and focus groups will be conducted to understand consumer and clinician perspectives on barriers and enablers to implementation and adoption of the virtual ED. Descriptive statistics will be used to describe the study population and key outcomes, including changes in ED presentations and length of stay. Thematic analysis will be conducted on transcribed interviews and focus group data. This will be triangulated with data collected from patient feedback surveys. This project will support the delivery of care to ED patients by evaluating the 'virtual ED' model of care.

Retrospective identification of latent subgroups of emergency department patients: A machine learning approach.

This research aims to (i) identify latent subgroups of ED presentations in Australian public EDs using a data-driven approach and (ii) compare clinical, socio-demographic and time-related characteristics of ED presentations broadly using the subgroups. We examined presentations to four public hospital EDs in Queensland from 2009 to 2014. An unsupervised machine learning algorithm, Clustering Large Applications, was used to cluster ED presentations. There were six subgroups common across the EDs, primarily distinguishable by age, and subsequently by triage category, ED length of stay, arrival mode, departure status and several time-related attributes. Around 10% to 30% of the total presentations had high resource utilisation, with half of these from older patients (55+ years). ED resource utilisation per population was highest among the oldest cohort (75+ years). Children and young adults more frequently presented to the ED outside general-practitioner hours, mostly on Sundays. Older persons were more likely to present at any time, rather than specific hours, days or seasons. ED service performance measured against commonly used access-target indicators were rarely satisfied for older people and frequently satisfied for children. Clustering Large Applications is effective in finding latent groups in large-scale mixed-type data, as demonstrated in the present study. Six types of ED presentations were identified and described using clinically relevant characteristics. The present study provides evidence for policy makers in Australia to develop alternative ED models of care tailored around the care needs of the differing groups of patients and thereby supports the sustainable delivery of acute healthcare.

Facilitators and barriers to post-overdose service delivery in Rhode Island emergency departments: A qualitative evaluation

BackgroundEmergency departments (EDs) in the US have increasingly incorporated interventions that seek to reduce opioid-related morbidity and mortality. However, many of these interventions are underutilized. This study examined ED provider-identified barriers and facilitators to policy-prescribed service provision for patients treated for an opioid overdose in Rhode Island EDs, and opportunities to improve care delivery. MethodsSemi-structured qualitative interviews were conducted with 55 ED providers (management and clinical staff) across Rhode Island EDs from November 2019 to July 2020. Thematic analysis of interviews focused on gaps and best practices in post-overdose care delivery, including social and structural factors driving access to, and uptake of, services. ResultsParticipants highlighted how automatic service delivery (opt out vs. opt in) and the integration of peer-based services enhanced post-overdose service provision. However, social and structural factors (e.g. insurance barriers, limited outpatient treatment resources) and gaps in provider knowledge of medications for opioid use disorder created barriers to care. Addressing long ED wait times and establishing dedicated care teams for patients following an overdose were seen as critical to improving ED service delivery. ConclusionOur findings suggest that post-overdose service delivery within EDs is a useful approach for connecting patients to services, particularly when peer support specialists are involved. However, standardizing service delivery approaches and improving provider education of harm reduction services must be prioritized alongside state-level policy changes to improve access to care for ED patients.

A 10-year retrospective study of paediatric emergency department visits for dental conditions in Montreal, Canada.

Trends of paediatric emergency visits (ED) for dental conditions have been broadly discussed; however, little has been published in the Canadian context. To describe the utilization of ED for dental conditions among children and to investigate demographic characteristics influencing its use. A comprehensive review of records of all children aged 1-17years who attended the ED service of a paediatric hospital in Montreal, Canada, for dental conditions over a 10-year period (2004-2013) was completed. Information on the child's principal dental diagnosis, sociodemographic data, and source of referral was obtained. A total of 10905 paediatric ED visits were seen during the study period. Among the children, 54.7% were male and the majority was younger than 6years old. Dental caries constituted the most common reason for ED presentation comprising close to 43% of total visits for a dental complaint. Females, teenagers, and self-referred children were more likely to experience ED visits due to non-traumatic dental conditions. The utilization of ED for dental conditions has increased among pre-school children in the last decade and was mostly due to caries-related dental problems. Effective preventive strategies are needed to improve the oral health condition of children.

Abstract TP411: Improving Pediatric Stroke Recognition Among Pediatric Health Care Providers

Introduction: Pediatric acute ischemic stroke (P-AIS) is an under-recognized disease by pediatric healthcare providers, resulting in delay of its diagnosis. In spite of diagnostic tools such as the FAST and BE FAST mnemonics, lack of awareness leads to increased morbidity and mortality. This study aims to elucidate whether a brief educational activity would modify the identification and perception of P-AIS. Methods: Forty-nine pediatric healthcare providers were surveyed to assess their baseline skills in recognizing P-AIS. Providers attended a 30-minute activity outlining incidence, natural history, diagnosis, and examples of P-AIS treatment. The mnemonics “FAST” and “BE FAST” as applicable to children were futher expounded. Pre and post-surveys assessed providers’ profession, type of practice, ED service involvement, familiarity with the mnemonics, and P-AIS recognition performance for infants and children. Results: The forty-nine pediatric healthcare providers surveyed had the following degrees: 61% MD, 20% NP, 6% RN, 6% student, 4% PA, 2% DO. Futhermore, 78% work in private outpatient enviroments, 17% in academic outpatient institutions, 4% in private outpatient settings, and only 10% had emergency department involvement. Pre-Activity: 53% had heard of “FAST,” and 8% had heard of “BE FAST.” Correct knowledge of individual letters ranged between 12-39%, with the lowest recognition rates for “B” and “E.” At baseline, 65% of providers correctly recognized pediatric and specifically infant stroke cases. Post-Activity: 97% felt familiar with “BE FAST.”. Correct knowledge of individual letters following the educational activity improved to 100%. 95% of providers correctly recognized P-AIS, and 95% correctly identified infant stroke. Univariate logistic analysis showed that completing the training activity was the only significant factor improving the ability to identify P-AIS (OR: 10.35, CI: 2.2 to 48.2). Profession and type of practice were not significant. Conclusion: A 30-minute focused educational activity was sufficient to improve the perception and ability to recognize P-AIS among different levels of healthcare providers. The long-term effects of these interventions should be examined.

The burden of cancer on primary and secondary health care services before and after cancer diagnosis in New South Wales, Australia

BackgroundPrimary and secondary healthcare service usage is assessed in the year before and following a cancer diagnosis, in cancer cases versus matched non-cancer controls in New South Wales (NSW), Australia over 2006–2012, for all invasive cancers collectively and for selected common sites: breast, prostate, colorectal and lung, and melanoma.MethodsThe 45 and Up cohort (n ≈267,000) was linked to NSW Cancer Register (NSWCR), Emergency Department Data Collection (EDDC) and Medical Benefits Schedule (MBS) data using probabilistic record linkage. First-ever malignant cancers diagnosed after enrolment in the 45 and Up study comprised the study cases. Where possible, five controls were randomly selected per case from the 45 and Up cohort, matched by sex and year of birth. Controls comprised those with no cancer recorded on the NSWCR. For each month in the year preceding and following the cancer diagnosis, general practitioner, specialist and specified hospital ED service use was compared between cases and controls using proportions, means, and odds ratios derived from conditional logistic regression.ResultsCompared to controls, cases of all cancers combined had a significantly higher likelihood of GP and specialist consultation in the year leading up to diagnosis. This was most pronounced in the 3–4 months leading up diagnosis for all cancers, similarly for lung cancer (GPs and specialists) and melanoma (GPs), and colorectal cancer (specialists). Likelihood of a GP consultation remained significantly higher in cases than controls in the 12 months following diagnosis.During most of the year preceding cancer diagnosis, the likelihood of specified ED presentations was also significantly higher in cases than controls for all cancers, and most pronounced in the 2–3 months before diagnosis. Excepting melanoma, the likelihood of specified ED presentations remained significantly elevated for most of the year following diagnosis for all cancers combined and for the selected cancers.ConclusionsPeople with cancer experience a higher use of primary and secondary healthcare services in the year preceding and following diagnosis, with GPs continuing to play a significant role post diagnosis. The higher likelihood of pre-diagnosis GP consultations among cancer cases requires further investigation, including whether signals might be derived to alert GPs to possibilities for earlier cancer detection.

Interventions to improve patient flow in emergency departments: an umbrella review

ObjectivesPatient flow and crowding are two major issues in ED service improvement. A substantial amount of literature exists on the interventions to improve patient flow and crowding, making it difficult...

Predictors of emergency department referral in patients using out-of-hours primary care services

BackgroundOut of hours (OOH) doctors could manage many cases limiting the inappropriate accesses to ED. However the possible determinants of referral to ED by OOH doctors are poorly studied. We aimed to characterize patients referred from the OOH to ED service in order to explore the gate-keeping role of OOH service for hospital emergency care and to facilitate future research in improving its cost-effectiveness. MethodsA retrospective study was made through data collection of 5217 contacts in a local OOH service in the North-East of Italy (from 10/01/2012 to 03/31/2013). ResultsOnly 8.7% (=454 people) of the total contacts were referred to ED. In the multivariate analysis, the significant predictors of being sent to ED were: age; residence in nursing home (odds ratios (OR)=2.00, 95%CI: 1.30–3.10); being visited by a OOH physician (OR=2.64, 95%CI: 2.09–3.34). Taking infections as reference, cardiovascular diseases (OR=18.31, 95%CI: 12.01–27.90), traumas (OR=8.75, 95%CI: 5.36–14.26) and gastrointestinal conditions (OR=7.69, 95%CI: 4.70–11.91) increased the probability to be referred to ED. ConclusionsOOH service addresses several common medical conditions in community-dwelling and in nursing home context, supporting its filtering function for the ED access. The main reasons of ED access could be a crucial aspect in general population education in order to avoid the overcrowding of the ED.

The Impact of Absa Enterprise Development on Small and Micro Enterprise Growth

ABSA Enterprise Development (ABSA ED), a division within Barclays Africa Group Limited (bank and finance sector), was established with the mandate to create an enabling environment that supports, advances funding and grants access to markets directed at small and micro enterprise (SME) growth and sustainability. The primary research objective was to determine the impact of the ABSA ED service on the development and growth of the SMEs that bank with ABSA and make use of ABSA ED. The secondary research objective was to identify and assess SMEs that are using the ABSA ED service and to determine their growth position by assessing business growth, competition, business strategy and business development. A quantitative research approach was adopted and included a survey in which 106 SMEs participated. Findings reveal that SMEs are positively impacted by ABSA ED interventions in business growth, strategy and development, but they lacked awareness of competition. SME strategy was significantly related to firm growth, and use of ABSA ED showed a strong positive relation of .8034, although a small effect correlation (.0149) on improving business sales/turnover. Business development indicated no significant correlation between the number of training opportunities the entrepreneur attended and the growth levels of the firm. The age of 55.2% of the businesses surveyed ranged between 1 and 5 years, indicating the relative start-up phase of the SMEs. SMEs confirmed the use of business skills acquired through ABSA ED training seminars. Although findings reflect positive impact on the growth of the SME, the Procurement Portal product reflects low growth impact. A link was found between business strategy and SME growth, where the use of ABSA ED had medium correlation, while business development correlated negatively to business growth.

Satisfaction with emergency department service among non‐English‐speaking background patients

The present study aims to investigate non-English-speaking background (NESB) patients' satisfaction with hospital ED service and compare it with that of English-speaking background (ESB) patients. A cross-sectional survey was conducted at the ED of an adult tertiary referral hospital in Queensland, Australia. Patients assigned an Australasian Triage Scale score of 3, 4 or 5 were surveyed in the ED, before and after their ED service. Pearson χ(2) -test and multivariate logistic regression analyses were performed to examine the differences between the ESB and NESB groups in terms of patient-reported satisfaction. In total, 828 patients participated in the present study. Although the overall satisfaction with the service was high - 95.1% (ESB) and 90.5% (NESB) - the NESB patients who did not use an interpreter were less satisfied with their ED service than the ESB patients (odds ratio 0.5, 95% confidence interval 0.3-0.8, P = 0.013). The promptness of service received the lowest satisfaction rates (ESB 85.4% [82.4-88.0], NESB 74.5% [68.5-79.7], P < 0.001), whereas courtesy and friendliness received the highest satisfaction rates (ESB 98.8 [97.6-99.4], NESB 97.0 [93.9-98.5], P = 0.063). All participants reported the promptness of service (33.5%), quality and professional care (18.5%) and communication (17.6%) as the most important elements of ED service. The NESB patients were significantly less satisfied than the ESB patients with the ED service. Use of an interpreter improved the NESB patients' level of satisfaction. Further research is required to examine what NESB patients' expectations of ED service are.

Food for thought: Enabling and constraining factors for effective rural eating disorder service delivery

This study examined the effectiveness of an assessment and referral model of eating disorder service delivery in the Northern Rivers of New South Wales and its potential as a model for rural service delivery. A qualitative evaluative research design used brief and extended semistructured interviews with clients, and surveys and semistructured extended interviews with service providers who either referred clients to the service or to whom clients were referred. A sole practitioner service based in a small non-government women's health service in rural New South Wales. Clients of the service, all but one of whom was woman; service providers including general practitioners, private practice psychologists and social workers, dietitians, mental health service workers. Participant identified enabling and constraining factors which contributed to the effectiveness of the service model. Whilst all service providers and most clients found the assessment process to be beneficial, they identified a number of constraining factors in the referral part of the service which undermined the effectiveness of the model of service delivery, especially for those with more complex or severe presentations. For a rural ED service to be effective, a number of enabling factors must be present including the capacity to provide: treatment services as well as assessment; a multidisciplinary team approach to assessment and treatment; and expert consultation and training to generalist practitioners, counsellors, hospital wards and other service providers.

A analysis of emergency nurse practitioner role development in improving ED service of Hong Kong

A analysis of emergency nurse practitioner role development in improving ED service of Hong Kong

Characterizing Waiting Room Time, Treatment Time, and Boarding Time in the Emergency Department Using Quantile Regression

The objective was to characterize service completion times by patient, clinical, temporal, and crowding factors for different phases of emergency care using quantile regression (QR). A retrospective cohort study was conducted on 1-year visit data from four academic emergency departments (EDs; N = 48,896-58,316). From each ED's clinical information system, the authors extracted electronic service information (date and time of registration; bed placement, initial contact with physician, disposition decision, ED discharge, and disposition status; inpatient medicine bed occupancy rate); patient demographics (age, sex, insurance status, and mode of arrival); and clinical characteristics (acuity level and chief complaint) and then used the service information to calculate patients' waiting room time, treatment time, and boarding time, as well as the ED occupancy rate. The 10th, 50th, and 90th percentiles of each phase of care were estimated as a function of patient, clinical, temporal, and crowding factors using multivariate QR. Accuracy of models was assessed by comparing observed and predicted service completion times and the proportion of observations that fell below the predicted 10th, 50th, and 90th percentiles. At the 90th percentile, patients experienced long waiting room times (105-222 minutes), treatment times (393-616 minutes), and boarding times (381-1,228 minutes) across the EDs. We observed a strong interaction effect between acuity level and temporal factors (i.e., time of day and day of week) on waiting room time at all four sites. Acuity level 3 patients waited the longest across the four sites, and their waiting room times were most influenced by temporal factors compared to other acuity level patients. Acuity level and chief complaint were important predictors of all phases of care, and there was a significant interaction effect between acuity and chief complaint. Patients with a psychiatric problem experienced the longest treatment times, regardless of acuity level. Patients who presented with an injury did not wait as long for an ED or inpatient bed. Temporal factors were strong predictors of service completion time, particularly waiting room time. Mode of arrival was the only patient characteristic that substantially affected waiting room time and treatment time. Patients who arrived by ambulance had shorter wait times but longer treatment times compared to those who did not arrive by ambulance. There was close agreement between observed and predicted service completion times at the 10th, 50th, and 90th percentile distributions across the four EDs. Service completion times varied significantly across the four academic EDs. QR proved to be a useful method for estimating the service completion experience of not only typical ED patients, but also the experience of those who waited much shorter or longer. Building accurate models of ED service completion times is a critical first step needed to identify barriers to patient flow, begin the process of reengineering the system to reduce variability, and improve the timeliness of care provided.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care