Emergency Department Access Research Articles

Risk Stratification of Older Patients in the Emergency Department: Comparison Between the Identification of Seniors At Risk and Triage Risk Screening Tool

The increasing number of elderly patients accessing emergency departments (ED) requires use of validated, rapid assessment instruments. The aim of this study was to compare the Identification of Seniors at Risk (ISAR) and Triage Risk Screening Tool (TRST), based on direct patient evaluation. This study was a prospective observational study with 6 months follow-up. Subjects were 2,057 residents in the Marche Region, aged 65 or more years, accessing the first-level ED of a geriatric hospital in Ancona, Italy, over a 6-month period. ISAR and TRST were administered at triage by nurse. Outcomes were in need of hospital admission and mortality at the index ED access, early (within 30 days) and late ED revisit, hospitalization, and death in 6 months. ISAR (cutoff of≥2) was positive in 68% of patients, whereas 64% were TRST-positive. The two scores were significantly correlated and had similar areas under the receiver operating characteristic (ROC) curves in predicting hospital admission (ISAR, 0.68; TRST, 0.66) and mortality (ISAR, 0.74; TRST, 0.68), as well as early ED revisit (ISAR, 0.63; TRST, 0.61). In the 6-month follow-up of patients discharged alive, the tools predicted comparably ED return visit (ISAR, 0.60; TRST, 0.59), hospital admission (ISAR, 0.63; TRST, 0.60), and mortality (ISAR, 0.74; TRST, 0.73). A similar performance was observed in the subgroup of participants discharged directly from the ED. Risk stratification of elderly ED patients with ISAR or TRST is substantially comparable for selecting elderly ED patients who could benefit from geriatric interventions. ISAR had slightly higher sensitivity and lower specificity than TRST.

The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter

BackgroundObtaining vascular access is difficult in certain patients. When routine peripheral venous catheterization is not possible, several alternatives may be considered, each with its own strengths and limitations. DiscussionWe describe a novel technique for establishing vascular access in Emergency Department (ED) patients: the placement of a standard catheter-over-needle device into the internal jugular vein using real-time ultrasound guidance. We present a series of patients for whom this procedure was performed after other attempts at vascular access were unsuccessful. In all cases, the procedure was performed quickly and without complications. ConclusionAlthough further study of this technique is required, we believe this procedure may be a valuable option for ED patients requiring rapid vascular access.

Intraosseous Vascular Access for In-Hospital Emergency Use

Intraosseous (IO) vascular access is a viable primary alternative in patients requiring emergent vascular access in the hospital emergency department (ED) (eg, resuscitation, shock/septic shock) but is underutilized. This review has 3 objectives: (1) review the evidence supporting the use of IO access; (2) determine the utilization of IO access as described in the literature; and (3) assess the level of specialty society support. Electronic and hand searches were undertaken to identify relevant articles. English-language-only articles were identified. The Cochrane Review methodology along with data forms were used to collect and review data. The evidence evaluation process of the international consensus on emergency cardiovascular care was used to assess the evidence. Studies were combined where meta-analyses could be performed. In levels 2 to 5 studies, IO access performed better versus alternative access methods on the end points of time to access and successful access. Complications appeared to be comparable to other venous access methods. Randomized controlled trials are lacking. Newer IO access technologies appear to do a better job of gaining successful access more quickly. Intraosseous access is underutilized in the ED because of lack of awareness, lack of guidelines/indications, proper training, and a lack of proper equipment. Recommendations/guidelines from physician specialty societies involved in the ED setting are also lacking. Underutilization exists despite recommendations for IO access use from a number of important medical associations peripherally involved in the ED such as the American Academy of Pediatrics. To encourage the IO approach, IO product champions (as both supporter and user) in the ED are needed for prioritizing and assigning IO access use when warranted. In addition, specialty societies directly involved in emergent hospital care should develop clinical guidelines for IO use.

Prognostic Stratification of Elderly Patients in the Emergency Department: A Comparison Between the “Identification of Seniors at Risk” and the “Silver Code”

The increasing number of elderly patients accessing emergency departments (EDs) requires use of validated assessment tools. We compared the Identification of Seniors at Risk (ISAR), using direct patient evaluation, with the Silver Code (SC), based on administrative data. Subjects aged 75+ years accessing a geriatric ED over an 8-month period were enrolled. Outcomes were need for hospital admission and mortality at the index ED access, ED return visit, hospitalization, and death at 6 months. Of 1,632 participants (mean age 84 ± 5.5 years), 75% were ISAR positive, and the sample was homogeneously distributed across the four SC risk categories (cutoffs of 0-3, 4-6, 7-10, and 11+). The two scores were mildly correlated (r = .350, p < .001) and had a similar area under the receiver-operating characteristic curve in predicting hospital admission (ISAR: 0.65, SC: 0.63) and mortality (ISAR: 0.72, SC: 0.70). ISAR-positive subjects were at greater risk of hospitalization and death (odds ratio 2.68 and 5.23, respectively, p < .001); the risk increased across SC classes (p < .001). In the 6-month follow-up of discharged patients, the tools predicted similarly ED return visit, hospital admission, and mortality. The SC predicted these outcomes even in participants not hospitalized at the index ED access. Prognostic stratification of elderly ED patients with the SC is comparable with that obtained with direct patient evaluation. The SC, previously validated in hospitalized patients, predicts ED readmissions and future hospitalizations even in patients discharged directly from the ED.

Does decreased access to emergency departments affect patient outcomes? Analysis of acute myocardial infarction population 1996-2005.

We analyze whether decreased emergency department (ED) access results in adverse patient outcomes or changes in the patient health profile for patients with acute myocardial infarction (AMI). We merge Medicare claims, American Hospital Association annual surveys, Medicare hospital cost reports, and location information for 1995-2005. We define four ED access change categories and estimate a ZIP Code fixed-effects regression models on the following AMI outcomes: mortality rates, age, and probability of percutaneous transluminal coronary angioplasty (PTCA) on day of admission. We find a small increase in 30-day to 1-year mortality rates among patients in communities that experience a <10-minute increase in driving time. Among patients in communities with >30-minute increases, we find a substantial increase in long-term mortality rates, a shift to younger ages (suggesting that older patients die en route), and a higher probability of immediate PTCA. Most of the adverse effects disappear after the transition years. Deterioration in geographic access to ED affects a small segment of the population, and most adverse effects are transitory. Policy planners can minimize the adverse effects by providing assistance to ensure adequate capacity of remaining EDs, and facilitating the realignment of health care resources during the critical transition periods.

A prospective study on the effectiveness of a project for early discharge of elderly and frail patients from the emergency department

Frail patients have increased chances of access to Emergency Department (ED) and hospital admission. ED discharge of frail patients (FP) implies high risk of poor outcome. A program of early ED discharge of FPs managed by community nurses (CN) for patients whose hospitalization is not indicated, but cannot be discharged is described. Prospective observational study. A CN, in cooperation with other professionals, assessed the feasibility of discharge and activated the appropriate facilities for a safe patient return to the community. Patients' length of stay in ED, mortality and readmission rate to ED 3 months after discharge were measured. The mean age of the 210 enrolled patients was 82.9 years. The reasons for ED access were either acute or worsened chronic diseases, mainly related to orthopedic/traumatic events and pain. Ninety-two persons were sent back home and 118 to residential facilities. In the following 3 months, mortality was 15.7%; almost 36% of discharged patients had at least one access to hospital and the overall readmission rate was 55.7%, higher in sent home group. CNs, when integrated with other ED staff, can successfully manage early discharges of 'at risk' patients. The high readmission rate may reflect some enduring difficulties to manage in the community, problems traditionally treated in hospital.

Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally versus externally led intervention

IntroductionIn response to increasing demand for hospital beds, institution-wide clinical process redesign has been advocated for improving efficiency.MethodsThis retrospective, before–after study involved five tertiary hospitals in Queensland, Australia and assessed...

The role of full capacity protocols on mitigating overcrowding in EDs

ObjectiveOvercrowding is an important issue facing many emergency departments (EDs). Access block (admitted patients occupying ED stretchers) is a leading contributor, and expeditious placement of admitted patients is an area of research interest. This review examined the effectiveness of full capacity protocols (FCPs) on mitigating ED overcrowding. MethodsA comprehensive literature search was undertaken to identify potentially relevant studies between 1966 and 2009. Intervention studies in which an FCP was used to influence ED/hospital length of stay and ED/hospital access block were included as a single program or part of a systemwide intervention. Two reviewers independently assessed citation relevance, inclusion, study quality, and extracted data; because of limited data, pooling was not undertaken. ResultsFrom 14 446 potentially relevant studies, 2 abstracts from the same comparative study were included. From 29 studies on systemwide intervention, 4 contained an FCP component. The included study was a single-center ED study using a before-after design; its methodological quality was rated as weak. One of the abstracts reported that an FCP was associated with less ED length of stay (5-hour reduction) when compared with the comparison period; the other reported that an FCP decreased ED and hospital access block (28% and 37% reduction, respectively). The ED triggers, format, and implementation of FCP protocols varied widely. ConclusionAlthough FCPs may be a promising alternative for overcrowded EDs, the available evidence upon which to support implementation of an FCP is limited. Additional efforts are required to improve the outcome reporting of FCP research using high-quality research methods.

Patient perceptions of caring and association with emergency department activity and access block

To develop and validate a questionnaire isolating patients' perceptions of caring as individuals provided by ED doctors. This tool was then applied to explore the relationship between ED activity and patient perceptions of caring. Following questionnaire development and reliability analysis, a prospective, cross-sectional study was performed of ED patients who completed the written questionnaire regarding perceptions of caring. The ED tracking database obtained demographic data, patient visit characteristics and markers of departmental activity. Spearman's rho evaluated associations between perceptions of caring and activity. Free text responses were analysed thematically. In reliability testing the questionnaire demonstrated Kappa 0.679, Cronbach's alpha 0.891. The survey was completed by 467 patients. Over 95% of patients agreed that ED doctors: identified themselves; took the problem seriously; treated patients with respect; were courteous and considerate; and demonstrated an overall caring attitude towards patients. Lower agreement occurred with doctors: not distracted by other issues; patient involvement in decisions about care; respect for cultural or religious needs; and doctors going out of their way to help. There were no significant differences in the proportion of patients recruited from different days of the week, shifts or sex. No clinically important associations were demonstrated between perceptions of caring and departmental activity. Least liked aspects of ED care related to system issues rather than the interpersonal relationship with the ED doctors. This study has validated a questionnaire isolating caring attributes. ED activity was not associated with patients' perceptions of being cared for by ED doctors.

Changes in Emergency Department Access between 2001 and 2005 among General and Vulnerable Populations

This retrospective review sought to analyze how geographic access to emergency departments (EDs) changed between 2001 and 2005 in the overall population and in vulnerable communities. Communities nationwide were divided based on zip code-level data from the 2000 Census, and hospital data were extracted from the American Hospital Association Annual Surveys from 2001 and 2005. The number of hospital EDs decreased from 4176 to 3195 between 1995 and 2005, whereas the number of annual ED visits increased from 96.5 to 115.3 million during this period.

Improving emergency department access by using a regional dashboard for ambulance diversion

Improving emergency department access by using a regional dashboard for ambulance diversion

Evaluating the effects of increasing surgical volume on emergency department patient access

AimTo determine how increases in surgical patient volume will affect emergency department (ED) access to inpatient cardiac services. To compare how strategies to increase cardiology inpatient throughput can either accommodate...

Access block and emergency department overcrowding

Access block affecting the emergency department (ED), also known as boarding in the United States and Canada, can be described as a phenomenon comprising almost all the challenges in the world of modern EDs. We use the analogy of parallel universes to illustrate both the complexity and the severity of the problem. In the world of physics, many attempts have been made to create a mathematical solution that can answer the more basic questions about physical phenomena in the universe. This has been known as ‘Theory of Everything’. Albert Einstein spent 30 years of his life trying to solve this ‘Theory of Everything’, but failed [1].

Optimizing care for acute medical patients: the Australasian Medical Assessment Unit Survey

To ascertain the design and operational characteristics of acute Medical Assessment Units (MAU) located within Australasian hospitals, and to compare these with formal standards promulgated by the Internal Medicine Society of Australia and New Zealand (IMSANZ). Descriptive study based on responses to questionnaires mailed to clinical and nursing leads of MAU in March 2009 with follow-up reminders over 3months. Hospitals that had an MAU that met predefined criteria were identified from an IMSANZ directory of sites based on recent contact with IMSANZ members and health department personnel and interrogation of hospital websites and attendance lists at recent MAU workshops. Questionnaires were returned from 32 of 50 hospitals (response rate 64%). Most MAU (15/22; 68%) were less than 2years old. MAU were smaller than recommended by IMSANZ. Sixty-eight per cent were located over a 5-min walk from the emergency department (ED). Delay in transfer of patients from the ED to the MAU was common. The medical service to the majority of MAU was provided by General Medicine physicians and cover was reduced at weekends. In the majority of MAU the emphasis on function was facilitating discharge of patients rather than managing patients with high acuity of illness. Our survey suggests that despite some variation in staffing and procedures, MAU seem to be well established and a promising means of decreasing ED access block. Future comparative study is required to evaluate further the effect of MAU on ED access block and ED length of stay.

Emergency medical residents' use of Google® for answering clinical questions in the emergency room

Emergency Department (ED) residents perceive Internet resources as reliable and regularly search the Internet to answer clinical questions in the ED. To determine the validity of the Internet and the Google® Search Engine, as a source for accurate information to answer clinical questions in ED, a single blinded prospective study was conducted. The search strategies used by Emergency Medical (EM) Residents and Internet resources most frequently visited to find answers to clinical questions were reviewed. Residents completed a PreTest consisting of questions that might routinely occur in ED, and were instructed to answer questions without outside resources, and if they were confident the information was suitable for patient care. Questions that EMR were unsure of, or had answered incorrectly on the PreTest, were used to create a Google® Test. On the pretest 32% of the questions that residents answered were correct, while 28% were incorrect. Residents were unsure of 40% of the questions that they responded to. On the Google® Test 59% of residents' responses were correct, 33% were incorrect and residents were unsure of 8%. Percent of unsure answers dropped significantly when residents searched Google®. Results indicated EM Residents are naive searchers who use single word or short phrase searches and derive query terms directly from the questions; advanced search features of Google® were not used; and websites frequently visited were designed for laypersons, sites for publishers, medical journals, and Google® Scholar and Google® Books. Results also indicated that while EM Residents often retrieved inaccurate information using Google® they believed the information was reliable enough to use in patient care. Findings have major implications for medical informatics, medical practice, and patient safety. Providing Internet access in ED should be carefully reviewed for reliability as a tool for teaching and clinical decision-making. Also, education of EM Residents should include training on Internet and database searching.

Changes in Emergency Department Access Between 2001 and 2005 Among General and Vulnerable Populations

We analyzed how ease of geographic access to emergency departments (EDs), defined as driving time to the closest ED, changed between 2001 and 2005, and whether access deterioration was more likely to occur in vulnerable communities. We classified communities on the basis of American Hospital Association and Census data into 3 categories according to driving time to the nearest ED: no increase, less than a 10-minute increase, and a 10-minute or more increase. We estimated a multinomial logit model to examine the relative risk ratio (RRR) of various community characteristics. More than 95% of communities experienced no ED access deterioration. However, 11.4 million people experienced increased driving time to their nearest ED. Low-income communities had a higher risk of facing deteriorating access compared with high-income communities (urban: RRR = 3.67; P < .01; rural: RRR = 1.75; P < .10), and communities with higher shares of Hispanics also had higher risks of facing declines (urban: RRR = 3.41; P < .10; rural: RRR = 2.67; P < .01). Deteriorating access to EDs is more likely to occur in communities with economic hardship and high shares of Hispanic populations. The uneven access to critical services warrants increased attention from policymaking bodies.

Prognostic value of stable troponin T elevation in patients discharged from emergency department

Troponin elevation in the absence of myocardial infarction is a challenging diagnostic problem in the emergency department (ED). Elevated troponin levels have a short-term negative prognostic value in critically ill patients hospitalized for all causes. No data are available about the short-term prognostic value of elevated troponin in ED patients discharged from hospital without clinical evidence of acute diseases. The aim of the study was to evaluate the short-term prognostic value of elevated stable troponin T (TnT) in ED patients discharged from hospital. Two hundred and thirty-two consecutive adult individuals admitted to ED evaluation for all causes, with TnT test and without evidence of acute diseases requiring hospitalization, were evaluated. The patients with TnT positive tests, without dynamic changes during in-hospital observation and discharged from hospital, were considered as case patients. For each case patient enrolled, the consecutive patient of the same sex and similar age, admitted to the ED on the same day and discharged with normal plasma TnT values, was enrolled as her/his control. The incidence of adverse clinical events in both cases and controls assessed by a phone call at 24 h, 7 days and 30 days after the ED discharge was recorded. Ninety-four cases and 94 controls were finally considered. The 30-day adverse events (death, hospitalization and ED access) were 35 of the 94 (37.2%) in cases and 18 of the 94 (19.1%) in controls (P < 0.01). The patients discharged from ED with stable elevated TnT levels, but without acute diseases, had a short-term prognosis worse than that of patients with similar clinical presentation but with normal TnT values.

Effectiveness of acute medical units in hospitals: a systematic review

To assess the effectiveness of acute medical units (AMUs) in hospitals. (i) Controlled and observational studies in peer-reviewed journals retrieved from PubMed, EPOC, CINAHL and ERIC databases published between January 1990 and July 2008; and (ii) reports from non-peer-reviewed websites combined with Google search. Articles reporting effects of the introduction of an AMU on mortality, length of stay, discharge disposition, readmissions, resource use and patient and/or staff satisfaction. Data extraction Data on unit operations and outcome measures were extracted by a single author and confirmed by a second author, with disagreement settled by consensus. Nine peer-reviewed reports of before-after analyses of seven units introduced into the UK and Ireland were analysed. Two studies, one prospective, reported significant reductions in in-patient mortality between 0.6 and 5.6% points following commencement of AMU. Four studies reported significant reductions in the length of stay between 1.5 and 2.5 days. Waiting times for patient transfer from emergency departments to medical beds decreased by 30% in one study. In three studies, the proportion of medical patients discharged directly home from the AMU increased by 8-25% points. Three studies noted no increase in 30-day readmission rates following unit commencement. Two studies described significant improvements in patient and staff satisfaction with care. Eight non-peer-reviewed reports relating to 48 units confirmed reductions in the length of stay. Limited observational data suggest AMUs reduce in-patient mortality, length of stay and emergency department access block without increasing readmission rates, and improve patient and staff satisfaction.

A case of mesenteric panniculitis

Mesenteric panniculitis is a rare disease leading to recurrent acute abdominal pain, whose recognition is important in order to avoid any unwarranted aggressive surgery. A case of this condition is described. The patient, a 73-year-old man, attended our emergency room with acute abdominal pain, fever and prolonged partial thromboplastin time. He had a history of recurrent emergency department access and complained of the same rapidly reversible clinical picture. Findings at abdominal CT and at diagnostic laparascopy performed during admission, including histology of a biopsy, helped reach a correct diagnosis and treatment. This brief report from literature analysis presents what is known so far about the diagnosis and treatment of mesenteric panniculitis. Finally we briefly discuss some peculiar pathogenesis and hypothesis.

Emergency department access block occupancy predicts delay to surgery in patients with fractured neck of femur

The present study aimed to identify any relationship between existing access block occupancy (ABO) at the time of patient presentation and delay to definitive procedure. Retrospective descriptive cohort study of all patients aged over 50 years with an ED diagnosis of fractured neck of femur admitted through a tertiary ED over 2 years. The independent variable was the ABO at the start of the hour in which the patient presented, derived from existing ED records, and expressed as the quartile for that hour of the day. The dependent variable was start of surgery more than 24 h after arrival without a documented reason for delay. The data abstractor was blinded to the ABO. All 442 diagnoses of fractured neck of femur recorded in the ED were reviewed, 73 were excluded (16 age, 5 misdiagnosis, 31 no surgery, 21 documented medical reasons for delay). There was a significant relationship between ABO quartile and the rate of delay to surgery ranging from 54% (95% CI 43-63%) for those presenting in the lowest ABO quartile to 77% (68-85%) in the highest (P= 0.006, chi(2)). Subgroup analysis showed that arrival ABO predicted patient access block, and that patient access block was associated with delay to surgery and longer postoperative length of stay (geometric mean 12.9 vs 9.9 days, P < 0.01, t-test). The number of access block patients at the time of arrival directly predicts delay to operation in this setting. This suggests that access block occupancy is a marker of hospital dysfunction.