Emergency Department Boarding Time Research Articles

Implementing and Evaluating a Discharge Before Noon Initiative in a Large Tertiary Care Urban Hospital

Discharging clinically ready patients before noon on their discharge day may influence overall discharge process quality, emergency department (ED) boarding times, and length of stay (LOS). This study evaluated the effectiveness of a discharge before noon (DBN) initiative. Many DBN components were refined or added during a pilot, including incorporating the DBN process into daily rounds, an electronic tracking system, and other elements for possible DBN patients such as a car service when appropriate and expedited lab results and physical therapy consults. DBN was evaluated through a retrospective pre-post study (12-month periods). Study patients were from Maimonides Medical Center's medicine units. Kaplan-Meier estimates and a log-rank test characterized and compared the discharge time probabilities in pre-DBN and post-DBN groups. Log-logistic accelerated failure time (AFT) analysis assessed the influence of DBN on discharge time. Secondary analyses examined the relationship between LOS and readmission within 30 days for any cause and DBN. The percentage of patients discharged before noon increased from 5.0% to 11.4% pre/post-DBN (p < 0.001). The AFT analysis estimated that post-DBN patients had discharge times 41.5% earlier (p < 0.001). DBN as an independent factor was not associated with LOS or subsequent readmissions within 30 days for any cause. Despite an increase in the percentage of patients admitted during the daytime (8:00 a.m. to 5:00 p.m.), the median ED boarding time increased by 41 minutes in post-DBN patients (p < 0.001). The DBN initiative was associated with an increased percentage of patients discharged before noon. Further research is needed to identify strategies that reliably improve discharge timeliness while reducing ED boarding.

Impact of Access Block Is Increasing Mortality in Emergency Departments in Nepal

Introduction:Emergency patients have to stay in the Emergency Department (ED) for hours to days to get ward admission for definite care in Nepal. Access block is a major issue in the ED of University Level Teaching Hospitals (ULTH) in Nepal. This study aimed to analyze the impact of access blocks in the EDs of Nepal.Method:Meta-analysis of different publications on ‘duration of ED Boarding’ and ‘mortality outcome of ED’ of ULTHs of Nepal till November 15, 2022Results:9.7% of ED patients were admitted to the ward. The time period from ED arrival to respective ward team consultation is 5.7 hours, consultation to ward admission is 5.6 hours, and admission to ward transfer is 8 hours. The average ED boarding time is 18.1 hours. 38% of patients arrived in ED via Ambulances. The time period from ED arrival to ward team consultation for those who need transfer to another center are 6.9 hours, consultation to admission is 5.7 hours, and admission to transfer is 8.7 hours (ED Boarding time 21.3 hours). Meta-analysis of three major ULTH’s showed mortality with respect to ED boarding time to be 17% in &lt; 1 hour, 40.4% in 1 - 6 hours, 27.4% in 6-12 hours, 9.1% in 12-24 hours, 4% in 24-28 hours and 2.1% in &gt;48 hours. Among them, higher age, greater mortality rate. The immediate causes of mortality comparing 2018 vs 2010 are Sepsis &amp; Septic shock 32.2% vs 18%, Cardiac Causes 21.8% vs 14.8%, Aspiration Pneumonia 19.5% vs 14.8%, Severe Lung Diseases 12.7% vs 16.4%, Hypovolumic &amp; Haemorrhagic Shock 9.2% vs 34.4% and Poisoning 4.6% vs 1.6%.Conclusion:Prolonged ED boarding due to Access Block is triggering increased mortality in the ED.

Race and Other Disparate Demographic Variables Identified Among Emergency Department Boarders.

IntroductionEmergency department (ED) boarding, the process of holding patients in the ED due to a lack of inpatient beds after the decision is made to admit, has profound consequences. Increased ED boarding times are associated with adverse patient outcomes, including increased mortality. While previous studies have demonstrated racial disparities with regard to ED boarding, current literature lacks insight into discrepancies that may exist among other demographic groups as it pertains to ED boarding. We sought to review ED boarding times differentiated by demographic characteristics.MethodsWe conducted a retrospective review of all ED admissions from an academic ED in the Southeast from April–September 2019. The primary outcome assessed was boarding time, defined as time from decision to admit to ED departure. Patient demographic data including race, gender, and age were collected and analyzed. We performed descriptive statistics and chi-square analyses.ResultsThe study population included 17,606 patients with a mean age of 56.3. Nearly half (49.8%) of the patients were female. Additionally, 43.8% of patients were Black and 48.6% White. For all admissions, there was no difference in mean boarding time among Black and White patients (5.2 ± 8.8 vs 5.2 ± 8.2 hours, P = 0.11). Among Emergency Severity Index (ESI) level I admissions, Black patients boarded longer than White patients (4.1 ± 0.3 vs 2.7 ± 0.3 hours, P = 0.009). Black patients also boarded significantly longer than White patients for psychiatric admissions (22.7 ± 23.7 vs 18.5 ± 19.4 hours, P <0.05). For all admissions, males boarded longer than females (5.5 ± 8.5 vs 4.9 ± 8.2 hours, P <.0001). Patients older than 75 boarded for less time (3.8 ± 6.2 hours) compared to younger groups (15–24: 6.4 ± 10.8 hours; 25–44: 6.6 ± 10.8; 45–64: 5.0 ± 7.6; and 64–75: 4.7 ± 6.7; all P <.05).ConclusionThis analysis demonstrated significant differences in ED boarding times between races among psychiatric and ESI I admissions, gender, and age. This data provides insight into differences in ED boarding times among demographic groups and provides a focal point for examining possible factors contributing to the observed differences.

To Batch or Not to Batch? Impact of Admission Batching on Emergency Department Boarding Time and Physician Productivity

Trade-offs Caused by Batching Inpatient Admissions from Emergency Departments In “To Batch or Not to Batch? Impact of Admission Batching on Emergency Department Boarding Time and Physician Productivity,” Feizi and coauthors tackle the important problem of identifying causes of emergency department (ED) boarding with the goal of identifying a managerial lever to reduce it. They investigate the impact of batching admissions of ED patients. The authors empirically show that batching occurs frequently at the end of shifts when physicians wrap up their tasks. Interestingly, Feizi et al. find a trade-off. Batching improves individual physician productivity, which explains its prevalence. However, it increases boarding times, an outcome that negatively impacts patients and the hospital. A counterfactual analysis comparing empirical results to theoretical queuing models finds that eliminating batching reduces boarding times by 15%. The paper highlights that boarding can be reduced by physicians completing admissions work as it occurs rather than delaying to the end of shift.

Influencing Discharge Efficiency: Addressing Interdisciplinary Communication, Transportation, and COVID-19 as Barriers.

At one tertiary, academic medical center, two general medicine units averaged 94% and 97% occupancy causing strain on patient throughput. This project was implemented at these two comparable general medicine units, totaling 64 beds. On each of these units, Pareto analyses on causal factors related to discharge order to exit time (DOTE) were performed. DOTE was defined as the period in minutes from when a provider orders a discharge to when the patient actually exits a room. Prime DOTE reduction opportunities were elicited that highlighted the need to address coordination of hospital discharge transportation; that is, arriving family members averaged 120 and 129 min for the two units, and medicars and ambulances averaged 122 and 156 min, which fell above the established 90-min overall strategic DOTE goal. Coordinating efficient discharges decreases the likelihood of hospital bottlenecking and improves patient satisfaction. The health care team is composed of physician and provider services, nursing, and case management, as well as the patient and family. Team-focused interventions aimed at reducing DOTE included leveraging interdisciplinary communication technology and messaging for efficiency and accuracy within the health care team and proactive scheduling of hospital discharge transportation arrival. Process objectives measured included percentage of the health care team educated and utilization of the discharge suite. Outcome objectives measured included median DOTE times, patient satisfaction, and emergency department boarding volume and times. Significantly, admissions for coronavirus disease-2019 (COVID-19) cases were also rapidly increasing early on during program implementation resulting in one of the two general medicine units to be designated for COVID-19 overflow. Using Lean methodology, the project design was formed based on the Institute for Healthcare Improvement's work on improving hospital-wide patient flow and the Agency for Healthcare Research and Quality's (AHRQ) IDEAL patient discharge framework to better achieve the well-known, triple aim. In response to COVID-19 demands, the Plan-Do-Study-Act process was warranted to be able to manage acute changes, using iterative processing. This program evaluation study assessed whether a communication training program that taught an interdisciplinary team of case managers, nurses, physicians, and related staff how to reduce DOTE was useful. The program had a material impact on the DOTE metric knowing that the hospital's ultimate strategic goal is to reduce DOTE to 90 min or less. A reduction in discharge time was documented when using weekly data from the hospital's discharge dashboard powered by the Maestro database. More specifically, nurses fully trained in the interdisciplinary communications program aimed to reduce DOTE had significantly lower DOTE outcomes on their discharges compared with untrained staff (i.e., average untrained = 127 min, average trained = 93 min). In addition, the fully trained nurses had 14% more of their discharges fall at or below the 90-min goal compared with untrained staff (i.e., untrained = 40%, trained = 54%). Supplemental research also suggested that the content of the communication training program was very relevant (e.g., empowering families to pick up the patients and using scheduling vs. will-call transportation strategies with patients lowered the DOTE metric). Corollary analyses showed that readmissions were also lowered, and patient satisfaction ratings increased. In addition, the interdisciplinary communications training program can benefit from being updated to include content on how COVID-19 issues adversely impact discharge times since significant relationships between various COVID-19 measures and higher discharge exit times were documented.

Accelerated Critical Therapy Now in the Emergency Department Using an Early Intervention Team: The Impact of Early Critical Care Consultation for ICU Boarders.

OBJECTIVES:Evaluate the impact of an emergency department (ED)–based critical care consultation service, hypothesizing early consultation results in shorter hospital length of stay (LOS).DESIGN:Retrospective observational study from February 2018 to 2020.SETTING:An urban academic quaternary referral center.PATIENTS:Adult patients greater than or equal to 18 years admitted to the ICU from the ED. Exclusion criteria included age less than 18 years, do not resuscitate/do not intubate documented prior to arrival, advanced directives outlining limitations of care, and inability to calculate baseline modified Sequential Organ Failure Assessment (mSOFA) score.INTERVENTIONS:ED-based critical care consultation by an early intervention team (EIT) initiated by the primary emergency medicine physician compared with usual practice.MEASUREMENTS:The primary outcome was hospital LOS, and secondary outcomes were hospital mortality, ICU LOS, ventilator-free days, and change in the mSOFA.MAIN RESULTS:A total 1,764 patients met inclusion criteria, of which 492 (27.9%) were evaluated by EIT. Final analysis, excluding those without baseline mSOFA score, limited to 1,699 patients, 476 in EIT consultation group, and 1,223 in usual care group. Baseline mSOFA scores (±sd) were higher in the EIT consultation group at 3.6 (±2.4) versus 2.6 (±2.0) in the usual care group. After propensity score matching, there was no difference in the primary outcome: EIT consultation group had a median (interquartile range [IQR]) LOS of 7.0 days (4.0–13.0 d) compared with the usual care group median (IQR) LOS of 7.0 days (4.0–13.0 d), p = 0.64. The median (IQR) boarding time was twice as long subjects in the EIT consultation group at 8.0 (5.0–15.0) compared with 4.0 (3.0–7.0) usual care, p < 0.001.CONCLUSIONS:An ED-based critical care consultation model did not impact hospital LOS. This model was used in the ED and the EIT cared for critically ill patients with higher severity of illness and longer ED boarding times.

Simulating emergency patient flow during the COVID-19 pandemic

ABSTRACT The work presented in this paper is based on two projects that were conducted at St. Olavs Hospital (Norway) when preparing for the COVID-19 pandemic. Three discrete event simulation models are provided to evaluate the resource requirements during the peak of the pandemic. First, we estimate the number of beds needed in the emergency department (ED). In the second model, we estimate the number of ambulances required to maintain prepandemic response times for emergency patients. The third model is a coupling of the two former models, and it is used to study the effects of ED boarding time for COVID-19 patients. The resource needs are analysed under different COVID-19 testing policies. A strict testing policy increases the bed requirements in the ED, while it has the opposite effect for ambulances. Two distinct mechanisms causing boarding time are found. The effects from boarding time are most prominent during night and weekends.

Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine

Proactive consultation-liaison (C-L) psychiatry has been shown to reduce hospital length of stay (LOS), increase psychiatric C-L consult rate, and improve hospital staff satisfaction. Nursing attrition has not been studied in relation to proactive C-L. Our primary aim in evaluating the proactive C-L service called Proactive Integration of Mental Health Care in Medicine (PRIME Medicine) is to analyze change in LOS over 10 months using historical and contemporary comparison cohorts. As secondary aims, we assess change in psychiatric consultation rate, time to consultation, and change in nurse attrition. PRIME Medicine was implemented on 3 hospital medicine units as a quality-improvement project. Team members systematically screened patients arriving to assigned units for psychiatric comorbidity. Identified patients were reviewed with hospitalist teams and nurses with the goal of early intervention. Including historical and contemporary comparison cohorts, the mean sample age was 62.4 years (n=8884). Absolute LOS was unchanged, but difference-in-difference analysis trended toward reduced LOS by 0.16 day (P=0.08). Consultation rate increased from 1.6% (40 consults) to 7.4% (176 consults). Time to consultation was unchanged (4.0-3.8 d). Annual per-unit nursing turnover increased from 4.7 to 5.7 on PRIME units but from 8.5 to 12.0 on comparison units. Nurses citing "population" as the reason for leaving decreased from 2.7 to 1.7 on PRIME units but increased from 1.5 to 4.5 on comparison units. PRIME Medicine led to increased consultation rate, and our unit-wide outcomes provide a conservative estimate of effect. Factors that may have influenced effect size include our cohort's advanced age, considerable emergency department boarding times, increasing proportion of patients discharged to skilled nursing facilities, and concurrent LOS-reduction initiatives on all units. The favorable trends in nursing attrition on PRIME units may be explained in part by our prior finding that PRIME Medicine was associated with enhanced nursing satisfaction. While PRIME Medicine had no more than a modest effect on LOS, it was associated with a markedly increased psychiatric consult rate and favorable trends in nursing retention. This analysis highlights important factors that should be considered when implementing and determining value metrics for a proactive C-L service.

Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America.

The objective was to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit in the emergency department (ED) on hospital admissions, ED length of stay, and 30-day follow-up for patients presenting with suicidal ideation or attempt. This study was a before-and-after analysis of introducing the EmPATH unit within a Midwestern academic medical center on outcomes of adult patients (≥18years) presenting with suicidal ideation or suicidal attempt. The primary outcome in this study was the change in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED before and after implementation of the EmPATH unit. Secondary outcomes compared were changes in proportion of any admission, incomplete admission defined as discharge from the ED after admission request placed, outpatient follow-up, return ED visits within 30days of admission, and ED boarding time. Association between the EmPATH unit implementation and categorical outcomes were determined using log-binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). Continuous outcomes were log-transformed and generalized estimating equations were used to examine as the mean difference by time period. There were 962patients presenting with suicidal ideation (n=435 before EmPATH unit, n=527 after EmPATH unit). Compared to the pre-EmPATH-unit period, there was a reduction in psychiatric admission (RR= 0.48, 95% CI= 0.40 to 0.56), any admission (RR= 0.65, 95% CI= 0.58 to 0.73), incomplete admission (RR= 0.22, 95% CI= 0.11 to 0.43), and 30-day return to the ED (RR= 0.74, 95% CI= 0.56 to 0.98). ED boarding time among admitted patients was reduced by approximately two-thirds both in admitted patients (RR= 0.34, 95% CI= 0.30 to 0.39) and among those with incomplete admissions (RR= 0.37, 95% CI= 0.23 to 0.61). There was a 60% increase in a 30-day follow-up care established at the time of discharge (RR= 1.60, 95% CI= 1.40 to 1.82). The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care.

Improving hospital flow ‘Ensiab Project’

Emergency department (ED) boarding is an indicator of less efficient hospital flow and is associated with longer inpatient length of stay, higher readmission rates and increased risk of mortality and...

Using Accountable Care Teams to Improve Timely Discharge: A Pilot Study.

Hospitals worldwide are faced with the problem of discharging patients on time. Delayed discharge creates domino effects with significant implications for hospitals. The accountable care team (ACT) is a multidisciplinary, unit-based approach to identifying opportunities to improve patient care and address inefficiencies in care delivery and throughput, including assuring timely discharges. In response to concerns about emergency department boarding times and delays in timely discharge, the ACT recommended a set of strategies to improve communication across team members and to reduce wait times for transportation within and outside the hospital. Collectively these strategies were thought to increase the proportion of patients discharged on time. In this article, we describe and assess changes in timely discharge resulting from the implementation of strategies recommended by the ACT. This study uses a retrospective, quasi-experimental design to compare the percentage of discharges by 1 pm of hospital units implementing the ACT intervention to those units not implementing the intervention. Median discharge time was compared pre- and post-implementation using the Wilcoxon rank sum test. Difference-in-differences modeling was employed to assess whether changes in the percentage of discharges by 1 pm differed between units implementing the intervention and units not implementing the intervention. One month post-implementation, the percentage discharged by 1 pm was statistically significantly higher for units implementing the intervention (53.6%) compared with comparison units (22.5%, t = -4.48, P < .01). Statistically significant differences in the percentage discharged by 1 pm were also seen at 3 and 6 months post-implementation. The median discharge time showed a statistically significant decrease by 77 minutes from the baseline to intervention period ( P < .01). The result from the study suggests that ACTs can be used to develop approaches aimed at improving patient care in general, and discharge efficiencies in particular. Health care organizations are encouraged to utilize and then evaluate the specific activities of multidisciplinary teams aimed at developing recommendations for practice improvement.

50 Emergency Department Management and Outcomes of COVID-19 Acute Hypoxemic Respiratory Failure During the New York City Surge

Delays in intensive care unit (ICU) admission for critically ill patients are associated with worse outcomes, but the effect of “boarding” during the COVID-19 pandemic has not been well characterized. This study describes the emergency department (ED)-based care for patients presenting with COVID-19-related acute hypoxemic respiratory failure (AHRF) to five hospitals in a large, academic health system during the initial surge in New York City, examining both respiratory modality choice and settings. For those managed with noninvasive respiratory support, we also aimed to explore the association between ED boarding time and patient morbidity and mortality. We conducted a retrospective cohort study of ED patients presenting from 3/1/2020 to 7/10/2020 with COVID-19-related AHRF and requiring ICU admission at any time during their hospitalization. Patient demographics, comorbidities, severity of illness (Mortality Probability Model III on admission), clinical course, including the use, settings (initial and changes), and duration of respiratory support modalities (ie, noninvasive ventilation [NIV], high flow nasal cannula [HFNC], invasive mechanical ventilation [IMV]), as well as hospital site, were collected through validated electronic query and standardized manual chart abstraction. AHRF severity was defined using a PaO2/FiO2 ratio (PF): 200-300 (mild), 100-199 (moderate), and <100 (severe). For patients without a PaO2, the PF was imputed using SpO2/FiO2 ratio using previously validated non-linear conversion. Boarding was defined as the time interval from ED request for admission to ED departure. The primary outcome was a composite outcome of ICU admission, intubation, or mortality within 48 hours of ED arrival. Descriptive analyses stratified by boarding duration and AHRF were completed. Multivariable logistic regression modelling was used to determine the association between ED boarding and the primary outcome. A total of 679 ED patients with COVID-19 AHRF required ICU admission during the study period. They were managed with low flow oxygen only (261, 38.4%), or with NIV (120, 17.7%), HF (51, 7.5%), and/or IMV (99, 14.6%), with setting ranges detailed in Table 1. Of the patients with a known PF ratio (N=418), 110 (26.35%) had mild, 34 (5.0%) had moderate, and 274 (40.4%) had severe AHRF. Of these patients, 279 (41.1%) had a change documented to their settings, with increased likelihood of adjustments with longer boarding time (p<0.001) and higher AHRF severity (p<0.001). Median boarding duration across all site was 9.5 hours (IQR 5.3-16.9 hours) with site variation. AHRF severity and support modality were not associated with differences of boarding time (p = 0.77 and p=0.54). Controlling for age, sex, race, and severity of illness, boarding time was not associated with worse patient outcomes in 48 hours (OR 0.85, 95% CI 0.67-1.08, p=0.17) During the COVID-19 pandemic, critically ill patients presented to the ED and boarded for long periods of time, requiring prolonged ventilatory management. Despite the surge state and resource limitations, boarding times did not worsen post-ED outcomes for patients managed with non-invasive modalities.

Association of emergency department boarding times on hospital length of stay for patients with psychiatric illness

BackgroundExtended periods awaiting an inpatient bed in the emergency department (ED) may exacerbate the state of patients with acute psychiatric illness, increasing the time it takes to stabilise their acute...

Pressure Injury Prevention in Patients with Prolonged ED Stays Prior to Admission.

The purpose of this project was to examine whether initiating a standardized pressure injury (PI) assessment and prevention protocol early in adult patients' ED stay reduces hospital-acquired PIs (HAPIs) in those patients admitted from the ED to acute care inpatient medical units. A nurse-led evidence-based practice team studied the problem of increasing HAPIs on four acute care inpatient units and found that, among patients who had been admitted to inpatient care from the ED, longer ED boarding times correlated with a higher rate of HAPIs. ED staff and acute care unit nurses collaborated to develop new protocols to prevent HAPIs in the ED, including staff education and standardized assessments and prevention care for at-risk patients. Data collection was performed at three time periods over approximately two and a half years: baseline, intervention, and postintervention. The incidence rate for HAPIs decreased from 3.56 per 1,000 patient-days at baseline to 1.31 per 1,000 patient-days during the intervention period. This reduction was sustained over the next five months, during which the HAPI incidence rate was 1.53 per 1,000 patient-days. At a time when ED length of stay is difficult to manage and continues to increase, the use of evidence-based interventions and protocols can reduce the rate of PIs in high-risk patients waiting for hospital admission, leading to a reduction in PI rates and overall hospital costs.

To Batch or Not to Batch? Impact of Admission Batching on Emergency Department Boarding Time and Physician Productivity

We study the behavior of batching by discretionary workers in the first stage of a two-tier queuing system, and explore the trade-off it causes between their productivity and second stage wait times. Specifically, we focus on the behavior of batching admissions by emergency department (ED) physicians. Using data from a large hospital, we show that the probability of batching admissions is increasing in the hour of an ED physician's shift, and that batched patients experience a 4.6% longer delay from hospital admission to receiving an inpatient bed. Using a mediation analysis we show that this effect is partially due to the increase in the coefficient of variation of inpatient bed-requests caused by batching. However, we also find that batching admissions is associated with an average of11.4% more patients seen in a shift, and a 2.5 minute reduction a physician's average throughput time. An important implication of our work is that workers may induce delays in downstream stages, caused by practices that increase their productivity.

Evaluation of a Bed Reaggregation Initiative at an Urban Academic Medical Center.

Hospital flow disruptions have been linked to treatment delays, longer length of stay (LOS), poor patient outcomes, and overburdened staff leading to disengagement. This project was designed to evaluate and determine if the bed reaggregation was successful at meeting its goals. Donabedian's framework guided the following evaluation points: 1) patient placement accuracy, 2) LOS variance, 3) emergency department (ED) boarding times, 4) hospital bypass hours, 5) operational declination rates, 6) patient satisfaction, and 7) RN engagement. Data were analyzed using pre-post percent change and χ analysis. Primary placement of patients, LOS variance, and operational declinations improved. Hours on bypass and ED boarding times were not reduced. RN engagement scores varied widely with significant decreases on 2 of the reaggregated units. Patient satisfaction scores varied, but overall did not decrease. Further consideration is needed for improving hospital bypass, ED boarding times, and RN engagement.

A Multimodal Intervention to Improve the Quality and Safety of Interhospital Care Transitions for Nontraumatic Intracerebral and Subarachnoid Hemorrhage

Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. The researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT. Pre and post analyses of timeliness, effectiveness, and communication outcome measures were performed for patients transferred to an urban, academic center with nontraumatic ICH/SAH following implementation of a multimodal intervention. Intervention components included clinical practice guideline dissemination, IHT process redesign, electronic patient arrival notification, electronic imaging exchange, and electronic health record improvements. Three months of preintervention outcomes were compared to six months of postintervention outcomes to assess impact and sustainability of the intervention; t-tests and chi-square tests were used to compare continuous and proportional outcomes, respectively. The IHT study population included 106 patients (37 preintervention, 69 postintervention). Significant improvements were observed in timeliness outcomes, including emergency department (ED) time to admission order (preintervention median: 66 minutes vs. postintervention: 33 minutes, p = 0.008), ED boarding time (preintervention median: 223 minutes vs. postintervention: 93 minutes, p = 0.001), and ED length of stay (preintervention median: 300 minutes vs. postintervention: 150 minutes, p ≤ 0.0001). Verbal communication between ED and neurocritical care clinicians prior to IHT improved from 40.0% preintervention to 90.9% postintervention. Application of scripted quality improvement interventions as part of the IHT process is feasible and effective at improving the timeliness of care and communication of critical information in patients with nontraumatic ICH/SAH.

405 Crisis Stabilization Unit Reduces Admission Rates for Suicidal Patients in a Midwest Emergency Department

In an attempt to improve patient care and hospital operations, our institution implemented a crisis stabilization unit (CSU) to provide psychiatric stabilization and treatment in a setting other than the emergency department (ED). After initial evaluation and medical clearance by an emergency medicine provider, patients transfer from the ED to the CSU. The CSU aims to decrease the time, space, and monetary burdens on the ED, and to preserve the limited inpatient psychiatry beds for patients who truly need admission, as patients may discharge home from the CSU. The purpose of this study is to determine the effect on hospital admission rates for suicidal patients in the emergency department after the opening of the CSU in a rural academic medical center. We performed a before-and-after analysis of introducing the CSU within a Midwestern tertiary referral center. We evaluated study periods of November 15, 2017 to May 15, 2018 and November 15, 2018 to May 15, 2019 to examine patients pre- and post-CSU implementation. Adult patients presenting with suicidal ideation or suicidal attempt were included. The primary outcome was difference in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED. Secondary outcomes compared were changes in proportion of any admission, use of code greens (code activated in cases where patient poses a threat, requiring immediate attention by psychiatry and security), incomplete admission (a bed request is made but the patient leaves prior to admission), restraint use, scheduling of follow-up within 30 days of discharge, ED returns within 30 days, and mean difference in ED boarding hours. We performed a descriptive analysis of patient visit characteristics presenting before and after CSU implementation. Association between categorical outcomes was determined to estimate relative risks (RR) and 95% confidence intervals (CI). Continuous outcomes were examined as the mean difference (MD) by time period. There were 962 patients presenting with suicidality (n=435 pre-CSU, n=527 post-CSU). There were no differences in population during the two study periods by age, sex, race, homelessness, or insurance. Compared to the pre-CSU period, there was a reduction in psychiatric admission (RR: 0.48; 95% CI: 0.40-0.56), any admission (RR: 0.65; 95% CI: 0.58-0.73), discharge after bed request (RR: 0.22; 95% CI: 0.11-0.43), 30-day return to the ED (RR: 0.74; 95% CI: 0.56-0.98), ED boarding time among admitted patients (MD: -9.0 hours; 95% CI: -13.5, -4.6) and incomplete admissions (MD: -12.5 hours; 95% CI: -21.3, -3.7). There was no significant difference in restraint use or code green use in the ED. There was a 60% increase in a 30-day follow-up being scheduled (RR: 1.60; 95% CI: 1.40-1.82). This study showed that the rate of any inpatient admission, discharge after bed request, 30-day ED return, and ED boarding time decreased after the implementation of the CSU.

Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit.

We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307)minutes (mean difference= 189minutes, 95% confidence interval [CI]= 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517)minutes (mean difference= 114 minutes, 95% CI= 87 to 143 minutes). The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.

Emergency Department Boarding of Non-Trauma Patients Adversely Affects Trauma Patient Length of Stay.

IntroductionEmergency Department (ED) boarding delays initiation of time-sensitive protocols for trauma patients and makes them susceptible to increased mortality and morbidity. In this study, we compared the ED boarding times of non-trauma patients and ED length of stay (LOS) of trauma patients.MethodsThis was a single-center retrospective cohort study in a Level 1 trauma center. The median boarding time among non-trauma patients and ED LOS among trauma patients was determined by month between the period of April 2018 to March 2019. Linear regression and Pearson correlation coefficient were used to express the magnitude and direction of the relationship between these two variables.ResultsDuring the study period, the mean number of non-trauma patients admitted in our ED per month was 1,154 and trauma patients was 89. The mean of the median boarding time per month for non-trauma patients was 76 minutes, and the mean of the median ED LOS per month for trauma patients was 198 minutes. There was a significant positive correlation between boarding time for non-trauma patients and ED LOS for trauma patients (Pearson correlation coefficient: 0.73; p = 0.007).ConclusionThe long boarding times for non-trauma patients is associated with ED LOS for trauma patients, indicating that the total patient volume in the hospital contributes to the trauma patient's stay in the ED. Thus, ED LOS of trauma patients can be minimized by improving overall ED and hospital flow, including non-trauma patients.