Pathway In Emergency Department Research Articles

The transition experiences of new nurse graduates participating in an emergency department pathway from undergraduate to 3 months post-pathway: An interpretive description study

The transition experiences of new nurse graduates participating in an emergency department pathway from undergraduate to 3 months post-pathway: An interpretive description study

Hyperacute assessment of vertigo in suspected stroke

The management of patients with acute vertigo is most challenging in the hyperacute phase, both due to the complexity of vertigo as a symptom, the range of possible causes, and the lack of training in neuro-otology for non-specialists. Perhaps of greatest relevance is differentiating between peripheral (usually benign, e.g., inner ear) causes and central (potentially more sinister, e.g., stroke) causes. Several diagnostic algorithms have been introduced to help detect stroke in patients with acute vertigo. However, these algorithms have been largely validated in patients with an acute vestibular syndrome (with nystagmus) for whom symptoms have been present for a minimum of 24 h. The most challenging period within the diagnostic process is the hyperacute phase that determines triage and treatment, but where none of the established algorithms have been validated. In this review, we specifically describe practical implementation considerations for evaluating patients with hyperacute vertigo, including the timing of diagnostic testing within the emergency department pathway, resource availability, and pitfalls associated with current practices.

Prospective evaluation of an emergency department protocol to prevent hospitalization in mild acute pancreatitis: Outcomes and predictors of discharge

BackgroundWhile acute pancreatitis (AP) contributes significantly to hospitalizations and costs, most cases are mild with minimal complications. In 2016, we piloted an observation pathway in the emergency department (ED) for mild AP and showed reduced admissions and length of stay (LOS) without increased readmissions or mortality. After 5 years of implementation, we evaluated outcomes of the ED pathway and identified predictors of successful discharge. MethodsWe reviewed a prospectively enrolled cohort of patients with mild AP presenting to a tertiary care center ED between 10/2016 and 9/2021, evaluating LOS, charges, imaging, and 30-day readmission, and assessed predictors of successful ED discharge. Patients were divided into two main groups: successfully discharged via the ED pathway (“ED cohort”) and admitted to the hospital (“admission cohort”), with subgroups to compare outcomes, and multivariate analysis to determine predictors of discharge. ResultsOf 619 AP patients, 419 had mild AP (109 ED cohort, 310 admission cohort). The ED cohort was younger (age 49.3 vs 56.3,p < 0.001), had lower Charlson Comorbidity Index (CCI) (1.30 vs 2.43, p < 0.001), shorter LOS (12.3 h vs 116 h, p < 0.001), lower charges (mean $6768 vs $19886, p < 0.001) and less imaging, without differences in 30-day readmissions. Increasing age (OR: 0.97; p < 0.001), increasing CCI (OR: 0.75; p < 0.001) and biliary AP (OR: 0.10; p < 0.001) were associated with decreased ED discharge, while idiopathic AP had increased ED discharge (OR: 7.8; p < 0.001). ConclusionsAfter appropriate triage, patients with mild AP (age <50, CCI <2, idiopathic AP) can safely discharge from the ED with improved outcomes and cost savings.

Abstract 15713: A Novel Chest Pain Pathway Triaging Low-Risk Emergency Department Patients via Ambulatory Care Reduces Hospital Admissions Without Increased 30-Day Readmissions or All-Cause Mortality

Introduction: Chest pain is a common presentation to the Emergency Department (ED). Current international guidelines emphasise the importance of triage pathways involving patient-centric algorithms. In 2019, a front-door ED pathway (Figure 1) was created to direct low-risk chest pain towards ambulatory care. We aimed to characterise clinical outcomes with this pathway in a real-world UK ED cohort presenting with cardiac chest pain. Methods: The chest pain pathway stratified patients as low-, intermediate- and high-risk at presentation. Patients presenting to the ED at our institution in London, UK, were consecutively included in two groups: a pre-pathway group prior to implementation of the chest pain pathway and a post-pathway group following implementation. Baseline demographics were compared using Pearson’s χ 2 test for categorical variables and unpaired t-tests for continuous variables. Primary endpoints were 30-day readmissions, and all-cause mortality. Multiple logistic regression models were constructed to assess the impact of the pathway on the primary outcomes, adjusting for age, sex, risk category and HEART score. Results: Baseline demographics were similar between pre-pathway and post-pathway groups, except for presence of a smoking history ( p = 0.04). Smoking was therefore adjusted for in multivariable analyses. Approximately 10% (13/136) of post-pathway patients avoided hospital admission and were triaged towards ambulatory care. There was no significant difference in 30-day readmissions: 18/139 post-pathway vs 12/167 pre-pathway (OR 1.79, 95% CI 0.79 - 4.22, p = 0.17); or all-cause mortality: 2/167 pre-pathway vs 5/139 post-pathway (OR 2.96, 95% CI 0.49 - 25.68, p = 0.26). Conclusions: This novel chest pain pathway demonstrated a 10% reduction in hospital admissions without concurrent increases in 30-day readmissions or all-cause mortality. This is likely to reduce burdens on hospital resources and patient flow whilst maintaining safety.

Implementation of a Urinary Tract Infection Management Pathway to Evaluate Emergency Department Length of Stay in a Pediatric Emergency Department

Point-of-care urine testing is an alternative to urine microscopy in children. However, it remains unclear if utilizing point-of-care urine testing without urine microscopy decreases length of stay in the emergency department (ED). We implemented a point-of-care-driven urinary tract infection management pathway to evaluate effects on length of stay. This was an uncontrolled before and after study examining a point-of-care urinalysis pathway in a children's ED. We obtained preliminary data by prospectively evaluating urine microscopy. We then implemented a pathway in which point-of-care urine testing determined treatment and disposition. Outcomes included time from urinalysis order to discharge order, length of stay, and rate of delayed treatment. A total of 118 patients were enrolled before pathway initiation, and 97 patients were enrolled after. Demographics and infection rates were similar between the 2 groups. When urine microscopy was compared to point-of-care urine testing, there were significant reductions in time from urinalysis order to discharge order (median difference of 30 minutes; 95% confidence interval 19 to 42 minutes) and length of stay (median difference of 36 minutes; 95% confidence interval 19 to 55 minutes). There was no treatment delayed because of institution of the point-of-care pathway. Using point-of-care urine testing as an alternative to urine microscopy significantly reduced pediatric ED length of stay and time from urinalysis order to discharge order.

142 FRAILTY IDENTIFICATION AND INTERDISCIPLINARY ASSESSMENT OF OLDER PEOPLE IN THE EMERGENCY DEPARTMENT

Abstract Background Older People are attending Emergency Departments (EDs) in increasing numbers but the optimal assessment measures to use have yet to be established. This study examined the clinical utility of different assessments of strength, functional mobility, sarcopenia, cognition and frailty used by the physiotherapist in an interdisciplinary team (IDT) in the ED and determined any associations with clinical outcomes. Methods This observational cross-sectional study recruited adults ≥70 years who were assessed by an IDT on weekdays during working hours. Demographic variables such as age, gender, social situation, baseline mobility, falls and clinical measures such as Clinical Frailty Scale (CFS), 4AT, hand-held dynamometry, calf circumference and functional mobility in ED were recorded. Clinical outcomes were admission to hospital, discharge from ED with onward referral (ambulatory care or community) and discharge from ED with no referral. Ethical approval was obtained and SPSS was used for statistical analysis. Results Two hundred and fifty four participants were recruited, 58.3% female, mean age 80.23 (SD 6.56). Median CFS was 4 (IRQ 2.0), range 1–7 with 32.7% (n = 83) considered frail. Sarcopenia prevalence was 89.3% using grip strength and 7.1% using calf circumference. Grip strength predicted frailty even after adjusting for age (p &amp;lt; 0.0001), gender (p &amp;lt; 0.0001) and falls (p = 0.043). Admission to hospital was predicted by major diagnostic category (p = 0.016) and inability to sit to stand independently in ED (p &amp;lt; 0.0001). Seventy percent (n = 179) of participants were discharged from ED, with 27.6% referred to ambulatory care or community services. Onward referral was predicted by frailty (p = 0.016) and falls in the last six months (p = 0.028). Conclusion Grip strength in addition to a validated tool such as CFS may assist an experienced IDT in identifying frailty, which can in turn inform decision-making regarding ED disposition and pathways of care for older people. Functional assessment in the ED is also important to determine the need for hospital admission.

Preventing SARS-CoV-2 transmission in the emergency department by implementing a separate pathway for patients with respiratory conditions.

This study aimed to describe the development and implementation of a separated pathway to check and treat patients with a suspected/confirmed coronavirus disease 2019 (COVID-19) in the emergency department (ED) at King Abdullah bin Abdulaziz University Hospital in Riyadh. We conducted a retrospective, descriptive longitudinal study from March to July 2020by analyzing data of all confirmed cases of COVID-19 among ED visitors and healthcare workers in King Abdullah bin Abdulaziz University Hospital. During the study period, a total of 1,182 swab samples were collected for testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of which 285 (24.1%) tested positive. Of the 285 cases of confirmed SARS-CoV-2 infection, 18 were healthcare workers and 267 were patients. As a result of using the respiratory pathway for COVID-19 patients, the hospital managed to limit transmission of SARS-CoV-2 not only between patients but also between patients and healthcare workers, while also containing the pandemic. There were no cases of nosocomial SARS-CoV-2 infection recorded among the patients who visited the ED or the flu clinic. All confirmed cases were community acquired and patients were cared for under constrained measures. Implementing infection control measures and restricting those with respiratory symptoms to the ED pathway prevented nosocomial spread of SARS-CoV-2 infection in the ED.

Determinants of asthma-related emergency department return visits in adults: A population-based study

RATIONALE: Emergency department (ED) return-visit rates provide a measure of the quality of acute asthma care. OBJECTIVES: We sought to assess the impact of patient and site characteristics, including asthma management strategies, on return visits within 72 hours, prior to implementation of a standardized adult ED asthma care pathway in EDs throughout Ontario, Canada. METHODS: This population-based cohort study utilized comprehensive administrative health data from the Institute for Clinical Evaluative Sciences for adults 20 to 64 years old who had at least one ED visit for asthma from April 1, 2006 to March 31, 2008. Detailed information on ED management strategies was available on a subset of 37 sites whose staff attended pathway implementation workshops. MEASUREMENTS AND MAIN RESULTS: A total of 41,140 asthma visits to 167 EDs were analyzed. Most patients (64.8%) were triaged as high acuity and the majority (92.8%) were discharged. The return-visit rate was 2.8%. Female gender, younger age, higher acuity, leaving the ED before visit completion and prior admission or ED visit for asthma were associated with increased odds of a return visit. The only management strategy associated with reduced ED visits was access to 24-hour peak flow measurement. CONCLUSION: This study identified well-recognized patient- and hospital-level risk factors for return ED visits. Access to peak flow monitoring was the only protective management strategy found. As many ED asthma service and care gaps exist, province-wide implementation of a standardized care pathway may greatly impact ED management and improve patient outcomes including return ED visits.

Invasive Coronary Angiography after Chest Pain Presentations to Emergency Departments.

We investigated patients presenting to emergency departments (EDs) with chest pain to identify factors that influence the use of invasive coronary angiography (ICA). Using linked ED, hospitalisations, death and cardiac biomarker data, we identified people aged 20 years and over who presented with chest pain to tertiary public hospital EDs in Western Australia from 1 January 2016 to 31 March 2017 (ED chest pain cohort). We report patient characteristics, ED discharge diagnosis, pathways to ICA, ICA within 90 days, troponin test results, and gender differences. Associations were examined with the Pearson Chi-squared test and multivariate logistic regression. There were 16,974 people in the ED chest pain cohort, with a mean age of 55.6 years and 50.7% males, accounting for 20,131 ED presentations. Acute coronary syndrome was the ED discharge diagnosis in 10.4% of presentations. ED pathways were: discharged home (57.5%); hospitalisation (41.7%); interhospital transfer (0.4%); and died in ED (0.03%)/inpatients (0.3%). There were 1546 (9.1%) ICAs performed within 90 days of the first ED chest pain visit, of which 59 visits (3.8%) had no troponin tests and 565 visits (36.6%) had normal troponin. ICAs were performed in more men than women (12.3% vs. 6.1%, p < 0.0001; adjusted OR 1.89, 95% CI 1.65, 2.18), and mostly within 7 days. Equal numbers of males and females present with chest pain to tertiary hospital EDs, but men are twice as likely to get ICA. Over one-third of ICAs occur in those with normal troponin levels, indicating that further investigation is required to determine risk profile, outcomes and cost effectiveness.

Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception.

Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children's hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.

The Vital Role of a Full Continuum of Psychiatric Care Beyond Beds.

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

The cost-effectiveness of upfront point-of-care testing in the emergency department: a secondary analysis of a randomised, controlled trial

BackgroundTime-saving is constantly sought after in the Emergency Department (ED), and Point-of-Care (POC) testing has been shown to be an effective time-saving intervention. However, when direct costs are compared, these tests commonly appear to be cost-prohibitive. Economic viability may become apparent when the time-saving is translated into financial benefits from staffing, time- and cost-saving. The purpose of this study was to evaluate the cost-effectiveness of diagnostic investigations utilised prior to medical contact for ED patients with common medical complaints.MethodsThis was a secondary analysis of data from a prospective, randomised, controlled trial in order to assess the cost-effectiveness of upfront, POC testing. Eleven combinations of POC equivalents of commonly-used special investigations (blood tests (i-STAT and complete blood count (CBC)), electrocardiograms (ECGs) and x-rays (LODOX® (Low Dose X-ray)) were evaluated compared to the standard ED pathway with traditional diagnostic tests. The economic viability of each permutation was assessed using the Incremental Cost Effectiveness Ratio and Cost-Effectiveness Acceptability Curves. Expenses related to the POC test implementation were compared to the control group while taking staffing costs and time-saving into account.ResultsThere were 897 medical patients randomised to receive various combinations of POC tests. The most cost-effective combination was the i-STAT+CBC permutation which, based on the time saving, would ultimately save money if implemented. All LODOX®-containing permutations were costlier but still saved time. Non-LODOX® permutations were virtually 100% cost-effective if an additional cost of US$50 per patient was considered acceptable. Higher staffing costs would make using POC testing even more economical.ConclusionsIn certain combinations, upfront, POC testing is more cost-effective than standard diagnostic testing for common ED undifferentiated medical presentations – the most economical POC test combination being the i-STAT + CBC. Upfront POC testing in the ED has the potential to not only save time but also to save money.Trial registrationClinicalTrials.gov: NCT03102216.

Effectiveness of clinical pathway for upper respiratory tract infections in emergency department

ObjectiveWe aimed to demonstrate the benefits of implementing a clinical pathway to decrease the inappropriate use of antibiotics in upper respiratory tract infections (URTI) in an emergency department (ED). MethodsThe study was performed in a hospital with 300 beds. All patients who applied with URTI from 1st to 30th of April 2017 were included and the appropriateness of the antibiotics were compared with the patients in the same period in 2016. A checklist for the clinical pathway of URTI was completed by the ED physicians. Results351 patients were included, 176 these patients were in pre-ASP period and 175 patients were in post-ASP period. The rate of prescriptions including antibiotics was 49% in pre-ASP period and has decreased to 29% in post-ASP period (p < 0.001). Adherence to clinical pathway has increased from 50% to 80% (p < 0.001). In the post-ASP period, clinical pathway was used in 133 out of 175 patients (76%) and the consequently rate of appropriate antibiotic use was 82%. ConclusionThe implementation of clinical pathway for URTI has decreased inappropriate antibiotic use in ED. As the secondary effect, using clinical pathway in ED also has increased the awareness of ED physicians who did not adhere to clinical pathway.

Identifying and managing patients with acute coronary conditions

In 2004, the then National Institute for Clinical Excellence (NICE) published a technology-appraisal guideline on the treatment of patients with unstable angina (UA) or non-ST elevation myocardial infarction (NSTEMI). This article reports the results of a study in which triage and treatment for this patient group in one emergency department (ED) was assessed against this NICE guideline. The study found that patients were triaged by ED staff successfully but that there had been a lack of awareness of prognostic risk groupings and that compliance with guidelines on early antiplatelet therapy had not been ideal. The authors conclude, therefore, that the introduction of an ED pathway for patients with UA or NSTEMI would improve clinicians' compliance with the NICE guideline.