Emergency Department Performance Measures Research Articles

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study

BackgroundOlder adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients.MethodsA 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1–9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round.ResultsTwenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management.ConclusionResults provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Coping with stress in emergency department physicians through improved patient-flow management

This paper provides a method for the real-time monitoring of job stress in emergency department (ED) physicians. It is implemented in a Decision Support System (DSS) designed for patient-to-physician assignment after triage. Our concept of job stress includes not only the workload but also time pressure and uncertainty. A job stress function is estimated based on the consensus views of ED physicians obtained through a novel methodology involving stress factor analysis, questionnaire design, and the statistical analysis of expert opinions. The resulting stress score enables the assessment of job stress using workload data from the ED physicians’ whiteboard. These data can be used for the real-time measurement and monitoring of ED physician job stress in a stochastic and dynamic environment, which is the main novelty of this method as compared to previous workload and stress measurement proposals. A further advantage of this methodology is that it is general enough to be adapted to physician job stress monitoring in any ED. The use of the DSS for ED patient-flow management reduces job stress and spreads it more evenly among the whole team of physicians, while also improving other important ED performance measures such as arrival-to-provider time and the percentage of compliance with patient waiting time targets. A case study illustrates the application of the methodology for the construction of a stress-score, the monitoring of physician stress levels, and ED patient-flow management.

The relationships between quality management systems, safety culture and leadership and patient outcomes in Australian Emergency Departments.

We aimed to examine whether Emergency Department (ED) quality strategies, safety culture and leadership were associated with patient-level outcomes, after controlling for other organization-level factors, in 32 large Australian hospitals. Quantitative observational study, using linear and multi-level modelling to identify relationships between quality management systems at organization level; quality strategies at ED level for acute myocardial infarction (AMI), hip fracture and stroke; clinician safety culture and leadership and patient-level outcomes of waiting time and length of stay. Thirty-two large Australian public hospitals. Audit of quality management processes at organization and ED levels, senior quality manager at each of the 32 participating hospitals, 394 ED clinicians (doctors, nurses and allied health professionals). Within the multi-level model, associations were assessed between organization-level quality measures and ED quality strategies; organization-level quality measures and ED quality strategies and ward-level clinician measures of teamwork climate (TC), safety climate (SC) and leadership for AMI, hip fracture and stroke treatment conditions; and organization-level quality measures and ED quality strategies and ward-level clinician measures of TC, SC and leadership, and ED waiting time and length of stay (performance). We found seven statistically significant associations between organization-level quality systems and ED-level quality strategies; four statistically significant associations between quality systems and strategies and ED safety culture and leadership; and nine statistically significant associations between quality systems and strategies and ED safety culture and leadership, and ED waiting time and length of stay. Organization-level quality structures influence ED-level quality strategies, clinician safety culture and leadership and, ultimately, waiting time and length of stay for patients. By focusing only on time-based measures of ED performance we risk punishing EDs that perform well on patient safety measures. We need to better understand the trade-offs between implementing safety culture and quality strategies and improving patient flow in the ED, and to place more emphasis on other ED performance measures in addition to time.

Impact of Transcervical Ultrasound for the Diagnosis of Pediatric Peritonsillar Abscesses on Emergency Department Performance Measures.

To evaluate the impact of transcervical ultrasound (US) as the initial imaging study for suspected peritonsillar abscesses (PTAs) on pediatric emergency department (ED) throughput measures. A retrospective cohort study of patients evaluated for suspected PTAs between January 2009 and April 2017 was conducted. We compared the ED length of stay (LOS) before and after implementation of transcervical US to diagnose a PTA. The balancing measure was the rate of return visits within 2 weeks. There were 387 eligible patients over the study period. A total of 101 patients were evaluated for PTAs with computed tomography and 286 with US. The mean LOS was significantly less for patients who had US (347 minutes; 95% confidence interval [CI], 330, 364 minutes) compared to computed tomography (426 minutes; 95% CI, 392, 459 minutes), with an absolute difference of 79 minutes (95% CI, 44, 113 minutes). Patients who were evaluated with US did not have an increased rate of return visits (5.9% versus 8.0%; P = .66). The introduction of transcervical US was associated with a decrease of greater than 1 hour in the ED LOS for patients with suspected PTAs. Given the better radiation profile of US and no increase in the rate of return visits after its implementation, we propose the adoption of a transcervical US-first approach for the diagnosis of PTAs in pediatrics.

Patient classification based on volume and case-mix in the emergency department and their association with performance.

Predicting daily patient volume is necessary for emergency department (ED) strategic and operational decisions, such as resource planning and workforce scheduling. For these purposes, forecast accuracy requires understanding the heterogeneity among patients with respect to their characteristics and reasons for visits. To capture the heterogeneity among ED patients (case-mix), we present a patient coding and classification scheme (PCCS) based on patient demographics and diagnostic information. The proposed PCCS allows us to mathematically formalize the arrival patterns of the patient population as well as each class of patients. We can then examine the volume and case-mix of patients presenting to an ED and investigate their relationship to the ED's quality and time-based performance metrics. We use data from five hospitals in February, July and November for the years of 2007, 2012, and 2017 in the city of Calgary, Alberta, Canada. We find meaningful arrival time patterns of the patient population as well as classes of patients in EDs. The regression results suggest that patient volume is the main predictor of time-based ED performance measures. Case-mix is, however, the key predictor of quality of care in EDs. We conclude that considering both patient volume and the mix of patients are necessary for more accurate strategic and operational planning in EDs.

Development and validation of a data dictionary for a feasibility analysis of emergency department key performance indicators

ObjectivesThe primary study objective was to describe the development of a data dictionary for a feasibility analysis of 11 emergency department (ED) key performance indicators (KPIs). The secondary objective was to internally validate the data dictionary by measuring the inter-observer agreement between data abstractors at participating study sites. MethodsA list of data variables based on the minimum data set elements relevant to the KPIs was developed by a panel of emergency medicine (EM) specialists and from the EM literature. A summit involving the relevant stakeholders, including ED frontline staff, a health economist, an ED clinical data manager and a health care informatician, was convened. For the feasibility analysis project, each data abstractor was furnished with a copy of the data dictionary and attended a one-hour training session prior to commencing data abstraction. Data was independently abstracted for each KPI by two abstractors at each of 12 participating EDs. Inter-rater agreement between abstractors was calculated using Cohen’s kappa and results were reported using the Landis and Koch criteria. ResultsA data dictionary was developed by creating clear definitions and establishing abstraction instructions for each variable. A total of 43 data variables were included in the study data dictionary: 4 on patient demographics; 19 time variables; 5 outcome variables; 8 ED service and staffing units and 7 medical definitions. A clear definition and a set of data abstraction instructions including data sources were developed for each variable to aid data abstraction during the feasibility analysis. Overall 9,276 ED patient records were used for data abstraction to internally validate the data dictionary. The median Cohen kappa score ranged between 0.56 to 0.81. ConclusionThere is a continued need to standardize definitions of KPIs for the purpose of comparing ED performance and for research purposes. This is a necessary first step in the implementation of valid and reliable ED performance measures. This study successfully developed an internally valid data dictionary that can be used for day-to-day ED operations and for research purposes.

Emergency Department Length of Stay for Critical Care Admissions. A Population-based Study.

Hospital emergency department (ED) strain is common in North America. Excessive strain may result in prolonged ED length of stay and may lead to worse outcomes for patients admitted to intensive care units (ICUs). To describe patient, ED, and hospital characteristics associated with prolonged ED length of stay for adult patients admitted from EDs to ICUs. We conducted a population-based cohort study in the Province of Ontario, Canada, including patients admitted to an adult ICU from an ED and excluding only interhospital transfers and scheduled visits. Using regression modeling, we examined associations between patient- and hospital-level characteristics and two ED performance measures: length of stay in the ED of more than 6 hours and 90-day mortality. From April 2007 to March 2012, 261,274 adults presented to 118 EDs in Ontario, generating 314,836 ICU admissions. This activity represented 4.1% of all adult ED visits (incidence, 1,374 ICU admissions/100,000 ED visits). Median (interquartile range) ED length of stay was 7 (4-13) hours. Less than half (41.4%; 95% confidence interval [CI], 41.2-41.5) of these patients had an ED length of stay of 6 hours or less, whereas 10.5% (95% CI, 10.4-10.6) stayed 24 hours or longer. Hospital characteristics associated with ED length of stay more than 6 hours included shift-level ED crowding (mean length of stay of patients of similar acuity registering during same 8 h epoch) (odds ratio [OR], 1.19/h; 95% CI, 1.19-1.19), ED annual visit volume (OR, 1.01/1,000 patients; 95% CI, 1.01-1.01), time of ED presentation (00:00-07:59) (OR, 1.41; 95% CI, 1.38-1.45), and ICU functioning at greater than 20% above the average annual census (OR, 1.10; 95% CI, 1.08-1.12). ED length of stay more than 6 hours was not associated with 90-day mortality after adjustment for selected confounders (OR, 0.99; 95% CI, 0.97-1.02). In this population-based study, less than half of adult ED patients were admitted to an ICU 6 hours or less after arrival to an ED, an internationally recognized performance indicator for ED care quality. ED and ICU strain generated by time-varying demand on capacity was an important determinant of ED length of stay. However, prolonged length of stay in an ED did not measurably reduce 90-day mortality.

Emergency department performance measures updates: proceedings of the 2014 emergency department benchmarking alliance consensus summit.

The objective was to review and update key definitions and metrics for emergency department (ED) performance and operations. Forty-five emergency medicine leaders convened for the Third Performance Measures and Benchmarking Summit held in Las Vegas, February 21-22, 2014. Prior to arrival, attendees were assigned to workgroups to review, revise, and update the definitions and vocabulary being used to communicate about ED performance and operations. They were provided with the prior definitions of those consensus summits that were published in 2006 and 2010. Other published definitions from key stakeholders in emergency medicine and health care were also reviewed and circulated. At the summit, key terminology and metrics were discussed and debated. Workgroups communicated online, via teleconference, and finally in a face-to-face meeting to reach consensus regarding their recommendations. Recommendations were then posted and open to a 30-day comment period. Participants then reanalyzed the recommendations, and modifications were made based on consensus. A comprehensive dictionary of ED terminology related to ED performance and operation was developed. This article includes definitions of operating characteristics and internal and external factors relevant to the stratification and categorization of EDs. Time stamps, time intervals, and measures of utilization were defined. Definitions of processes and staffing measures are also presented. Definitions were harmonized with performance measures put forth by the Centers for Medicare and Medicaid Services (CMS) for consistency. Standardized definitions are necessary to improve the comparability of EDs nationally for operations research and practice. More importantly, clear precise definitions describing ED operations are needed for incentive-based pay-for-performance models like those developed by CMS. This document provides a common language for front-line practitioners, managers, health policymakers, and researchers.

Using lean-based systems engineering to increase capacity in the emergency department.

IntroductionWhile emergency department (ED) crowding has myriad causes and negative downstream effects, applying systems engineering science and targeting throughput remains a potential solution to increase functional capacity. However, the most effective techniques for broad application in the ED remain unclear. We examined the hypothesis that Lean-based reorganization of Fast Track process flow would improve length of stay (LOS), percent of patients discharged within one hour, and room use, without added expense.MethodsThis study was a prospective, controlled, before-and-after analysis of Fast Track process improvements in a Level 1 tertiary care academic medical center with >95,000 annual patient visits. We included all adult patients seen during the study periods of 6/2010–10/2010 and 6/2011–10/2011, and data were collected from an electronic tracking system. We used concurrent patients seen in another care area used as a control group. The intervention consisted of a simple reorganization of patient flow through existing rooms, based in systems engineering science and modeling, including queuing theory, demand-capacity matching, and Lean methodologies. No modifications to staffing or physical space were made. Primary outcomes included LOS of discharged patients, percent of patients discharged within one hour, and time in exam room. We compared LOS and exam room time using Wilcoxon rank sum tests, and chi-square tests for percent of patients discharged within one hour.ResultsFollowing the intervention, median LOS among discharged patients was reduced by 15 minutes (158 to 143 min, 95%CI 12 to 19 min, p<0.0001). The number of patients discharged in <1 hr increased by 2.8% (from 6.9% to 9.7%, 95%CI 2.1% to 3.5%, p<0.0001), and median exam room time decreased by 34 minutes (90 to 56 min, 95%CI 31 to 38 min, p<0.0001). In comparison, the control group had no change in LOS (265 to 267 min) or proportion of patients discharged in <1 hr (2.9% to 2.9%), and an increase in exam room time (28 to 36 min, p<0.0001).ConclusionIn this single center trial, a focused Lean-based reorganization of patient flow improved Fast Track ED performance measures and capacity, without added expense. Broad multi-centered application of systems engineering science might further improve ED throughput and capacity.

Development of balanced key performance indicators for emergency departments strategic dashboards following analytic hierarchical process.

Dynamic reporting tools, such as dashboards, should be developed to measure emergency department (ED) performance. However, choosing an effective balanced set of performance measures and key performance indicators (KPIs) is a main challenge to accomplish this. The aim of this study was to develop a balanced set of KPIs for use in ED strategic dashboards following an analytic hierarchical process. The study was carried out in 2 phases: constructing ED performance measures based on balanced scorecard perspectives and incorporating them into analytic hierarchical process framework to select the final KPIs. The respondents placed most importance on ED internal processes perspective especially on measures related to timeliness and accessibility of care in ED. Some measures from financial, customer, and learning and growth perspectives were also selected as other top KPIs. Measures of care effectiveness and care safety were placed as the next priorities too. The respondents placed least importance on disease-/condition-specific "time to" measures. The methodology can be presented as a reference model for development of KPIs in various performance related areas based on a consistent and fair approach. Dashboards that are designed based on such a balanced set of KPIs will help to establish comprehensive performance measurements and fair benchmarks and comparisons.

Real time shift reporting by emergency physicians predicts overall ED performance

ObjectiveTo investigate factors associated with emergency physician perception of the shift and to determine whether these perceptions were predictors of overall daily emergency department (ED) performance indicators.MethodsThis was an observational...

A literature review analysing endorsed performance and quality-in-care measures for emergency department assessment

Background Evaluation of the performance of an emergency department (ED) remains a difficult task due to the lack of consensus on performance measures that reflects both high quality and efficiency. Hence, this study describes, maps, and critically evaluates what performance measures that the published literature regards as being most relevant in assessing overall ED performance. Methods A systematic literature review in the databases of PubMed, Cochrane Library, and Web of Science of articles on suggested ED performance measures. Results A number of articles addressed this study’s objective (n =1 4 of 46 unique hits). Time intervals and patientrelated measures were dominant in the recommendations made in studies from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission are recommended by the majority of studies. Concurrently, ‘patients left without being seen’ (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents make out the most recommended performance measures related directly to the patient. Performance measures related directly to employees were only stated in two of the 14 included studies. Operational performance measures are deemed covered for by the two clusters 1) time intervals and 2) patient-related performance measures. Conclusion 54 performance measures have been extracted from 14 studies. ED time intervals are the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures are rarely mentioned in the investigated literature. Further work will include working towards consensus agreement on ED performance measures that preferably should include several aspects of performance. Moreover, investigation of the interconnectivity between the performance measures and how to measure if launched initiatives have the wanted effects.

The effect of a zero-diversion policy on emergency department performance measures

This study examines how emergency department (ED) performance measures at an academic tertiary care center in the Midwest were affected by a regionally-adopted zero diversion policy. Two six-month periods before and after the policy was enacted were selected to measure differences in key performance measures, including left without treatment (LWOT), left without being seen (LWBS), left against medical advice (AMA), mortality, length of stay and hospital admission rate. Total ED census during the two periods was similar. While the zero diversion policy was in effect, LWOT and LWBS rates were 19.4% and 18.2% lower, respectively, than the prior period, p &lt; .002; discharged patients had faster treatment times (228 + 8.0 minutes vs. 242 + 9.0 minutes), p = .015. No differences were observed in AMA or mortality rates. This study revealed no worsening of ED performance measures after adoption of a zero diversion policy.

Evaluation of emergency department performance – a systematic review on recommended performance and quality-in-care measures

BackgroundEvaluation of emergency department (ED) performance remains a difficult task due to the lack of consensus on performance measures that reflects high quality, efficiency, and sustainability.AimTo describe, map, and critically evaluate which performance measures that the published literature regard as being most relevant in assessing overall ED performance.MethodsFollowing the PRISMA guidelines, a systematic literature review of review articles reporting accentuated ED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science. Study eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures best reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level performance measures, thus reflecting an overall departmental performance level.ResultsA number of articles addresses this study’s objective (n = 14 of 46 unique hits). Time intervals and patient-related measures were dominant in the identified performance measures in review articles from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission were highlighted by the majority of articles. Concurrently, “patients left without being seen” (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents were the most highlighted performance measures that related directly to the patient. Performance measures related to employees were only stated in two of the 14 included articles.ConclusionsA total of 55 ED performance measures were identified. ED time intervals were the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures were rarely mentioned in the investigated literature. The study’s results allow for advancement towards improved performance measurement and standardised assessment across EDs.

Abstract WP237: Improved Thrombolysis Rates and Quality of Care for Stroke Patients Through a Provincial Emergency Department Quality Improvement Initiative

Background: The care of stroke patients in the emergency department (ED) is time sensitive and complex. We sought to improve quality of care for stroke patients in British Columbia (B.C.), Canada, emergency departments. Objectives: To measure the outcomes of a large-scale quality improvement initiative on thrombolysis rates and other ED performance measures. Methods: This was an evaluation of a large-scale stroke quality improvement initiative, within ED’s in B.C., Canada, in a before-after design. Baseline data was derived from a medical records review study performed between December 1, 2005 to January 31, 2007. Adherence to best practice was determined by measuring selected performance indicators. The quality improvement initiative was a collaboration between multidisciplinary clinical leaders within ED’s throughout B.C. in 2007, with a focus on implementing clinical practice guidelines and pre-printed order sets. The post data was derived through an identical methodology as baseline, from March to December 2008. The primary outcome was the thrombolysis rate; secondary outcomes consisted of other ED stroke performance measures. Results: 48 / 81 (59%) eligible hospitals in B.C. were selected for audit in the baseline data; 1258 TIA and stroke charts were audited. For the post data, 46 / 81 (57%) acute care hospitals were selected: 1199 charts were audited. The primary outcome of the thrombolysis rate was 3.9% (23 / 564) before and 9.3% (63 / 676) after, an absolute difference of 5.4% (95% CI: 2.3% - 7.6%; p=0.0005). Other measures showed changes: administration of aspirin to stroke patients in the ED improved from 23.7% (127 / 535) to 77.1% (553 / 717), difference = 53.4% (95% CI: 48.3% - 58.1%; p=0.0005); and, door to imaging time improved from 2.25 hours (IQR = 3.81 hours) to 1.57 hours (IQR 3.0), difference = 0.68 hours (p=0.03). Differences were found in improvements between large and small institutions, and between health regions. Conclusions: Implementation of a provincial emergency department quality improvement initiative showed significant improvement in thrombolysis rates and adherence to other best practices for stroke patients. The specific factors that influenced improvement need to be further explored.

Evaluating Emergency Department Resource Capacity Using Simulation

Emergency departments open 24 hours every day and may receive patients at any time most unexpectedly. Adequate resource planning to meet the various demands in emergency departments is arguably amongst the most critical challenges faced by hospital administrators due to the complexity of the system and diverse patient flows. In this paper, we present a computer simulation model to evaluate resource utilization among personnel and physical resources in a typical emergency department (ED) of a government hospital in Malaysia. The model allows administrators to see patient movement flows as well as how these flows are affected by resource capacity level in the ED. The use of this simulation model helps to evaluate ED operations, provides useful insight for possible areas of improvement, and directs the allocation of specific resources for maximal impact. Three scenarios were tested to find out the impact of patient surge on ED performance measures. Results from the scenarios show that a 30% increase of attendances according to triage zones affects most of the performance measures. In addition, medical assistants are the critical resources with average utilization greater than 70%.

A simulation analysis of the impact of FAHP–MAUT triage algorithm on the Emergency Department performance measures

Emergency Department (ED) crowding is a major problem in the U.S. like in many other countries world-wide. This problem is adversely affecting the safety of the patients who rely on receiving a timely treatment in EDs. As a part of solving this problem, a triage process is utilized. Triage is a pre-hospital process by which patients are sorted according to the severity of their illnesses or injuries. Improvements to this process would affect the patient flow positively, and in turn would enhance patient satisfaction and quality of care. In a previous study, we developed a triage algorithm that uses Fuzzy Analytic Hierarchy Process (FAHP) and Multi-Attribute Utility Theory (MAUT) to rank the patients according to their characteristics: chief complaint, age, gender, pain level, and vital signs. The main purpose of this study is to compare two triage systems using Discrete Event Simulation (DES); one system uses the typical Emergency Severity Index (ESI), and the other uses the FAHP and MAUT algorithm. Overall, there was no strong statistical evidence that either system would do better than the other for all the performance measures when the average is taken across all ESI levels. On the other hand, the collected simulated data by each ESI level showed that the FAHP–MAUT algorithm tends to balance the time-to-bed (TTB) and length of stay (LOS) for ESI levels 2–5. In terms of the percentage of tardy patients, FAHP–MAUT system significantly outperforms the ESI system for ESI levels 4 and 5; 34% vs. 61% and 25% vs. 70%, respectively. Both systems were performing about equally for ESI level 1 and level 3 patients; 25% vs. 26% and 64% vs. 67%, respectively. While ESI system slightly outperforms FAHP–MAUT system for ESI level 2 patients, 56% vs. 66%. Based on these results, we recommend using FAHP–MAUT not only because it performs better in terms of minimizing the number of patients with longer than the allotted upper limits of wait times, but also it reduces potential bias and errors in decision making in clinical settings; and thus, it can be used as the basis of an expert system to advise triage nurses.

Exogenous Predictors of National Performance Measures for Emergency Department Crowding

We explore the relationship between exogenous-level predictors and performance on 4 emergency department (ED) throughput measures approved by the National Quality Forum: median ED length of visit for admitted and discharged patients, median waiting time, and rate of left without being seen. We seek to find predictors for benchmarking and public reporting. This was a study of 424 US hospitals that reported data to the National Hospital Ambulatory Care Survey in 2008 to 2009. Wald F tests and generalized linear models were used to test the relationship between exogenous variables (case mix, age mix, ED volume, teaching status, and Metropolitan Statistical Area status) and performance on the measures. Median waiting time was 35 minutes (95% confidence interval [CI] 26 to 43 minutes), median length of visit for patients treated but not admitted was 131 minutes (95% CI 121 to 142 minutes), median length of visit for patients admitted was 244 minutes (95% CI 218 to 270 minutes), and rate of left without being seen was 1.3% (95% CI 0.9% to 1.8%). Most exogenous variables, including ED volume, Metropolitan Statistical Area, teaching hospital status, age mix, and case mix, demonstrated significant association with waiting times and lengths of visit. Older age and a higher proportion of respiratory complaints were associated with differences in rates of left without being seen. Several exogenous factors outside of a hospital's control are associated with National Quality Forum-approved ED performance measures, which will have important implications for future benchmarking and public reporting of these data.

Supplemented Triage and Rapid Treatment (START) Improves Performance Measures in the Emergency Department

Background: Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care. Study Objectives: This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients. Methods: This retrospective before–after study compared performance measures over two 3-month periods (September–November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA). Results: In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001). Conclusions: In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.

In reply

Academic Emergency MedicineVolume 14, Issue 4 p. 383-384 Free Access In reply First published: 28 June 2008 https://doi.org/10.1197/j.aem.2006.11.019AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References Asplin BR. Measuring crowding: time for a paradigm shift Acad Emerg Med 2006; 13: 459– 461. Asplin BR, Flottemesch TJ, Gordon BD. Developing models for patient flow and daily surge capacity research Acad Emerg Med 2006; 13: 1109– 1113. Welch SJ, Augustine J, Camargo CA Reese C. Emergency department performance measures and benchmarking summit Acad Emerg Med 2006; 13: 1074– 1080. Volume14, Issue4April 2007Pages 383-384 ReferencesRelatedInformation