Emergency Department Resources Research Articles

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer.

Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care. We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer. We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N=1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality. Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values<0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality. ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

P071: A three-year analysis of adult protection patients in the emergency department

Introduction: While boarding of patients in the emergency department (ED) has been well documented and is carefully monitored, the time spent in emergency beds by patients waiting for Adult Protection (AP) placement is often relatively unnoticed, as they are not flagged as ‘admitted’. These patients have no emergency needs, yet consume considerable ED resources, often in excess of patients requiring emergency care. Staff familiarity with this issue may also bias them to premature diagnostic closure of patients as ‘placement problems’, risking misdiagnosis of active medical conditions. An observational study to retrospectively quantify the time spent in the ED by patients referred to AP services for urgent placement from the ED. Methods: A three-year audit of ED social work records of patients referred for AP. Results: For the period of October 1 2015-September 30, 2018, the ED social work service kept records of patients referred for AP from the ED. During this period, a total of 142 patients were referred to AP (40, 50, and 52 in each year respectively). There was an increase of 10 patients between 2015/16 and 2016/17 and two patients from 2016/17 to 2017/18. The overall length of stay for this subset of ED patients during this three-year period was alarmingly high, with an average length of stay of four days per patient (range 2.7 hours-18.5 days) compared to an average of all patients of 4.9 hours and admitted patients of 13.6 hours. Conclusion: Patients in the ED who are referred to AP services consume considerable ED resources, often requiring complete medical work-up, capacity assessments and close monitoring by multiple emergency personnel. This has been reported to cause considerable stress and friction between staff and consulting services. Furthermore, these patients are poorly served in a hectic, brightly lit, and noisy environment. The impact is often not fully appreciated due to ineffective capture by patient tracking systems.

P108: Characterizing use of next-day ultrasound from the emergency department

Introduction: Formal ultrasound imaging, with use of ultrasound technicians and radiologists, provides a valuable diagnostic component to patient care in the Emergency Department (ED). Outside of regular weekday hours, ordering formal ultrasounds can produce logistical difficulties. EDs have developed protocols for next-day ultrasounds, where the patient returns the following day for imaging and reassessment by an ED physician. This creates additional stress on ED resources – personnel, bed space, finances – that are already strained. There is a dearth of literature regarding the use of next-day ultrasounds or guidelines to direct efficient use. This study sought to accumulate data on the use of ED next-day ultrasounds and patient oriented clinical outcomes. Methods: This study was a retrospective chart review of 150 patients, 75 from each of two different tertiary care hospitals in Saskatoon, Saskatchewan. After a predetermined start date, convenience samples were collected of all patients who had undergone a next-day ultrasound ordered from the ED until the quota was satisfied. Patients were identified by an electronic medical record search for specific triage note phrases indicating use of next-day ultrasounds. Different demographic, clinical, and administrative parameters were collected and analyzed. Results: Of the 150 patients, the mean age was 35.9 years and 75.3% were female. Median length of stay for the first visit was 4.1 hours, and 2.2 hours for the return visit. Most common ultrasound scans performed were abdomen and pelvis/gyne (34.7%), complete abdomen (30.0%), duplex extremity venous (10.0%). Most common indications on the ultrasound requisition were nonspecific abdominal pain (18.7%), vaginal bleeding with or without pregnancy (17.3%), and hepatobiliary pathology (15.3%). Ultrasounds results reported a relevant finding 56% of the time, and 34% were completely normal. After the next-day ultrasound 5.3% of patients had a CT scan, 10.7% had specialist consultation, 8.2% were admitted, and 7.3% underwent surgery. Conclusion: Information was gathered to close gaps in knowledge about the use of next-day ultrasounds from the ED. A large proportion of patients are discharged home without further interventions. Additional research and the development of next-day ultrasound guidelines or outpatient pathways may improve patient care and ED resource utilization.

P045: Palliative care nurse specialist in the emergency department: a pilot project

Background: Patients presenting to the Emergency Department (ED) with unmet palliative care needs are often admitted to hospital and this can be a pivotal point in their subsequent health care journey. Literature from the United States supports the integration of palliative care resources in the ED and to our knowledge, this has yet to be done in a Canadian setting. Aim Statement: To develop, implement, and evaluate a model to support patients presenting to the ED with unmet palliative care needs. Measures &amp;amp; Design: A pilot project was implemented in one campus of the ED at a tertiary care academic center in Ottawa, Ontario. A palliative care nurse specialist was available for consultation with goals to: a) reduce admission to hospital for patients choosing to have a palliative approach to their care; b) increase coordination between ED and community resources; and c) be a resource for ED staff. Referral criteria were developed after systematic review of the literature and in consultation with palliative and emergency medicine experts. Evaluation/Results: Over the course of the study period (9 months), 50 referrals were made. The primary reason for referral was for increased community supports. Patient outcomes: 10 patients were discharged to hospice/palliative care units from the ED, 38 patients were discharged home. Of those discharged home, 66% had no returns to ED within 30 days. Qualitative feedback collected via pre and post survey has been extremely supportive from ED health care practitioners and community palliative care providers. Discussion/Impact: This ongoing project has led to positive, patient centered outcomes and decreased admission to acute care hospital. Ongoing evaluation will include consideration of Ontario Palliative Care Network quality indicators and cost-analysis to determine impact on health care system.

MP32: Mid-morning huddle: a coordinated team approach to facilitating disposition of older adults

Background: Older adults in the emergency department (ED) take an increasingly larger portion of resources, have increased length of stay and a higher likelihood of adverse outcomes. In many cases bad planning, multiple vague handovers, and lack of coordinated care exacerbate this problem. With the impending onset of our aging population this is a situation that can be expected to compound in complexity in the years to come. Aim Statement: We describe daily interdisciplinary review of ED patients over the age of 75 years (or otherwise identified as a challenging discharge) to discuss barriers and facilitators to discharge/disposition. We will use data to identify the impact of this particular population to ED flow. Measures &amp;amp; Design: This initiative developed from our participation in the Acute Care of the Elderly (ACE) Collaborative and applies Plan/Do/Study/Act (PDSA) cycles and run reports to compare: length of stay; Identification of Seniors at Risk (ISAR) screening tool; ED census, admission/discharge rates, bounce back rates, consulting services, and interdisciplinary participation. Evaluation/Results: The average daily census of our ED between the months of July-October of 2018 was over 211 patients/day, of which over 12% were patients 75 years and older. We conducted over 70 huddles, reviewing an average of 11 patients per day. The average length of stay for patients at the time of the huddle was 19 hours, significantly higher than the general emergency population. Next day admission and discharge rates were comparable, 44.8% and 43.1% respectively with the additional patients remaining in the ED with no disposition. Internal medicine was consulted on 30% of all huddle patients and 38.4% subsequently admitted. Thirty day bounce back rates for huddle patients discharged home was 29.3%. Around 60% of patients 75 and older were screened with the ISAR and 55.7% of these were positive (2 or more questions). Discussion/Impact: Older patients consume a disproportionate amount of ED resources. Daily interdisciplinary ‘geriatric huddles’ improved communication between members of the ED team and with consulting services. The huddles enhanced awareness of the unique demands that older adults place on the flow of the ED, and identified opportunities to enhance patient flow.

P120: Characteristics and outcomes of patients with neurologic complaints who have an unscheduled return visit to the emergency department within 72 hours

Introduction: Patients with neurologic presenting complaints comprised 12.5% of total University of Alberta Emergency Department (ED) visits in 2017. This group of patients has high rates of EMS utilization, admission, and ED resources including diagnostic imaging and consult services. We sought to analyze the characteristics and outcomes of the patients with neurologic complaints who have an unscheduled return visit (URV) to the ED within 72 hours to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care System databases to select adult patients presenting to the University of Alberta hospital in 2017 with neurologic complaints as defined by the Canadian Triage and Acuity Scale (CTAS). We additionally selected for return visits to Edmonton Zone EDs within 72 hours. Using standard descriptive statistics, we examined demographic and clinical characteristics of patients with 72-hour URV. Results: Of 8,770 total visits, 674 (7.69%) had a 72-hour URV to an Edmonton zone ED. The URV rate was 9.0% in patients seen by a physician and discharged with approval and 23.4-33.3% in patients who left against medical advice (LAMA), prior to completion of treatment (LPCT), or without being seen by a physician (LWBS). The mean age of URV patients was 45.6 years, 56.5% were male, with a mean ED length of stay of 7.37 hours. The top 5 diagnoses for URV patients were headache, migraine, alcohol related disorders, concussion, and transient ischemic attack. 14.7% of URV patients were admitted, 13.5% LWBS, 1.6% LAMA, 1.6% LPCT, and 66.1% were discharged. Conclusion: The majority of neurologic complaint patients with URV within 72 hours are those who LAMA, LPTC, or LWBS at index visit. The admission rate for URV patients (14.7%) is lower than for the index ED visit (55%), however these patients have high LWBS rates. Identifying strategies to limit the LWBS rate for these patients would reduce return visits and improve the quality and safety of patient care.

Behavioral Health Resource Utilization of Emergency Department Patients Presenting from Mass Gathering Events

Introduction:Behavioral health needs of attendees at mass gathering events who require emergency department (ED) evaluation are poorly understood. Appropriate resource allocation of mental health staff and other behavioral interventions necessary to support this patient population are also unclear.Aim:To describe behavioral characteristics and psychiatric resource utilization of patients presenting to a tertiary academic medical center emergency department from mass gathering events.Methods:Single-center retrospective study evaluating attendees at mass gathering events who presented to a Chicago ED. Electronic medical records for patients presenting between October 13, 2013, and December 31, 2015, were reviewed and descriptive analyses performed.Results:209 distinct records were reviewed. Most patients presented from large outdoor concerts (n = 186, 89%). Forty-two (20.1%) reported a mental health complaint at presentation, including concerns related to pre-existing psychiatric disturbances or onset of new symptoms. Twenty-seven of the total cohort (12.9%) endorsed a prior psychiatric history. Thirty-five (16.7%) reported use of prescribed psychotropic medications, including antidepressants, stimulants, mood stabilizers, and others. Diagnostic testing among the total sample included serum ethanol measurement (31.1%), urinary toxicology (25.4%), acetaminophen (6.2%), aspirin (5.3%), and creatine kinase measurements (11%). Computed brain tomography was ordered for 20 patients (9.6%). Twelve patients (5.7%) received an anxiolytic (lorazepam) and 113 (54.1%) received intravenous fluids. An antipsychotic (olanzapine) was administered to one patient (0.5%). There were no reports of suicidal ideation, but physical restraints for agitation were employed in 13 patients (6.2%). Police consultation occurred in 10 cases (4.8%). No formal psychiatric consultations were requested by ED providers.Discussion:Patients presenting to the emergency department from mass gathering events frequently endorse behavioral complaints requiring directed use of diagnostic and other emergency department resources for their ailments. The need for physical restraints and limited use of anxiolytics and antipsychotics in our sample suggest that psychiatric consultation is underutilized.

83. Emergency Department Utilization of Imaging Studies for Adolescents with Pelvic and Abdominal Pain Has Increased Over Time: Study from the United States National Emergency Department Sample

Pelvic and abdominal pain are common complaints among female adolescents, often bringing them to the emergency department (ED). However, little data exist regarding the utilization of ED resources for this complaint.

Epidemiology of opioid-related visits to US Emergency Departments, 1999–2013: A retrospective study from the NHAMCS (National Hospital Ambulatory Medical Care Survey)

GoalsTo characterize the epidemiology of opioid-related visits to United States (US) emergency departments (EDs) and describe trends in opioid-related visits over time. DesignRetrospective cohort study CasesThe National Hospital Ambulatory Care Survey (NHAMCS) was used to identify opioid-related ED visits between 1999 and 2013. MeasurementsThe NHAMCS is an annual, weighted, multi-stage survey which allows for the study of ambulatory care services within a nationally representative sample of US hospitals. We used ICD-9 codes to identify ED visits related to opioid use and abuse. We applied visit weights calculated by NHAMCS to generate nation-wide estimates regarding the overall prevalence of opioid-related visits, and demographic characteristics of these patients. We report trends with respect to opioid-related visits and ED resource utilization between 1999 and 2013. Results1072 visits were included, representing 2,731,000 nation-wide opioid-related ED encounters between 1999 and 2013. During this time, opioid-related ED visits increased from 125,000 in 1999 to over 300,000 visits in 2013. Between 1999–2001 and 2011–2013 opioid-related visits increased by 170%. Greater numbers of such visits occurred across nearly all demographic groups, and all regions of the US. Weighted visits among women increased by 250% between these time periods. Over these periods, opioid-related ED visits resulting in hospital admission increased by over 240%. The proportion of ED visits that were related to opioids doubled from 1999 (0.12%) to 2013 (0.25%). ConclusionsOpioid-related ED encounters and resource utilization both rose substantially between 1999 and 2013, with consistent increases across a broad spectrum of demographic groups.

Using Lean to Improve Patient Safety and Resource Utilization After Pediatric Adenotonsillectomy.

The objective of this quality improvement project was to decrease the rate of nonemergent use of emergency department (ED) resources in children undergoing adenotonsillectomy by 50% and/or reach a future state of 5% or less overall ED visits among all postoperative patients within 1 year. A secondary objective was to standardize the preoperative, intraoperative, and postoperative management of these patients. The study was a quality improvement project using Lean. The target population was children younger than 18 years undergoing tonsillectomy with or without adenoidectomy. A retrospective review of adenotonsillectomy was performed for a 12-month period. Lean tools including A3 Thinking, Ishikawa "fishbone" diagram, and value stream mapping were used to analyze the problem and identify interventions. Postintervention data were collected for a 10-month period. Compared with the baseline period, the ED visit rate after adenotonsillectomy decreased from 36.2% to 15.5% (P = 0.0095). The rate of ED visits for nonbleeding complaints decreased from 30.4% to 12.1% (P = 0.01748). There was no significant change in rate of ED visits for bleeding (decreased from 5.8% to 3.5% [P = 0.6873]). There was no significant change in the use of intraoperative dexamethasone and acetaminophen. Postadenotonsillectomy patients often use emergency resources better reserved for other patients. Addressing this problem with Lean principles significantly decreased postoperative ED visit rates by more than 50%. To our knowledge, this is the first reported use of Lean principles to decrease utilization of emergency resources in the postoperative period. Lean can be applied to other processes in our field to eliminate waste and add value to improve patient outcomes. NA.

Impact of age on the discriminative ability of an emergency triage system: A cohort study.

Emergency triage systems optimize resources in emergency departments (EDs) for those who need urgent care. Five-level triage systems, such as the Canadian Triage and Acuity Scale (CTAS), have been used worldwide. We examined whether the discriminative ability of an emergency triage system varies according to age group using a patient cohort triaged with the Japan Triage and Acuity Scale (JTAS), a validated system based on the CTAS. We conducted a cohort study of 27120 self-presenting patients aged 16years and older who were triaged with (JTAS) between June 2013 and May 2014 at a Japanese tertiary care hospital. Outcome measures were admission to intensive care units (ICUs) as the primary and in-hospital death as the secondary. We described the trends of the discriminative ability of JTAS using areas under the curve of the receiver operating characteristic (AUROC), sensitivity, specificity, positive predictive value, and negative predictive value of JTAS for seven age categories. The AUROC of JTAS for ICU admission decreased with age (maximum 0.85 to minimum 0.71), sensitivity non-significantly decreased (maximum 0.67 to minimum 0.32), and specificity declined with age (maximum 0.96 to minimum 0.88). The positive and negative predictive value increased (minimum 0.03 to maximum 0.09) and decreased (minimum 0.98 to maximum 0.99), respectively, with age. Overall misclassification increased across age groups (P<0.001). This trend was mostly consistent with the analysis of in-hospital death. Our study suggests that the discriminative ability of an emergency triage system decreases as patient age increases, corresponding to a decrease in specificity. Undertriage may not significantly increase, but misclassification significantly increases as patient age increases.

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

BackgroundPaediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes.MethodsWe studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children’s Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing.ResultsInfants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39–£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0–5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5–13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate ‘red flag’, treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations.ConclusionThe economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.

Emergency department visits in older patients: a population-based survey

BackgroundGiven the higher incidence of emergency conditions in older inhabitants, the global increase in aged population will pose a challenge for emergency services. In this study we examined the burden caused to emergency health care by the aged population.MethodsConsecutive patients aged 80 years or over visiting a high-volume, collaborative emergency department (ED) between 2015 and 2016 were included. The key factors under analysis were the incidence of emergency conditions and costs associated with emergency care.ResultsA total of 6944 patients (median age 85 years, range 80–104 years; 67% female) aged ≥80 years representing 1.5% of the local population, made 17,769 ED visits during the two-year observation period accounting for 15% of all ED visits. Forty-two percent (n = 2884) of patients had a single ED visit, whereas 8.2% (n = 570) made ≥5 ED visits/year for a total of 1400 visits (7.9%). Thirty-two percent of those aged ≥80 years required ED services each year. The number of ED visits increased with age (p < 0.001); and was 768/1000 person-years among octogenarians and 1007/1000 among nonagenarians, in comparison to 233/1000 among those aged < 80 years. One in five of the study population were discharged with non-specific diagnoses. Typical diagnoses included pneumonia (4.8%), malaise and fatigue (4.5%) and heart failure (4.3%). Non-specific diagnoses were frequent, and examination of patients with non-specific diagnoses incurred costs similar to or higher than those of other patients. The mean cost per ED visit in older patients was 422 €.ConclusionsWe demonstrated a high incidence of emergency department visits in older patients. While our aim was not to solve how the growing demand should be met, it seems unlikely that increasing ED resources is feasible. Instead, the focus should be on chronic care of the aged and prevention of potentially avoidable ED visits.

Can the emergency department sustain the first strike? Experience from the 2016 earthquake in Tainan

Background: After the main shock of a major earthquake, casualties cluster in a short period and may overwhelm the capacities of health care facilities. An earthquake with a magnitude of 6.4 on the Richter scale struck Tainan City causing 117 fatalities and 513 injuries. Objectives: We conducted a retrospective study to review the medical records of emergency department after the attack of earthquake. The aim of this study was delineating the medical resource requirements after the disaster. Methods: We reviewed the medical records of patients admitted to the emergency department of Chi Mei Medical Center. Each chart indicating that the emergency department visit was earthquake-related was reviewed. After the earthquake struck, the Chi Mei Medical Center mobilized off-duty staff through a preset 333 code. Subsequently, routine surgeries and nonurgent admissions were postponed to reserve the maximal capacity for wounded patients. Results: A total of 150 patients were reviewed during the study period. In all, 25 cases (23.8%) required admission, and 9 of them (8.6%) were admitted to the intensive care unit. Patients with earthquake-related injuries constituted 62.8% of all traumatic patients in the 24-h aftermath. The requirements for wound sutures, blood component transfusion, numbers of radiographic/computed tomographic scans, and invasive procedures increased dramatically (earthquake-related/total: 66.0%, 30.0%, 72.1%/57.4%, and 47.7%, respectively). Conclusion: Patients with earthquake-related injuries arrived at the emergency department soon after the earthquake occurred and substantial emergency department resources were utilized in the 24-h aftermath. Each hospital should have a preset mobilization signal to call in off-duty workers to treat casualties resulting from the main shock of an earthquake. Subsequently, hospital-based mobilization should be initiated to provide comprehensive care to severely injured patients.

Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study

BackgroundStudies on the reliability of the MTS and its predictive power for hospitalisation and mortality in the older population have demonstrated mixed results. The objective is to evaluate the performance of the Manchester Triage System (MTS) in older patients (≥65 years) by assessing the predictive ability of the MTS for emergency department resource utilisation, emergency department length of stay (ED-LOS), hospitalisation, and in-hospital mortality rate. The secondary goal was to evaluate the performance of the MTS in older surgical versus medical patients.MethodsA retrospective cohort study was conducted of all emergency department visits by patients ≥65 years between 01 and 09-2011 and 31-08-2012. Performance of the MTS was assessed by comparing the association of the MTS with emergency department resource utilisation, ED-LOS, hospital admission, and in-hospital mortality in older patients and the reference group (18–64 years), and by estimating the area under the receiver operating characteristics curves.ResultsData on 7108 emergency department visits by older patients and 13,767 emergency department visits by patients aged 18–64 years were included. In both patient groups, a higher emergency department resource utilisation was associated with a higher MTS urgency. The AUC for the MTS and hospitalisation was 0.74 (95%CI 0.73–0.75) in older patients and 0.76 (95%CI 0.76–0.77) in patients aged 18–64 years. Comparison of the predictive ability of the MTS for in-hospital mortality in older patients with patients aged 18–64 years revealed an AUC of 0.71 (95%CI 0.68–0.74) versus 0.79 (95%CI 0.72–0.85). The majority of older patients (54.8%) were evaluated by a medical specialty and 45.2% by a surgical specialty. The predictive ability of the MTS for hospitalisation and in-hospital mortality was higher in older surgical patients than in medical patients (AUC 0.74, 95%CI 0.72–0.76 and 0.74, 95%CI 0.68–0.81 versus 0.69, 95%CI 0.67–0.71 and 0.66, 95%CI 0.62–0.69).ConclusionThe performance of the MTS appeared inferior in older patients than younger patients, illustrated by a worse predictive ability of the MTS for in-hospital mortality in older patients. The MTS demonstrated a better performance in older surgical patients than older medical patients regarding hospitalisation and in-hospital mortality.

Development of Relationship between Triaging of Patients and Emergency Department Performance

Triage is a very important step in today's Emergency Departments (EDs). While triage mainly focuses on prioritizing patients based on their medical conditions, this is also an effective management tool to organize, monitor and evaluate the ED patients and resources. As the waiting time of a patient is highly influenced by the triage category, there is a possibility that the length of stay in ED (EDLOS) and overall performance of ED have a relationship with this classification. The main aim of this study is to investigate how the actual ED performance is affected by the number of ED presentations in different triage categories. A comprehensive case study has been conducted and ED patient data of two hospitals in Brisbane have been collected. Based on a statistical analysis of the collected data, a relationship has been identified between the arrival of patients in each category and ED performance. Descriptive statistics have been used to analyze the patients' data for each category. This result will help in managing the necessary resources to avoid the long waiting times as well as a drop in the performance level. Eventually, the outcome will facilitate the ED practitioners to maintain the quality of care in the health sector and also the patients' satisfaction.

Access to Palliative Care for Cancer Patients Living in a Northern and Rural Environment in Ontario, Canada: The Effects of Geographic Region and Rurality on End-of-Life Care in a Population-Based Decedent Cancer Cohort.

Background:Access to palliative care has been associated with improving quality of life and reducing the use of potentially aggressive end-of-life care. However, many challenges and barriers exist in providing palliative care to residents in northern and rural settings in Ontario, Canada.Aim:The purpose of this study was to examine access to palliative care and associations with the use of end-of-life care in a decedent cohort of northern and southern, rural and urban, residents.Design:Using linked administrative databases, residents were classified into geographic and rural categories. Regression methods were used to define use and associations of palliative and end-of-life care and death in acute care hospital.Setting/Participants:A decedent cancer cohort of Ontario residents (2007-2012).Results:Northern rural residents were less likely to receive palliative care (adjusted odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.83-0.97). Those not receiving palliative care were more likely to receive potentially aggressive end-of-life care and die in an acute care hospital (adjusted OR = 1.20, 95% CI: 1.02-1.41).Conclusions:Palliative care was significantly associated with reduced use of aggressive end-of-life care; however, disparities exist in rural locations, especially those in the north. Higher usage of emergency department (ED) and hospital resources at end of life in rural locations also reflects differing roles of rural community hospitals compared with urban hospitals. Improving access to palliative care in rural and northern locations is an important care issue and may reduce use of potentially aggressive end-of-life care.

Corneal and conjunctival injury seen in urgent care centres in Israel.

PurposeCorneal and conjunctival injuries (CCI) comprise a large portion of the cases presenting to hospital‐based emergency departments (ED) with ocular involvement. Urgent Care Centres (UCC) offer community based emergency care at lower cost than hospital‐based emergency departments (ED) and with greater temporal convenience than primary care office settings. While CCI prevalence and treatment at hospital‐based EDs has been well studied, this is the first report, to our knowledge, on CCI demographics and aetiology presenting to UCCs.MethodsThis retrospective study was approved by the institutional ethics committee. The setting is a UCC system in Israel, modelled on USA urgent care facilities, consisting of 17 branches at the time of the study. Electronic medical record data (between November 1, 2015 and October 31, 2016) of patients diagnosed with corneal disorder, foreign body or eye disorder were retrieved and reviewed for inclusion/exclusion criteria. Data collected included gender, age, chief complaint, diagnosis, treatment and discharge status (sent home or referred to ED). International Classification of Diseases, Ninth Revision (ICD‐9) codes were assigned to each record based on a review of all fields. UCC results were compared to all ED patients in Israel using data from a public report. Data were analysed by descriptive statistics and logistic regression analysis.ResultsOf the 602 074 charts screened, 4797 patients presented with CCI (0.8%). The average age was 32.6 ± 18.2 years and 71.3% were male. Among these, 26.4% were referred to the ED compared to 6.8% from the entire UCC cohort. ICD‐9 code Foreign body (FB) of the eye was the most common cause of CCI (56.5%) followed by the following ICD‐9 codes: trauma (18.1%), chemical in the eye (11.1%) and corneal disorder due to a contact lens (5.1%). Logistic regression analyses showed the following risk factors for ED referral: age (22–64), male gender, ICD‐9 code FB, work‐related injury and the presence of a clinical abrasion in the eye.ConclusionsThe aetiology of ocular injury at UCC is similar to previous studies of ED. Most CCI can be treated at UCC saving ED resources and underscores the importance of this mode of health care delivery in the overall health system.

Factors and outcomes associated with paediatric emergency department arrival patterns through the day.

Steadily increasing emergency department (ED) utilization has prompted efforts to increase resource allocation to meet demand. Little is known about the distribution and characteristics of patient arrivals by time of day. This study describes the variability and patterns of ED resource utilization related to patient, acuity, clinical, and disposition characteristics over a 24-hour period. Retrospective cross-sectional study of all visits to a tertiary children's hospital over a 1-year period. We use descriptive statistics to present ED visit details stratified by shift of arrival, and multivariable regression to explore the association between shift of presentation and hospital admission at index and 7-day return ED visits. Of 46,942 visits during the study period, 12% arrived overnight, 42% during the day, and 45% during the evening with variability in pattern of shift arrival by day of week. Overnight arrivals had a higher acuity (Canadian Triage and Acuity Scale [CTAS]) and different presenting complaints (more viral infection, less minor trauma) than day and evening arrivals, but similar ED length of stay. Shift of arrival was not associated with admission to hospital, but age, gender, socioeconomic status (SES), and day of week were. ED utilization patterns vary by shift of arrival. Though overnight arrivals represent a smaller proportion of total daily arrivals, their acuity is higher, and the spectrum of disease differs from day or evening arrivals. Understanding variations and patterns of ED utilization by shift of arrival and day of week may be helpful in tailoring resource allocation to more accurately and specifically meet demands.

A Descriptive Time Inventory of Emergency Department Nursing Workflows

Background: Previous emergency department (ED) process improvement efforts used probabilistic analytical or simulated models without considering the impact of specific tasks on ED patient flow and resource needs. We focus on the tasks and workflows that comprise nursing activity in an urban academic ED and level I trauma center receiving over 80,000 annual visits. &#x0D; Experimental Design: Using a time/motion observational methodology, we create a minute-by-minute time inventory account of nursing tasks and workflows as observed through the activities of 35 nurses over 124.5 hours, representative of 24/7 patient care in 7 ED care areas. “Tasks” were defined as discrete, measurable, and consequential step(s) to accomplish a clinically meaningful goal (“workflow”). The task with highest cognitive demand for each minute of observation was recorded. We also tracked 12 discrete highest-acuity (“shock”) events and catalogued second-by-second observational accounts of each nurse diverted. &#x0D; Results: Our data demonstrate significant variation in tasks based on time of day. We observed substantial operational load moving patients between care areas, with intake and discharge comprising 25% of nurse workflows. Downtime averaged 32%, with variation depending on care area. Downtime was highest (47%) with passive video monitoring of psychiatric care and lowest (22%) in high-turnover intake areas. Highest-acuity patient-care events result in significant and variable nurse diversion from other tasks averaging 1:03:29 in combined nursing effort. &#x0D; Conclusion and Potential Impact: Movement of patients between care areas represents significant operational load. Interruptions and task preparation accounted for a surprising portion of activity. Highest-acuity patient care events result in substantial and variable diversion of nurse care.