Emergency Department Throughput Time Research Articles

Legislating Nurse Staffing: Projected Impact on Hospital Economics, Process Flow, and Hospital-Associated Infections in Montana.

The aim of this study was to project the impact of legislated nurse staffing ratios on patient-, staff-, and system-level outcomes for Prospective Payment System (PPS) hospitals in Montana. In 2023, House Bill 568 was introduced in Montana focused on legislating hospital safe nursing standards. A quantitative design was used for a convenience sample of Montana PPS hospitals. Data were gathered through a newly developed survey and from other publicly available sources for the years 2018 to 2022. Independent t tests were conducted when appropriate with the significance threshold set at 0.05. Projections indicate no significant change in patient outcome metrics accompanied by increases in labor requirements, slower emergency department throughput times, and decreases in hospital operating margins. In Montana, legislating nurse staffing ratios would have downstream implications inconsistent with the intended impact on patient safety, emphasizing the complexity of variables within and external to the healthcare system that drive patient-, staff-, and system-level outcomes.

Mini-dose Bier's block vssystemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time.

Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).

Do racial disparities exist at various time points during an emergency department visit for chest pain

IntroductionIt is well documented that disparities in patient care based on race and ethnicity are prevalent in the emergency medical care setting. In most cases these evaluations are patient focused and outcome based. The timeliness of patient treatment in the emergency department (ED) is correlated with patient outcomes. In this study, we sought to evaluate whether the timeliness of care for patients with chest pain across stages of care was impacted by patient race. MethodsThis was a retrospective evaluation of ED throughput times including adults who presented to one of seventeen EDs in a large healthcare system from January 1, 2019 to December 31, 2019 and met criteria for inclusion. The effect of race on different intervals of care were assessed. Generalized Linear Models were used to estimate the effect of race on different intervals of care while controlling for Charlson Comorbidity index, age, gender, insurance, ED facility type and emergency severity index acuity level. ResultsA total of 28,705 patients were included, with a mean age of 54 ± 18 years. The majority of patients were White (63%), female (56%) and had Medicare or Medicaid (56%). Black patients experienced significantly increased wait times for resident physician examination, advanced practice provider examination, attending physician examination, and ED disposition. There was no difference in time to triage between Black patients and White patients. ConclusionBlack patients have longer wait times for resident physician evaluation, advanced practice provider evaluation, attending physician evaluation, and ED disposition when presenting to the ED with chest pain.

Evaluating the Benefits of Viral Respiratory Panel Test in the Reduction of Emergency Department Throughput Time for Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

IntroductionThere has been a widespread antibiotic prescription in the Emergency Department (ED) among patients presenting with acute exacerbation chronic obstructive pulmonary disease (AECOPD) irrespective of the causative agent of the disease. The viral respiratory panel (VRP) test is designed to detect viral pathogens in the respiratory tract, which may contribute to the exacerbation of chronic obstructive pulmonary disease (COPD), as the upper and lower respiratory tract infections are caused by a broad range of microbes and not only bacteria. The aim of this study is to weigh the benefits of obtaining a VRP in patients presenting with isolated symptoms pertaining to well-defined criteria of an AECOPD with preexisting COPD or reactive airway disease to find out how such test impacts patient throughput time in the ED and also investigate how obtaining a VRP affects the use of antibiotics in this patient population. It is important that ED physicians accurately diagnose the main cause of AECOPD to help optimize the use of health care resources, including antibiotics, antivirals, inpatient, and ED beds. VRP testing must be taken into consideration as it helps eliminate the need of administering antibiotics to every patient who presents to the ED with AECOPD.Design and methodThis is a case-control observational study using retrospective chart review to obtain patients’ data from our hospital data warehouse. Data on patients with the primary diagnosis of AECOPD in the past two years were retrieved. A comparison between those who had VRP on arrival in the ED and those who did not have a VRP obtained was performed. We also compared ED throughput time for patients with AECOPD who received antibiotics to those who did not receive antibiotics. Only patients between the ages of 18 and 64 were included in the study. Patients with other preexisting health conditions such as cardiac diseases, neurological problems, and abdominal complaints were excluded. Patients who required hospitalization and pregnant patients were excluded from the study.ResultsWe collected the data of 340 patients who met the study criteria. Of the 340 patients enrolled, 65 (19%) received the VRP test and 275 (81%) did not receive VRP test. Among the 65 patients who received the VRP test, 45 (70%) had a virus etiology detected and reported in the ED (p=0.001). Also, 138 (50.2%) did not receive VRP test and were not given antibiotics, and 137 (49.8%) did not receive VRP test but were treated with antibiotics; 11 patients received antibiotics despite haven tested positive to a virus. The result showed that those who received antibiotics with no VRP test on arrival in the ED had a shorter throughput time compared to patients who did not receive antibiotics but received VRP test.ConclusionThe study is a quality improvement study to help determine the efficacy and appropriateness of ordering a VRP prior to ED disposition and the impact of overall ED throughput time for each patient presenting with AECOPD. The study showed that antibiotics did play a significant role in the duration of the throughput time in patients with AECOPD. However, rapid VRP testing was indeed associated with a trend toward decreased antibiotic use in the ED.

Understanding Contributors to Racial/Ethnic Disparities in Emergency Department Throughput Times: a Sequential Mixed Methods Analysis.

Ensuring equitable care remains a critical issue for healthcare systems. Nationwide evidence highlights the persistence of healthcare disparities and the need for research-informed approaches for reducing them at the local level. To characterize key contributors in racial/ethnic disparities in emergency department (ED) throughput times. We conducted a sequential mixed methods analysis to understand variations in ED care throughput times for patients eventually admitted to an emergency department at a single academic medical center from November 2017 to May 2018 (n=3152). We detailed patient progression from ED arrival to decision to admit and compared racial/ethnic differences in time intervals from electronic medical record time-stamp data. We then estimated the relationships between race/ethnicity and ED throughput times, adjusting for several patient-level variables and ED-level covariates. These quantitative analyses informed our qualitative study design, which included observations and semi-structured interviews with patients and physicians. Non-Hispanic Black as compared to non-Hispanic White patients waited significantly longer during the time interval from arrival to the physician's decision to admit, even after adjustment for several ED-level and patient demographic, clinical, and socioeconomic variables (Beta (average minutes) (SE): 16.35 (5.8); p value=.005). Qualitative findings suggest that the manner in which providers communicate, advocate, and prioritize patients may contribute to such disparities. When the race/ethnicity of provider and patient differed, providers were more likely to interrupt patients, ignore their requests, and make less eye contact. Conversely, if the race/ethnicity of provider and patient were similar, providers exhibited a greater level of advocacy, such as tracking down patient labs or consultants. Physicians with no significant ED throughput disparities articulated objective criteria such as triage scores for prioritizing patients. Our findings suggest the importance of (1) understanding how our communication style and care may differ by race/ethnicity; and (2) taking advantage of structured processes designed to equalize care.

A Critical Pathway for Mass Casualty Incident Preparedness.

Rates of mass casualty incidents (MCIs) have been on the rise in the United States, highlighting the need for health care systems to have an emergency response plan. Trauma centers are fundamental during MCIs and serve a crucial leadership role in preparedness for them. The purpose of this study was to describe the design and implementation of simulated MCI drills at an American College of Surgeons verified Level I trauma center in the Midwest. A quasi-experimental time-series design was utilized to determine MCI simulation effects on staff performance using an emergency department checklist to measure emergency department throughput time. A multidisciplinary MCI design team developed a checklist for the emergency department, which identified tasks required to complete it. The 16-item checklist, Critical Pathway Management methodology, was used to identify the critical pathway for patient throughput during a surge. Two in situ MCI simulation drills were conducted in the emergency department (October and December 2019), and Critical Pathway Management identified the primary patient throughput rate limiters as notification and inpatient nursing staff presentation. Emergency department throughput decreased from a mean of 15 to 11 min (reduction of 26.7%) between the two time periods after focusing on rate-limiting tasks. This quality improvement project demonstrated that the use of institution-specific checklists and Critical Pathway Management to identify critical pathways and potential rate limiters led to patient throughput improvements.

Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review.

The objective of the review was to identify, critically appraise and synthesize evidence on the impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency. A key strategy to facilitate effective communication between limited-English-proficient migrant and refugee families and healthcare providers is the use of professional interpreters. Despite awareness of the importance of professional interpreters, interpreters are underutilized. This results in suboptimal care, including poor access to health care, increased risk of serious medical events, increased admission to hospital and inadequate health literacy. Limited-English-proficient migrant, refugee or asylum-seeker families with a hospitalized child aged 0 to 18 years, who had used a professional interpreter, were considered for this review. Comparators included standard care or no interpreter, and reported results of comparisons of the duration, frequency or mode of interpreter delivery. Outcomes were length of stay in hospital, unplanned readmission rates to hospital, non-attendance at hospital clinic appointments and ambulatory care, child and/or parent satisfaction with care in hospital, adherence to treatment, medication errors, and other adverse events relating to patient safety. The review considered all studies conducted using a quantitative approach. A three-step search strategy was used. Databases were searched in December 2018 for published and unpublished articles. Studies published in English were considered for inclusion. The recommended JBI approach to critical appraisal, study selection, data extraction and data synthesis was used. Six articles reporting results from three randomized controlled trials and one observational study were included. Studies were undertaken in the United States involving Spanish-speaking participants. Three studies were in emergency departments. There was a total of 1813 families, of whom 1753 had limited English proficiency. Migrant and refugee families with limited English proficiency reported greater satisfaction with aspects of care when a professional interpreter service was used compared with using ad hoc interpreters. Using professional in-person interpreters resulted in a shorter total emergency department throughput time compared to using professional interpreters via telephone. There was no difference in concordance of child's discharge diagnoses between parents assigned professional interpreters and those assigned bilingual physicians. Video interpretation provided better understanding of diagnoses than phone interpretation. There is evidence that use of ad hoc interpreters or no interpreter is inferior to use of professional interpreters of any mode. Although video and in-person interpreters are more favorable for some outcomes, mode of delivery may not be as important as the fact that a professional interpreter is being used. The mode of professional interpreter delivery should be based on accessibility, availability, language requirements and patient preference. PROSPERO CRD42017058161.

Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review

BackgroundThe growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions.MethodsSix major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects.ResultsOf the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician.ConclusionInter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention’s effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures.Trial registrationThe protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).

Dedicated MRI in the emergency department to expedite diagnostic management of hip fracture.

To determine the effect on time to diagnosis of making MRI imaging for hip fractures available directly in the emergency department (ED). We conducted a retrospective observational study of patients with MRI imaging of the hip for suspected occult fracture, comparing time to diagnosis and time to disposition of populations imaged in the year preceding and the year following installation of an MRI scanner in the ED. Time to diagnosis of hip fractures was 709min before installation of a dedicated ED MRI scanner and 280min after, a 60% reduction. Including the MRI in the diagnostic workup did not increase ED throughput time, and we were able to save 48% of the patients who had an ED-based MRI from an admission to the hospital. Implementation of an MRI scanner for dedicated emergency department use enables faster hip fracture diagnosis and surgical consultation, or definitive disposition without increasing ED throughput time.

Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department

ObjectiveTo determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led...

The Effect of Early Knowledge of Respiratory Syncytial Virus Positivity on Medical Decision Making and Throughput Time Within the Pediatric Emergency Department.

The aim of this study was to evaluate whether early knowledge of respiratory syncytial virus (RSV) positivity by rapid triage-based testing protocol improved emergency department (ED) throughput time and decreased ED ancillary testing and antibiotic administration. A retrospective cohort study was performed of ED patients aged 2 to 12 months, presenting November 1 to March 31 for the years 2008-2013. Included patients presented with fever and upper respiratory tract symptoms. Patients were excluded if they tested positive for influenza, had chronic underlying medical problems, or were admitted or transferred from an outside facility or if no RSV result was documented. The study group was compared with infants who tested negative for RSV by the triage-based protocol and were diagnosed as having (1) bronchiolitis and (2) a viral illness. Of 899 patients tested for RSV within triage, the study included 713 (79%); 231 (35.3%) tested positive for RSV. When comparing children diagnosed as having bronchiolitis, there was no statistically significant difference between RSV positive and negative in ED throughput time, ED administered antibiotics, or chest radiographs, urine analyses, blood cultures, or lumbar punctures obtained. When comparing children diagnosed as having a viral illness, RSV-positive patients had less chest radiographs, urine analysis, and blood cultures performed. Identifying the virus responsible for bronchiolitis through a triage-based protocol does not decrease ED throughput time, antibiotic administration, or chest radiographs, urine analysis, or blood cultures obtained. In infants presenting with upper respiratory tract symptoms and fever, knowing RSV infectivity through a triage-based protocol does significantly decrease chest radiographs, urine analysis, and blood cultures obtained.

Waiting for triage: unmeasured time in patient flow.

IntroductionThe Centers for Medicare and Medicaid Services (CMS) requires reporting of multiple time-sensitive metrics. Most facilities use triage time as the time of arrival. Little is known about how long patients wait prior to triage. As reimbursement to the hospital may be tied to these metrics, it is essential to accurately record the time of arrival. Our objective was to quantify the time spent waiting to be triaged for patients arriving to the emergency department (ED).MethodsWe conducted this study in an urban, academic, tertiary care center with approximately 54,000 annual ED visits. All patients arriving to the ED from November 1, 2012, to October 1, 2013, were enrolled. If patients didn’t go directly to a bed or triage, an observer greeted patients as they entered the ED and recorded the time of arrival. The triage time was recorded as normal. We calculated the difference between the arrival time and triage time.ResultsThere were 50,576 patient visits during the study period. Of these, 7,795 (15.4%) patients did not go directly to a bed or triage. For patients who waited for triage, median time from arrival to triage was 11 minutes (IQR 5–19, range 1–105). When stratified by the number of new patients who arrived in the ED in the previous hour, the percentage of greeted patients who waited more than 10 minutes for triage was: 0–5 new patients − 12.4%; 6–10 new patients − 48.8%; 11–15 new patients − 64.4%; 16+ new patients − 68%.ConclusionPatients often waited more than 10 minutes to be triaged. As the number of patients registered in the previous hour increased, the percentage of patients who waited more than 10 minutes for triage increased significantly. During times of peak volume, 8.5% of all patients arriving to the ED waited more than 10 minutes for triage. This wait is not accounted for in the normal reporting of ED throughput times and metrics.

Reducing Ambulance Diversion at the Hospital and Regional Levels: Systemic Review of Insights from Simulation Models

Introduction:Optimal solutions for reducing diversion without worsening emergency department (ED) crowding are unclear. We performed a systematic review of published simulation studies to identify: 1) the tradeoff between ambulance diversion and ED wait times; 2) the predicted impact of patient flow interventions on reducing diversion; and 3) the optimal regional strategy for reducing diversion.Methods:Data Sources: Systematic review of articles using MEDLINE, Inspec, Scopus. Additional studies identified through bibliography review, Google Scholar, and scientific conference proceedings. Study Selection: Only simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems were included. Data extraction: Independent extraction by two authors using predefined data fields.Results:We identified 5,116 potentially relevant records; 10 studies met inclusion criteria. In models that quantified the relationship between ED throughput times and diversion, diversion was found to only minimally improve ED waiting room times. Adding holding units for inpatient boarders and ED-based fast tracks, improving lab turnaround times, and smoothing elective surgery caseloads were found to reduce diversion considerably. While two models found a cooperative agreement between hospitals is necessary to prevent defensive diversion behavior by a hospital when a nearby hospital goes on diversion, one model found there may be more optimal solutions for reducing region wide wait times than a regional ban on diversion.Conclusion:Smoothing elective surgery caseloads, adding ED fast tracks as well as holding units for inpatient boarders, improving ED lab turnaround times, and implementing regional cooperative agreements among hospitals are promising avenues for reducing diversion.

Alarming Signs in the Manchester Triage System: A Tool to Identify Febrile Children at Risk of Hospitalization

To assess whether the flowcharts and discriminators of the Manchester Triage System (MTS) can be used as indicators of alarming signs of serious febrile illness to predict the risk of hospitalization for febrile children who present at the emergency department (ED). Observational study, which included 2455 children (<16 years) who came to the ED of a university hospital with fever as their main complaint (May 2007-July 2009). Alarming signs for serious febrile illness were matched with MTS flowcharts and discriminators. At triage, the percentage of alarming signs positive was calculated. The diagnostic ability of the percentage of alarming signs positive to identify children at risk of hospitalization was assessed by calculating positive and negative likelihood ratios. Thirty percent of children had at least 1 alarming sign positive at triage. Twenty-three percent were hospitalized. Positive likelihood ratios of hospitalization were 5.0 (95% CI: 3.9-6.5) for children with >20% of alarming signs positive at triage and 12.0 (95% CI: 5.2-27.6) for those with >40% of alarming signs positive. Negative likelihood ratios were 0.8 (95% CI: 0.8-0.8) and 1.0 (95% CI: 0.9-1.0), respectively. By alternatively using the flowcharts and discriminators of the MTS as alarming signs, rather than urgency classifiers, the MTS can function as a simple, readily available tool to identify febrile children at risk of hospitalization early in the care process. This knowledge may help to improve ED throughput times as well as admission and discharge management at pediatric EDs.

Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems

Objective:Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI + S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI + S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI + S vs NEB.Methods:A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1–18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded.Results:Three hundred and four patients were analyzed: 94 in the MDI + S group and 209 in the NEB group. Mean age in years for the MDI + S group was 9.57 vs 5.07 for the NEB group (p < 0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI + S group vs 61.7% in the NEB group (p < 0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI + S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p < 0.001; 95% CI = 3.8–31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of $213,532 annually using MDI + S vs NEB.Conclusion:In mild asthma exacerbations, administering albuterol via MDI + S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput.Limitations:The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.

Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

Background and PurposeWe examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification. MethodsA retrospective cohort study of 30 461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification—using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages. ResultsThere were 15 687 precertification ED visits and 11 040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival. ConclusionsStroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.

Community Pediatric Hospitalists Providing Care in the Emergency Department

Community hospital pediatric inpatient programs are being threatened by current financial and demographic trends. We describe a model of care and report on the financial implications associated with combining emergency department (ED) and inpatient care of pediatric patients. We determine whether this type of model could generate sufficient revenue to support physician salaries for continuous in-house coverage in community hospitals. Financial productivity and selected performance indicators were obtained from a retrospective review of registration and billing records. Data were obtained from 2 community-based pediatric hospitalist programs, which are part of a single health system and included care delivered in the ED and inpatient settings during a 1-year period from July 1, 2008, to July 1, 2009. Together, the combined programs were able to generate 6079 total relative value units and collections of $244,828 annually per full-time equivalent (FTE). Salary, benefits, and practice expenses totaled $235,674 per FTE. Thus, combined daily revenues exceeded expenses and provided 104% of physician salary, benefits, and practice expenses. However, 1 program generated a net profit of $329,715 ($40,706 per FTE), whereas the other recorded a loss of $207,969 ($39,994 per FTE). Emergency department throughput times and left-without-being-seen rates at both programs were comparable to national benchmarks. Incorporating ED care into a pediatric hospitalist program can be an effective strategy to maintain the financial viability of pediatric services at community hospitals with low inpatient volumes that seek to provide 24-hour pediatric staffing.

Comparison of ultrarapid and rapid intravenous hydration in pediatric patients with dehydration

Objective The purpose of this study is to test the efficacy of ultrarapidly infused vs rapidly infused intravenous (IV) hydration in pediatric patients with acute gastroenteritis and moderate dehydration. Methods Patients 3 to 36 months, with vomiting and/or diarrhea and moderate dehydration, were eligible. Subjects were randomly assigned “ultra” (50 mL/kg normal saline for 1 hour) vs “standard” (50 mL/kg normal saline for 3 hours) after failing an oral fluid challenge. Subjects were weighed and had serum electrolyte testing, and urine was obtained before/after IV hydration. Input/output and vital signs were tabulated hourly during the study. Subjects were discharged after fulfilling specified criteria. A follow-up questionnaire was completed 24 hours after discharge. Comparison data included success and timing of rehydration, number of patients who returned and/or were admitted, output during the rehydration period, laboratory differences, and serious complications. Results Eighty-eight of 92 subjects completed the study: 45 ultra and 43 standard. Four patients failed treatment (1 ultra and 3 standard), were hospitalized, and excluded from the study. Groups were similar regarding sex, days of symptoms, episodes of vomiting/diarrhea before treatment, capillary refill time, tears, and vital signs and laboratory results. No subject had evidence of serious complications. Ninety-one percent of subjects completed the follow-up questionnaire. Seven ultra and 6 standard subjects returned. Six ultra subjects received oral fluid, one received IV fluid, and all were discharged. Five standard subjects received oral fluid, one received IV fluid, and all were discharged. Conclusion Based on this pilot study, ultrarapid hydration for 1 hour preliminarily appears to be an efficacious alternative to standard rapid hydration for 3 hours and improves emergency department throughput time.

A Comparison of the Quality of Blood Specimens Drawn in the Field by EMS Versus Specimens Obtained in the Emergency Department

Emergency Department (ED) acceptance of blood specimens drawn by Emergency Medical Services (EMS) staff is not a consistent standard of practice across hospitals. The literature does not address acceptance of pre-hospital phlebotomy specimens drawn by EMS staff. The purpose of this study was to compare specimen redraw rates and ED throughput times for specimens drawn by EMS versus ED staff. Data was collected on 400 patients regarding phlebotomist type, intravenous (i.v.) site, i.v. angiocatheter size, number of i.v. attempts producing blood specimens, redraw reason, undue blood exposure to phlebotomist, diagnosis, and length of stay. In this study of 400 patients (EMS=200; ED=200), the redraw rate was higher for the ED group (11.5%) than the EMS group (9.5%). The primary reason for redraw in the EMS group was insufficient quantity (52.6%; ED=8.7%, p<.05). The primary reason for redraw in the ED group was hemolysis (52.2%; EMS=31.6%). Median ED throughput time was 17 minutes less for the EMS group (163 minutes) than for ED group (180 minutes). There were no incidences of undue blood exposure in either group. Based on no statistically significant differences between the two study groups in redraw rates, a decreased ED patient throughput time, and no undue blood exposure incidences, pre-hospital phlebotomy by EMS in the field and subsequent ED acceptance of samples is a standard of practice that can be implemented.

Active Bed Management by Hospitalists and Emergency Department Throughput

When emergency departments are overcrowded, ambulances are diverted. Interventions focused primarily on emergency departments have had limited success. To discover whether an active bed management, quality improvement initiative could reduce ambulance diversion hours and emergency department throughput times. Pre-post study that compared institutional data from November 2006 to February 2007 (intervention period) with data from November 2005 to February 2006 (control period). Johns Hopkins Bayview Medical Center, Baltimore, Maryland. All adult patients registered in the emergency department during the study periods. Active bed management is a hospitalist-led, multifaceted intervention that consists of proactive management of hospital and departmental resources, including twice-daily bed management rounds in the intensive care unit and regular visits to the emergency department to assess congestion and flow; assignment of all admissions to the department of medicine and facilitating transfer from the emergency department to the appropriate care setting; and support from the "bed director," who can mobilize additional resources in real time to augment hospital capacity to address emergency department throughput problems. Emergency department throughput times and ambulance diversion hours. The emergency department census was 8.8% higher during the intervention period than in the control period (17 573 patients vs. 16 148 patients). Throughput for patients who were admitted decreased by 98 minutes (SD, 10) (from 458 minutes in the control period to 360 minutes during the intervention period). Throughput for patients who were not admitted did not change (274 minutes vs. 269 minutes). The percentage of hours that the emergency department was on "yellow alert" (ambulance diversion because of emergency department crowding) decreased 6%, and the percentage of hours on "red alert" (ambulance diversion due to lack of intensive care unit beds in the hospital) decreased 27%. Staffing, length of stay, case-mix index, intensive care unit transfer rates, and mortality rates were stable across the 2 periods. Pre-post designs are less effective than randomized, controlled trials on the study design hierarchy, and unidentified external forces may have influenced the results. The study was done at a single hospital, and the findings may not be generalizable to other institutions. Emergency department throughput and diversion status improved with the implementation of an active bed management process coordinated by hospitalists.