Emergency Department Throughput Research Articles

PROPEL Discharge: An Interdisciplinary Throughput Initiative

BackgroundIncreased care demands at a healthcare institution led to strained resources, emergency department (ED) congestion, safety events, and patient and employee dissatisfaction. Moreover, high volumes of afternoon discharges contributed to limited early morning bed availability and admission bottlenecks. MethodsA 29-month pre-post design quality improvement project on 19 acute care, adult medicine units across two campuses at a large academic medical center was implemented to improve discharge timeliness, length of stay (LOS), and ED throughput by increasing pre-11:00 AM discharges. Based on Lean Six Sigma methodology, interventions included standardized interdisciplinary discharge processes and roles, processes to ensure performance data transparency and access, a recognition program, and a barrier tracking and mitigation process for continued improvements. ResultsDuring the intervention period, pre-11:00 AM discharges increased from 5.1% to 21.8% (p < 0.001), discharge orders were entered 42 minutes earlier (p < 0.001), patients were discharged 56 minutes earlier (p < 0.001), the percentage of discharges completed within 90 minutes from discharge order improved from 26.2% to 38.1% (p < 0.001), the percentage of discharges by 3:00 PM improved from 44.7% to 55.9% (p < 0.001), ED admissions arrived to units 44 minutes earlier (p < 0.001), median LOS decreased by 0.46 days (p < 0.001), median O:E LOS decreased by 0.05 (p < 0.001), and opportunity day reductions contributed to increased bed capacity of 18.84 beds per day. ConclusionEarly morning discharges are associated with improved patient throughput and are safe, achievable, and sustainable via interventions focused on frontline engagement, interdisciplinary collaboration, standardization, barrier mitigation, data accessibility, and accountability.

Lean-Based Approach to Improve Emergency Department Throughput.

Objective:Lean methodology can be utilized to increase throughput in a fast-track care area without changing staffing in a busy, urban emergency department (ED). Methods: A retrospective before-and-after analysis was performed to an improvement process in a fast-track care area within an ED with a census of 100,000 patients. The intervention utilized Lean methodologies to identify inefficiencies in the throughput model set for patients triaged to fast-track. Multiple ED stakeholders were involved in formulating a more efficient framework for how patients would receive care when triaged to fast-track. Results: There was a decline in the patient's overall length of stay (-9%, p=0.08), arrival to the room (-10%, p=0.4418), and ED attending to disposition (-9%, p=0.003). Additionally, all aspects of patients leaving prior to treatment completion (against medical advice (-29.4%, p=0.006), elopement (-20.4%, p=0.049), and left without being seen (-5.3%, p=0.11)) declined. Discussion:Identifying wasted time and resources in a patient's stay in the ED allowed for a more efficient throughput model to be developed. This resulted in patients being able to be seen in a more methodical manner leading to decreased wait times and lower left without being seen rates. Conclusion: A Lean-based throughput model was implemented to improve efficiency, reducing the length of stay and increasing the volume of patients evaluated per shift without additional costs. This improvement led to fewer patients leaving before treatment and demonstrated the value of process improvement in healthcare.

Does initiating care in alternate care sites decrease time to disposition in the emergency department?

During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition. Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time. The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p<0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p=0.09). Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.

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.

Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis.

Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators. This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs). We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality). Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.

Quality of care and emergency department throughput during the COVID-19 pandemic in a community health system Pandemic in a Community Health System

Objective: This retrospective study explores the strategic plan formulated by AHMC Health System in California, USA, to sustain and improve quality of care and emergency department (ED) efficiency during the COVID-19 pandemic. It also analyzes the plan’s outcomes.Background: The COVID-19 pandemic has posed challenges for both individuals and healthcare industries alike, impacting decision-making and access to care. AHMC faced staff and resource shortages, patient reluctance, and difficulties adapting to rapidly evolving public health guidelines. These challenges highlighted the critical need for effective plans to maintain or improve healthcare quality and ED performance.Methods: AHMC adopted a comprehensive three-layer strategic plan in 2020. The first layer, “Pandemic Response,” focused on leadership, staff training and education, infection control, new treatments, and employee vaccination rates. The second layer, “ED Throughput,” set objectives for metrics such as door-to-doctor (door-to-doc) time, ancillary turnaround time (TAT), ED length of stay (LOS), and the left-without-being-seen (LWBS) rates. Progress was monitored through monthly improvement meetings. The third layer, “Quality Excellence,” tracked improvements in COVID-adapted objectives on quality initiatives, based on CMS Quality Star Ratings, Leapfrog Hospital Safety Grades, and Yelp review scores.Results: By 2023, the three-layer strategic plan had led to many improvements in the quality of care and ED efficiency. AHMC identified 22,287 positive COVID-19 cases, expanded its ventilator inventory by 50%, and enhanced patient outcomes by applying updated treatments. Additionally, AHMC saw a 3% reduction in ED wait times and sustained its overall patient satisfaction rates, CMS Quality Star Rating, and Leapfrog Hospital Safety Grade scores.Conclusions: AHMC’s three-layer strategic plan showed effectiveness in maintaining quality of care and ED efficiency during the COVID-19 pandemic. By focusing on “Pandemic Response,” “ED Throughput,” and “Quality Excellence,” AHMC was able to adapt to the rapidly evolving public health guidelines, expand its capacity to treat COVID-19 patients and sustain its overall patient safety, satisfaction, and quality ratings. The implementation of this plan highlights the importance of proactive and comprehensive strategies in managing healthcare crises.

Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.

During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7-July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including "abdominal pain." We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7-May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6-July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes, P = <0.001) declined by 16.5 minutes (95% confidence interval -10, -22). Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.

The Impact of Involving a Senior Emergency Physician in the Triage Process

BACKGROUND: Emergency Department (ED) overcrowding has been demonstrated in several studies to be associated with undesirable effects such as longer waiting times, reduced patient satisfaction, and, most importantly, poor patient outcomes. Furthermore, long waiting times for walk-ins result in more complaints and patient dissatisfaction than illness management itself, with the majority of issues arising as a result of real and perceived waiting periods before being seen by the doctor. AIM: We set out to investigate whether introducing a senior emergency physician into the triage system would reduce waiting time, door-to-decision time, and door-to-doctor time, as well as increase patient satisfaction across the ED. METHOD: This was an interventional pre-post study that utilised retrospective data to evaluate the effect on ED throughput of triage by senior emergency physicians. We aimed to measure its impact on waiting time, door-to-decision time, and door-to-doctor time, along with ED patient satisfaction. RESULTS: Patient satisfaction, the overall assessment of treatment received during the visit, increased, from 74.975 to 77.425, and the likelihood of patients recommending the ED increased from 71.36 to 75.21. Operational metrics revealed a considerable drop in door-to-decision time (admit or discharge) of 46 minutes and 3 seconds, as well as a 1 minute and 21 second reduction in time from door to doctor (arrival to first provider). CONCLUSION: The mixed results hint at an effective but iterative process of enhancing patient flow and experience in the ED through senior physician triage.

Is boarding compromising our residents' education? A national survey of emergency medicine program directors.

Boarding patients in the emergency department (ED) potentially affects resident education. Program director (PD) perceptions of the impact of boarding on their trainees have not been previously described. We surveyed a cross-sectional convenience sample of emergency medicine PDs using a mixed-methods approach to explore their perceptions of how boarding has affected their residents' training. Descriptive data were reported as percentages and differences were calculated using Pearson's chi-square test, with p < 0.05 considered significant. A framework model was used to qualitatively analyze free-text responses. A total of 170 responses were collected, for a response rate of 63%. Most respondents felt that boarding had at least some effect on resident education with 29%, 35%, 18%, and 12% noting "a little," "a moderate amount," "a lot," and "a great deal," respectively, and 5% noting "no effect at all." Respondents perceived a negative impact of boarding on resident education and training, with 80% reporting a "somewhat" or "extremely negative" effect, 18% feeling neutral, and 2% noting a "somewhat positive" effect. Most noted a "somewhat" or "extremely negative" effect on resident education in managing ED throughput (70%) and high patient volumes (66%). Fifty-four percent noted a "somewhat" or "extremely negative" impact on being involved in the initial workup of undifferentiated patients. Thirty-two percent saw a "somewhat" or "extremely positive" effect on learning the management of critically ill patients. Qualitative analysis of challenges, mitigation strategies, and resident feedback emphasized the lack of exposure to managing departmental patient flow, impact on bedside teaching, and need for flexibility in resident staffing. Most PDs agree that boarding negatively affects resident education and identify several strategies to mitigate the impact. These findings can help inform future interventions to optimize resident learning in the complex educational landscape of high ED boarding.

Association between physician resource utilization, throughput, and patient experience in the emergency department

Background and Importance: Emergency department (ED) care is complex, involving multifaceted factors such as patient volume, provider experience, throughput metrics, and patient-provider interactions. While some studies have explored relationships between these parameters, there is still much to understand about the nuances in ED care. Objective: Our study aimed to analyze the statistical relationships between admission rates, Press Ganey (PG) scores, and various throughput/resource utilization variables in the ED. These variables include imaging and lab ordering rates, door-to-doctor (D2D) success rate, disposition times for specific patient acuities, and elopement or discharge against medical advice (AMA) rates. Design: A retrospective cohort study was conducted using data from eight emergency facilities within the Valley Health System. Settings and Participants: Data from six community hospital EDs and two freestanding emergency departments (FEDs) in the Valley Health System, spanning August 1, 2020, to July 31, 2021, were examined. The analysis involved 99 physicians and approximately 200,000 adult patients. Outcome Measures and Analysis: Correlations between admission rates, PG scores, and various ED metrics were examined using the Jamovi software. Separate analyses were conducted based on facility type using ANOVAs. Main Results: Our findings revealed several significant correlations. There was a positive correlation between lab ordering and admission rates, while D2D success rates showed a negative correlation with admission rates. Additionally, there was a positive association between D2D success rates and quick dispositioning of lower acuity patients. Patient satisfaction (PG score) was negatively correlated with admission, AMA, and D2D success rates, whereas it positively correlated with lab ordering rates. Conclusion: This study identifies significant relationships among ED throughput, resource utilization, and patient satisfaction metrics. These findings can guide further research to understand the patient experience better, optimize resource utilization, and improve overall ED efficiency.

Emergency Department Length of Stay: A Community Hospital Initiative.

This quality improvement initiative was conducted to determine if a provider in triage and split flow model could decrease the length of stay (LOS) of discharged patients seen in a community hospital emergency department (ED). Extended LOSs within the ED lead to delays in the care of patients, increase the number of patients who leave without being seen by a provider, decrease patient satisfaction, and cause a loss of revenue for health care organizations. Using a provider in triage and a split flow model, where patients can be seen and dispositioned without delays, can improve ED throughput and decrease the overall LOS. Through a structured, interdisciplinary approach using the Plan-Do-Study-Act Shewhart Cycle of Process Improvement, a provider was placed in triage, and an interior waiting room was used to evaluate emergency severity index level 3 and 4 patients to expedite diagnostic testing and perform procedures. This model allowed lower acuity patients to be cared for separately from higher acuity patients, who were being treated in the main ED. In addition, the median arrival to provider, arrival to bed, and LOS from arrival to departure of discharged patients were compared to the current departmental processes. There was a significant improvement in the LOS of discharged patients and the time of arrival to triage, arrival to bed, and arrival to provider using a provider in triage and a split flow model compared to the current intake. Implementation of a provider in triage and a split flow model can demonstrate a decrease in the LOS of discharged patients along with other ED metrics and improve efficiencies in patient care within a community hospital.

Impacts of the 2021 heat dome on emergency department visits, hospitalizations, and health system operations in three hospitals in Seattle, Washington.

Extreme heat events (EHEs) are associated with excess healthcare utilization but specific impacts on emergency department (ED) operations and throughput are unknown. In 2021, the Pacific Northwest experienced an unprecedented heat dome that resulted in substantial regional morbidity and mortality. The aim of this study was to examine its impact on ED utilization, unplanned hospitalization, and hospital operations in a large academic healthcare system. Retrospective electronic medical records from three Seattle-area hospitals were used to compare healthcare utilization during the EHE compared to a pre-event reference period within the same month. Interrupted time series analysis was used to evaluate the association between EHE exposure and ED visits and hospitalizations. Metrics of ED crowding for the EHE were compared to the reference period using Student's t-tests and chi-squared tests. Additionally, multivariable Poisson regression was used to identify risk factors for heat-related illness and hospital admission. Interrupted time series analysis showed an increase of 21.7 ED visits per day (95% confidence interval [CI]=14.7, 28.6) and 9.9 unplanned hospitalizations per day (95% CI=8.3, 11.5) during the EHE, as compared to the reference period. ED crowding and process measures also displayed significant increases, becoming the most pronounced by day 3 of the EHE; the EHE was associated with delays in ED length of stay of 1.0h (95% CI=0.4, 1.6) compared to the reference period. Higher incidence rate ratios for heat-related illness were observed for patients who were older (incidence rate ratio [IRR]=1.02; 95% CI=1.01,1.03), female (IRR=1.47; 95% CI=1.06, 2.04), or who had pre-existing diabetes (IRR=3.19; 95% CI=1.47, 6.94). The 2021 heat dome was associated with a significant increase in healthcare utilization including ED visits and unplanned hospitalizations. Substantial impacts on ED and hospital throughput were also noted. These findings contribute to the understanding of the role extreme heat events play on impacting patient outcomes and healthcare system function.

A Retrospective Comparison of Emergency Department Throughput Before and After Instituting a Waiting Room Evaluation Process.

The COVID-19 pandemic has strained the healthcare system with emergency department (ED) boarding and workforce shortages. This prompted the need for strategies to evaluate and treat patients while they waited for an ED room. The objective is to describe a waiting room evaluation process and ED throughput in the setting of ED staffing shortages and boarding. This is a retrospective before and after cohort study evaluating ED throughput before and after initiation of the assessed waiting room (aWR) process. The aWR process is a joint effort by emergency clinicians and ancillary staff to evaluate and treat patients in the ED waiting room when no ED bed is available. Throughput data 6 months before and 6 months after institution of aWR was collected and analyzed. The arrival to provider time and the number of patients who left without being seen (LWBS) decreased with initiation of the aWR process. The remainder of throughput metrics remained unchanged. There was more ED boarding at Wisconsin sites during the aWR process period. The aWR process may minimize LWBS and improve arrival to provider time in the setting of staff shortages and more ED boarders. It may help other ED throughput metrics although numerous confounding factors make it difficult to make definitive conclusions. This process may be trialed during times of challenging healthcare landscape, such as pandemic conditions and with workforce shortages.

Emergency Department Overcrowding: An Environmental Scan of Contributing Factors and a Summary of Systematic Review Evidence on Interventions

&#x0D; Emergency department (ED) overcrowding occurs when the demand for health services in the ED exceeds the capacity of the ED, hospital, or community to deliver quality care in a reasonable amount of time. Overcrowding is worsening in jurisdictions across Canada and there is a need to address its many causes and identify potential solutions.&#x0D; This report uses a modified version of a conceptual model developed by Asplin et al. (2003) that organizes the emergency care system into 3 interdependent parts: input (arrival to the ED), throughput (flowing through the ED), and output (leaving the ED). We also examined an additional fourth part related to contextual factors and systems that affect overcrowding but lay outside of input, throughout, and output.&#x0D; &#x0D; Examples of factors include, but are not limited to, increased complexity of needs (input), diagnostic testing and procedures (throughput), boarding (output), and limited resources for mental health and substance use (outside the ED).&#x0D; Examples of interventions that were effective in some settings include, but are not limited to, prehospital decision-making by first responders, which reduced ED visits (input); short stay crisis units for people experiencing mental health challenges, which improved emergency department length of stay, wait times, boarding, and patient safety (throughput); ED-based discharge planning, which reduced ED return visits (output); and time-based policy reforms, which reduced ED length of stay (outside the ED).&#x0D; &#x0D; &#x0D; Most of the factors we identified in the published literature existed either outside of the ED or at the interface of the ED and other health care services (input and output), whereas most of the interventions we identified existed within the ED (throughput).&#x0D; We heard from participants (during multistakeholder dialogue sessions) and content experts that ED overcrowding is a complex health system issue for which the causes, impacts, and solutions extend beyond the ED. Specifically, the novel insights we heard included:&#x0D; &#x0D; ED overcrowding is better viewed as a problem of hospital overcrowding and strained resources in the broader social and health care systems. Contributing factors both within and outside the ED influence and interact with each other and are affected by economic, cultural, and institutional realities.&#x0D; Solving the issue requires addressing accountability and implementing multifaceted solutions in which several systems and voices work collaboratively.&#x0D; Existing technologies and data use and collection are not being used to their full potential; they can be better leveraged to alleviate this issue.&#x0D; &#x0D; &#x0D; In the identified literature, there was a lack of explicit reporting around equity and ethical considerations for factors contributing to, and interventions to alleviate, ED overcrowding. Future work should strive to deliberately and explicitly include ethical considerations inherent in research, planning, and policy-making; considerations of equity-deserving groups; and dedicate the time needed to consider the various facets of this issue.&#x0D; This CADTH report and our series of reports on ED overcrowding are a starting point to bridge the literature, stakeholder discussion, and expert opinion to help decision-makers understand the various parts of the issue and consult the relevant updated evidence to inform their work.&#x0D;

Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke.

Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.

Difficult Intravenous Access Requiring Ultrasound in the Emergency Department: Associations With Delays in Care and Areas for Quality Improvement.

Background Patients with difficult intravenous access (DIVA) requiring ultrasound-guided intravenous (USGIV) access have been associated with delays in treatment, imaging, and disposition in academic emergency department (ED) patient populations. Our objective in this study was to characterize differences in time to intravenous access, imaging, and disposition between patients with DIVA versus those without DIVA requiring USGIV access in a community ED while also assessing for DIVA-associated comorbidities. Methods A cross-sectional, observational analysis was performed on admitted ED patients evaluated from September 2to September 31, 2022, at a community ED. Patients with DIVA were defined as patients with two failed attempts at traditional intravenous placement. These patients require USGIV placement per institutional protocol. Patients younger than 18 years of age, trauma admissions, repeated visits from the same patient, patients with missing data, and direct hospital admissions were excluded. Continuous variables were recorded with medians and included ED throughput measures of time to vascular access, contrast CT imaging, and disposition. Differences in median times between DIVA patients versus non-DIVA patients were assessed with the Mann-Whitney U-test. Categorical data involving comorbidities were reported as percentages, and differences in proportions between DIVA versus non-DIVA patients were assessed via chi-square tests. Multivariate logistic regression analysis evaluated for correlations between DIVA and times to access, contrast CT imaging, disposition, and significant covariates while adjusting for demographic information. Results A total of 1250 patients were included in this investigation (5.8% associated with DIVA requiring USGIV access). The median age of all subjects was 69 (interquartile range = 58, 79) with no significant difference between the DIVA and non-DIVA groups. Patients with DIVA were more likely to be female in comparison to patients without DIVA (65.3% and 51.2%, respectively, p < 0.05). Patients with a history of end-stage renal disease (ESRD) (p < 0.001), intravenous drug use (IVDU) (p < 0.001), and venous thromboembolism (p < 0.05) had statistically significant associations with DIVA. On regression analysis, patients with DIVA were more likely to have a history of ESRD with an odds ratio (OR) of 3.56 (95% confidence interval (CI): 1.62-7.81) and a history of IVDU with an OR of 14.29 (95% CI: 5.17-39.54). Patients with DIVA were associated with statistically significant greater median times to vascular access, contrast CT imaging, and disposition (p < 0.001 for time to access and disposition and p < 0.01 for time to contrast CT imaging). Conclusion In this study, DIVA cases requiring USGIV access were positively associated with significantly longer times to access, contrast CT imaging, and disposition compared to patients without DIVA at our community ED. Comorbidities such as IVDU and ESRD had statistically significant associations with DIVA requiring USGIV access.

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).

The contribution of physician associates or assistants to the emergency department: A systematic scoping review.

New health care professionals, such as the physician associate or assistant (PA), have expanded the ability of health systems to meet the needs of the population in both primary and secondary health care settings. Although PAs are widely deployed in the emergency department (ED), their role in the ED has not previously been formally described. This systematic scoping review synthesizes and critically analyzes existing literature on the impact and perception of the role of PAs working in the ED. We performed a systematic scoping review. We searched Medline, PubMed, Scopus, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE) and EMCare for English language peer-reviewed studies describing PA roles in the ED. Both qualitative and quantitative studies were included. We assessed the quality of the articles using QualSyst and the mixed methods appraisal tool. Themes regarding PA roles in the ED were identified. We included a total of 31 studies. Themes identified in the review included perceptions of the PA, wait times, acuity of patients seen, length of stay, those leaving without being seen (LWBS), clinical outcomes, pre-admission rates, well-being and scope of practice. Both the doctors' and patients' perception of PAs in the ED were generally high. The hindrance of them not being able to prescribe was evident. Studies showed a reduction in waiting times, length of stay, readmission rates, and those leaving without being seen when PAs work in the ED seeing moderate- to low-acuity patients. Evidence shows that PAs have a positive impact and the perceptions of the PAs are high in international EDs. There is significant evidence of PAs being key members of the health care team. Their work is particularly helpful for low- to moderate-acuity patients. With the increase in health care demand and a suffering UK National Health Service (NHS), the evidence synthesized in this review supports the potential positive impact PAs can have on the NHS and more specifically, the improvements of ED throughput metrics. This review identified the roles and positive influence of PAs in the ED. These findings highlight current and future challenges for PAs in the ED.

Mapping Nurses’ Advanced Roles in Emergency Departments Globally

Introduction:It is widely recognized that there is an increasing demand for healthcare in emergency departments (ED) around the world as well as a global shortage of healthcare workers (HCWs). This has led to ED overcrowding, which increases risks of avoidable complications and suboptimal care provision. Since ED overcrowding impacts patients, staff and quality of care, new strategies are needed for optimizing patient throughput and reducing waiting times. One such strategy is to reconsider the specific roles and professional duties of different cadres of HCWs. Empowering nurses to take on some of the tasks historically performed by physicians is a promising solution for improving ED healthcare provision. However, nurses’ professional responsibilities and competencies differ significantly from country to country. There are few studies about best practices and how to effectively implement such task-shifting strategies. The aim of this study is to map the evidence published in the scholarly literature on nurses’ advanced roles in ED as a strategy for reducing overcrowding, facilitating ED throughput, and, ultimately, improving quality of care.Method:A mapping review was performed by searching the following databases: PubMed, Embase, Scopus and Web of Science.Results:A total of 168 studies were analyzed and the data were grouped according to the countries where advanced tasks were implemented. The type of tasks that were carried out were: autonomous management of patients with minor injuries, triage-based ordering of exams and administration of therapy and management of patient flow.Conclusion:In some high-income countries having nurses take on advanced roles is well-established, and it contributes to reducing overcrowding in ED. Further evidence is needed to assess the barriers and facilitating factors to implementing this strategy in other contexts.

Reducing “Left without being seen” in a community emergency department: A rapid-cycle change project

Background and objective: The COVID-19 pandemic in 2020 increased the volume of patients seeking care in the Emergency Department (ED) for a respiratory crisis. Our community hospital experienced a filling of inpatient beds, leading to an overflow of admitted patients in the ED, where adequate staff (nurses, physicians, radiology, and laboratory staff), equipment, and rooms or places for patients were lacking. Times to obtain procedures that included cardiology, laboratory, and radiology performed and resulted significantly increased. Left without being seen (LWBS) is a challenge faced by EDs across the United States (US) and has become more prevalent since the COVID-19 pandemic. Best practice suggests an LWBS rate of less than 2%, but our hospital experienced an increasing rate of hitting over 5\% in January 2021. To reduce this rate, we implemented multiple rapid-cycle Plan-Do-Check-Act (PDCA) change interventions in triage and throughout the ED.Implementation/Methods: We implemented several rapid-cycle change interventions with a high-level action plan. These actions included hiring medical/surgical nurses to care for admitted patients awaiting beds, adding additional medical providers, implementing greeters, creating specialty chairs inside a major hospital thoroughfare, opening a 12-bed Admit Care Unit (ACU) adjacent to the ED, and more.Results: The rate of LWBS decreased from a high of 5.3% in January 2021 to 1.09% in January 2022.Conclusion/Implications to Practice: Patients in the ED recorded as LWBS are at higher risk for safety and quality transgressions. We continue to work toward excellent patient care by continuing to implement rapid-cycle changes in response to barriers as they arise. More research is needed to expand and rethink the process of ED throughput during pandemics and emergent national crises.