Emergency Department Throughput Research Articles

Impact of Provider-In-Triage in a Safety-Net Hospital.

Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1year prior (Group 3). There were significantly (p<0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p<0.001) lower for Group 1 (148min, interquartile range [IQR] 88, 226min) compared with 2 (187min, IQR 95.5, 266min) and 3 (215min, IQR 131, 290min). EDLOS was significantly (p<0.001) shorter for Group 1 (337min, IQR 215, 468min) compared with 2 (385min, IQR 271, 516min) and 3 (413min, IQR 299, 538min). We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.

Impact of a standardized admissions process using a nurse intermediary

Objective: Transitions of care, including those between the Emergency Department (ED) and Internal Medicine (IM) for hospital admissions are complicated, variable processes that impact efficiency and patient safety. At our institution, a new, standardized admissions process that involved a nurse coordinator intermediary who served a dual role of facilitating admissions and overseeing bed board was implemented in July 2017. We aimed to evaluate the impact of the new process on ED throughput and safety outcomes of admitted patients.Methods: A retrospective analysis of the admissions process for patients at an urban, academic ED was conducted over a 4-month period preceding and following process implementation. ED metrics, including admission decision to ED departure time, were reviewed. In addition, the number of admitted patients upgraded to the intensive care unit (ICU) via a rapid response team (RRT-ICU) within 24 hours of admission and direct physician-physician handoffs were analyzed via surveys of both IM and EM physicians.Results: A total of 1,109 admissions were reviewed. The new admissions process resulted in a statistically significant decrease in boarding times for admitted ED patients (p = .03). The number of RRT-ICUs within 24 hours of admission did not change as a result of the intervention (p = .5). Direct physician handoffs increased, but not significantly, according to surveys of IM (p = .39) and EM physicians (p = .34).Conclusions: The implementation of a standardized admissions process utilizing a nurse intermediary improved provider communication and ED throughput without negatively impacting patient safety.

Improving Quality With Emergency Department Throughput in a Critical Access Hospital.

The study objective was to determine the impact of specific measures to reduce the length of stay (LOS) in an emergency department (ED) in a critical access hospital (CAH). Despite mandates to reduce bottlenecks by increasing throughput, many EDs are not successful. Strategies available to larger hospitals may not be feasible for resource-limited CAHs. Interventions were implemented to decrease ED LOS in a rural CAH. Through retrospective chart reviews from time periods both preimplementation and postimplementation, the LOS was determined and compared using 2-sample t tests. Significant decreases were found between the groups in mean LOS times, as well as specific time intervals within the overall LOS time for nursing-centric activities and incidence of patients leaving prior to treatment completion. A significant decrease in LOS resulted from numerous actions taken to improve patient flow. Results may be used to enhance patient flow and decrease LOS in other CAHs, improving quality and access to care.

Which factors influence the ED length-of-stay after anterior shoulder dislocations: a retrospective chart review in 716 cases

BackgroundAnterior shoulder dislocations (ASD) are commonly seen in Emergency Departments (ED). ED overcrowding is increasingly burdening many healthcare systems. Little is known about factors influencing ED length-of-stay (LOS) for ASD. This study defines the factors influencing ED LOS for ASD patients.MethodsRetrospective chart reviews were performed on all patients ≥12 years admitted with an anterior shoulder dislocation at two regional hospitals in the Netherlands between 2010 and 2016. The electronic patient records were reviewed for baseline patient characteristics, trauma mechanism, reduction methods, medication used, complications and the LOS at the ED. The main objective was determining factors influencing the LOS in patients with an anterior shoulder dislocation at the ED.ResultsDuring the study period, 716 ASD occurred in 574 patients, 374 (65.2%) in males. There were 389 (54.3%) primary ASD; the remainder (327, 45.7%) were recurrent. Median LOS was 92 min (IQR 66 min), with a significantly shorter LOS in those with recurrent dislocations (p < 0.001), younger age group (p < 0.03) and in patients who received no medications in the ED (p < 0.001). Traction-countertraction and leverage techniques were associated with a significant more use of ED medication compared to other techniques. Although the use of more medication might suggest the LOS would be longer for these techniques, we did not find a significant difference between different reduction techniques and LOS.ConclusionTo our knowledge this study is the largest of its kind, demonstrating ED LOS in ASD patients is influenced by age, the need for medication and dislocation history, primary versus recurrent. Notably, we found that biomechanical reduction techniques, which are not primarily traction-countertraction or leverage techniques, e.g. scapular manipulation and Cunningham, were associated with less ED medication use. Further research is needed to define how reduction methods influence ED medication use, patient satisfaction and ED throughput times.

LO29: Interventions at triage to improve emergency department throughput: a systematic review

Introduction: Emergency Department (ED) crowding is the primary threat to emergency care quality. Input and outflow factors are important factors, but EDs must optimize throughput efficiency by improving internal processes from triage to disposition, and triage is the first throughput phase. Triage throughput interventions exclude strategies that direct patients away from the ED (these modify input rather than throughput). Previous research has described physicians in triage, team triage, telemedical triage, and nurse practitioner (NP) or physician assistant (PA) led triage, but their impact has never been systematically evaluated. Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without the use of filters or language restrictions of all triage interventions that effected ED throughput (PROSPERO:CRD42019125651). Two independent reviewers screened studies. Study quality was assessed using the Cochrane Risk of Bias tool (version 2) for randomized controlled trials, and the National Heart, Lung, and Blood Institute quality assessment tool for other designs. Results: 18 studies met inclusion criteria (Cohen's k = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. Studies were grouped into physician led, NP or PA led, and team triage interventions. Six physician in triage interventions reported LOS changes between -82 and + 18 minutes. Five NP/PA led triage interventions resulted in LOS changes of -106 to + 19 minutes. Five team triage interventions reported LOS reductions of 4 to 34 minutes. One telemedicine triage study reported a non-significant 8 minute increase in LOS. Six physician at triage interventions yielded significant LWBS rate improvement (relative risk {RR}= 0.29-0.82). Team triage interventions generated LWBS rate changes ranging from meaningful improvement (RR = 0.58) to substantial deterioration (RR = 1.68). Five studies have low risk of bias, 11 studies have some risk of bias, and 2 studies have high risk of bias (Cohen's kappa = 0.58). Conclusion: Fourteen of 18 triage interventions reduced EDLOS and/or LWBS rate. Physician, NP and PA led triage were the most effective triage interventions. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.

LO30: Optimizing diagnostic testing processes to improve emergency department throughput: a systematic review

Introduction: Emergency Department (ED) crowding is an intensifying crisis. While input, throughput, and output factors all contribute to crowding, throughput factors are the most dependent on ED staff and process. Diagnostic testing is a fundamental ED process that has not been systematically evaluated. We present a systematic review of interventions designed to reduce ED length of stay (LOS) by optimizing laboratory or imaging turnaround time, or by introducing point-of-care testing (POCT). Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without filters or language restrictions, of all interventions on diagnostic technology that affected ED throughput (PROSPERO:CRD42019125651). Studies were screened by two independent reviewers. Study quality was assessed using the Cochrane ROB-2 tools for randomized controlled trials (RCTs), and the National Heart, Lung, and Blood Institute tool for all other study designs. Results: 18 studies met inclusion criteria (Cohen's kappa = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. 12 POCT intervention studies reported LOS changes ranging from -114 to + 8 minutes (-26.8% to + 3.8%), although three were non-significant findings. Four studies that initiated POCT or lab-ordering at triage reported LOS reductions ranging from 22 to 174 minutes, but only one of these, at 29 minutes (16%), was statistically significant. One study of improved laboratory troponin processing reported a LOS reduction of 43 minutes (12.3%). Another, which allowed triage nurses to order ankle x-rays using the Ottawa ankle rules, reported a non-significant LOS reduction of 28 minutes for patients with ankle injuries. LOS improvements reflected the population of patients who underwent the testing modality, rather than overall ED LOS. Seven studies had low risk of bias, 11 studies had some risk of bias, and no studies had high risk of bias (Cohen's kappa = 0.58). Conclusion: Eleven of 18 diagnostic testing studies reported LOS reductions. POCT was the most common intervention type, and usually reduced EDLOS within relevant patient subsets, while triage-initiated testing generally did not. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.

Boarding is Associated with Reduced Emergency Department Efficiency that is not Mitigated by a Provider in Triage.

IntroductionBoarding of patients in the emergency department (ED) is associated with decreased ED efficiency. The provider-in-triage (PIT) model has been shown to improve ED throughput, but it is unclear how these improvements are affected by boarding. We sought to assess the effects of boarding on ED throughput and whether implementation of a PIT model mitigated those effects.MethodsWe performed a multi-site retrospective review of 955 days of ED operations data at a tertiary care academic ED (AED) and a high-volume community ED (CED) before and after implementation of PIT. Key outcome variables were door to provider time (D2P), total length of stay of discharged patients (LOSD), and boarding time (admit request to ED departure [A2D]).ResultsImplementation of PIT was associated with a decrease in median D2P by 22 minutes or 43% at the AED (p < 0.01), and 18 minutes (31%) at the CED (p < 0.01). LOSD also decreased by 19 minutes (5.9%) at the AED and 8 minutes (3.3%) at the CED (p<0.01). After adjusting for variations in daily census, the effect of boarding (A2D) on D2P and LOSD was unchanged, despite the implementation of PIT. At the AED, 7.7 minutes of boarding increased median D2P by one additional minute (p < 0.01), and every four minutes of boarding increased median LOSD by one minute (p < 0.01). At the CED, 7.1 minutes of boarding added one additional minute to D2P (p < 0.01), and 4.8 minutes of boarding added one minute to median LOSD (p < 0.01).ConclusionIn this retrospective, observational multicenter study, ED operational efficiency was improved with the implementation of a PIT model but worsened with boarding. The PIT model was unable to mitigate any of the effects of boarding. This suggests that PIT is associated with increased efficiency of ED intake and throughput, but boarding continues to have the same effect on ED efficiency regardless of upstream efficiency measures that may be designed to minimize its impact.

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics.

More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures. We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11am to 6pm, 7days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI]=2.0% to 2.5%) to 1.69% (95% CI=1.51% to 1.87%; p<0.001). Overall door to provider time decreased (median=19 [interquartile range {IQR}=9 to 38] minutes vs. 16.2 [IQR=7.8 to 34.3]minutes; p<0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median=184 [IQR=100 to 292]minutes vs. 184.3 [IQR=104.4 to 300]minutes; p<0.001). There was an increase in door to discharge times (median=146 [IQR=83 to 231]minutes vs. 148 [IQR=88.2 to 233.6]minutes; p<0.001) and door to admit times (median=330 [IQR=253 to 432]minutes vs. 357.6 [IQR=260.3 to 514.5]minutes; p<0.001). We saw an increase in LWTC (0.59% [95% CI=0.49% to 0.70%] vs. 1.1% [95% CI=0.9% to 1.2%]; p<0.001), but no change in AMA (1.4% [95% CI=1.2% to 1.6%] vs. 1.6% [95% CI=1.4% to 1.78%]; p=0.21) or LWOT (4.3% [95% CI=4.1% to 4.6%] vs. 4.4% [95% CI=4.1% to 4.7%]; p=0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

Tele-Intake in the ED Improves Left-Without-Being-Seen Rates but Not Overall ED Throughput

Researchers assessed the effects of a tele-intake triage intervention in the emergency department (ED) of a single community hospital. The intervention

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).

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

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

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.

115 Improving Emergency Department Efficiency: Decreasing Wait Times by Redistribution of Physician Staffing

Delays before receiving care in the emergency department (ED) can reduce the quality of care and increase risks and discomfort for patients with varying degrees of illnesses or injuries. The length of time patients wait to see a provider in the ED is also an important driver of patient satisfaction. We have an internal goal of performing a comprehensive (Full) exam on 90% of triage Emergency Severity Index (ESI) level 3 (urgent) patients within 120 minutes of arrival. We focused on this group because it represents both the largest volume of patients as well as having the greatest opportunity for improvement. We wanted to decrease wait time without using any additional physician or ancillary resources. Of the several hypothesized ways to reduce the wait time, we assessed the flow pattern in our ED and changed staffing patterns using staggered, overlapping shifts. Our goal was to reduce door to comprehensive provider exam time in ESI Level 3 patients. We performed a quasi-experimental, before and after study of patients from the ED of a large, urban, university-affiliated hospital. All patients who presented to the ED who were triaged to an ESI level 3 obtained from the departmental throughput report were included. The prior staffing pattern was of physician coverage of 12-hour shifts from 08:00-20:00 and 20:00-08:00, with some 11:00-23:00 hour coverage. We implemented multiple overlapping attending and resident physician shifts over 5 days on the weekdays to better align coverage with patient volume. ED throughput was evaluated from January 2018 through February 2019 after implementing the new staffing patterns in October 2018; encompassing times prior to, partial, and complete implementation. The throughput data was reviewed for total patients registered by triage, percentage of patients receiving full practitioner exam in less than 120 minutes from arrival, and median time in minutes to full exam. In the analyses pre- and post-intervention, continuous variables were assessed using Student t-test, while categorical data were assessed using chi-squares distribution. Prior to implementation of our overlapping physician scheduling intervention median Door-To-Full Exam was 84 minutes. Post implementation there was an immediate and sustained, in addition to statistically significant, reduction in our median Door-To-Full Exam. In Jan & Feb 2019 the median Door-To-Full was 52 minutes, which is a 62% decrease in median Door-To-Full Exam from the same period in 2018. Pre-intervention our percentage of level 3’s being seen under 120 min was 64%, and after intervention implementation was 82% representing a 18% increase of level 3’s being seen in goal time of under 120 minutes.Tabled 1JAN 18FEB 18MAR 18APR 18MAY 18JUN 18JUL 18AUG 18SEP 18OCT 18NOV 18DEC 18JAN 19FEB 19P-VALUETotal Volume Adult7,4596,6646,9156,8227,3386,9567,2187,2336,8667,0636,4726,7637,2046,5680.16Level 3 by Triage6,3705,9875,6875,6386,2395,6385,4455,5725,5045,8365,4235,9825,9295,5150.66Level 3 Percentage of Total Volume85%90%82%83%85%81%75%77%80%83%84%88%82%84%0.22Door To Full Exam (Triage Level 3)--Median Minutes91877284736889847665494952520.00Door To Full Exam (Triage Level 3)--Average Minutes10211196103968711210610188666967700.00Full Exam < 120 min (Triage Level 3) Percentage60%61%68%64%67%72%61%63%64%73%83%82%84%81%0.00 Open table in a new tab Without increasing attending and resident physician or ancillary staff hours, or redesign of physical space we were able to dramatically increase the number of ESI category 3 patients seen in less than 120 minutes. Patient volume data-driven redistribution of physician staffing led to marked improvement in emergency department efficiency.

Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients

BackgroundDelayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. MethodsThe Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. Results412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). ConclusionsED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.

Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates.

IntroductionThe emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates.MethodsThis study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015–March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not.ResultsOf 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%–5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%–3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%–5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%–63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%–0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters.ConclusionED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

LO10: Associations between ED crowding metrics and 72h-hour ED re-visits: Which crowding metrics are most highly associated with patient-oriented adverse outcomes?

Introduction: Emergency Department (ED) crowding is a pervasive problem and is associated with adverse patient outcomes. Yet, there are no widely accepted, universal ED crowding metrics. The objective of this study is to identify ED crowding metrics with the strongest association to the risk of ED revisits within 72 hours, which is a patient-oriented adverse outcome. Methods: Crowding metrics, patient characteristics and outcomes were obtained from administrative data for all ED encounters from 2011-2014 for three adult EDs in Calgary, AB. The data were randomly divided into three partitions for cross-validation, and further divided by CTAS category 1, 2/3 and 4/5. Twenty unique ED crowding metrics were calculated and assigned to each patient seen on each calendar day or shift, to standardize the exposure. Logistic regression models were fitted with 72h ED revisit as the dependent variable, and an individual crowding metric along with a common list of confounders as independent variables. Adjusted odds ratios (OR) for the 72h return visits were obtained for each crowding metric. The strength of associations between 72h revisits and crowding metrics were compared using Akaike's Information Criterion and Akaike weights. Results: This analysis is based on 1,149,939 ED encounters. Across all CTAS groups, INPUT metrics (ED census, ED occupancy, waiting time, EMS offload delay, LWBS%) were only weakly associated with the risk of 72h re-visit. Among THROUGHPUT metrics, ED Length of Stay and MD Care Time had similar adjusted ORs for 72h ED re-visit (range 0.99-1.15). Akaike weights ranging from 0.3/1.00 to 0.4/1.00 indicate that both THROUGHPUT metrics are reasonable predictors of 72h ED re-visits. All OUTPUT metrics (boarding time, # of boarded patients, % of beds occupied by boarded patients, hospital occupancy) had statistically significant ORs for 72h ED re-visits. The median boarding time had the highest adjusted OR for 72h ED re-visit (adjusted OR 1.40, 95% CI 1.33-1.47) and highest Akaike weight (0.97/1.00) compared to all other OUTPUT metrics, indicating that median boarding time had the strongest association with 72h re-visits. Conclusion: ED THROUGHPUT and OUTPUT metrics had consistent associations with 72h ED re-visits, while INPUT metrics had little to no association with 72h re-visits. Median boarding time is the strongest predictor of 72h re-visits, indicating that this may be the most meaningful measure of ED crowding.

LO87: Impact of an evidence-based clinical pathway for suspected renal colic in low-risk patients with previous nephrolithiasis on CT utilization and emergency department throughput

Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures &amp;amp; Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.

P051: Interventions to improve emergency department consultation processes: a systematic review

Introduction: Emergency Department (ED) consultations are often necessary for safe and effective patient care. Delays in throughput related to ED consultations can increase a patient's ED length of stay (LOS) and contribute to ED crowding. This review aimed to characterize and evaluate interventions to improve consultation metrics. Methods: Eight primary literature databases and the grey literature were comprehensively searched. Comparative studies of interventions to improve ED consultation metrics were included. Unique citations were screened for relevance and the full-texts of relevant articles were reviewed by two independent reviewers. Data on study characteristics and outcomes were extracted in duplicate onto standardized forms. Disagreements were resolved through consensus. Categorical variables are reported as proportions. Continuous variables are reported as the median of the means and total range. Results: After screening 2632 unique citations and 19 from the grey literature items, 24 studies were included. Seventeen interventions targeted specific conditions or speciality services, while the remainder targeted all ED presentations. Interventions fell into three broad categories: strategies to expedite patient care, including clinical pathways (42%); interventions to improve consultant responsiveness (33%); and addition of a specialized care team to the ED (25%). Overall, eight studies reported on the overall proportion of consults in the ED, of which six reported an increase in the consultation proportion (median: +0.6%, range: −11.3% to +49.6%). Six studies reported the proportion of consulted patients who were admitted, of which four reported an increase (median: +1.1%, range: −5.9% to +3.5%). On the other hand, six of seven studies reporting on time from request to consult arrival reported a decrease (median: −25 minutes, range: −66 to +3.8 minutes). Similarly, overall ED LOS was reported to be lower in 17/19 studies reporting this metric (median: −47.6 minutes, range: −600 minutes to +59 minutes). Conclusion: A variety of strategies have been employed to improve ED consultation processes and outcomes. Neither the proportion of consulted patients in the ED nor the proportion of admissions were improved; however, interventions appeared successful at improving consultant arrival times and overall ED LOS. Improvements in consultation processes may be an effective strategy to improve ED throughput and thereby reduce ED crowding.

P130: Timely initial assessment by a physician (IAP) improves community emergency department wait times

Introduction: Prior Canadian Emergency Department (ED) studies have demonstrated variable benefits of initial assessment physician (IAP) to rapidly assess and initiate care of ED patients after triage. These studies have been conducted primarily in academic teaching and large urban hospitals. It is not clear if such an IAP role could be beneficial in an small community hospital. Our pilot study hypothesized that instituting a supported IAP role can reduce physician intial assessment (PIA) time, total ED length of stay (LOS), and left-without-being-seen (LWBS) rates. Methods: This was a pre and post interrupted time series observational study at a community ED in Niagara Health Systems (Welland Ontario, 4 MD shifts, 36hrs total coverage, 30000 annual visits). In July 2017, an IAP ED shift (with separate assessment/treatment area) was re-purposed, with nursing support, to reduce initial time to MD assessment after triage. For lower acuity cases, the IAP MD generally completed full case management &amp;amp; disposition. Higher acuity complex cases were initiated by IAP, and transferred into the main ED care areas for “inside” MD management. Administrative data was accessed for 6 months prior to intervention, and 4 months available post-intervention. Descriptive statistics were calculated for collected data. Results: A modest improvement in different administrative ED performance metrics was observed. The following changes were noted pre and post IAP intervention: PIA time reduced from 3.6hrs to 3.2hrs, total ED LOS reduced from 19.2hrs to 13.8hrs, and daily LWBS rate reduced from 4.2% to 3.7%. This pilot study demonstrated improvement trends in ED performance metrics, although there is insufficient data to show statistical significance. Aggregate data was not subgrouped based on CTAS categories. This pilot was not intended to collect patient or staff satisfaction data, adverse events, nor designed to demonstrate cost-effectiveness Conclusion: Introducing an IAP shift in a small community ED has shown improvement trends for various ED throughput measures pertaining to outcomes such as PIA time, total LOS and LWBS rates. Further research is required to determine statistical significance of time reductions, satisfaction (patients, staff), resource utilization impact and CTAS subgroup performance. This improvement demonstrates potential impact system-wide across Niagara region.

Triaging Inpatient Admissions: an Opportunity for Resident Education.

In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.