Factors Affecting Emergency Department Research Articles

The effect of having a physician in the triage area on the rate of patients leaving without being seen: A quality improvement initiative at King Fahad Specialist hospital.

To evaluate the effect of the presence of a physician in the triage area on the number of patients who leave without being seen (LWBS) and some of the factors affecting emergency department (ED) crowding. This was a pre-post study carried out at King Fahad Specialist Hospital, Dammam, Saudi Arabia. The 3-month study, consisting of 7826 patients, was split into pre-physician and post-physician periods. Variables compared across these periods were the number of LWBS patients, length of hospital stay, time to physician, and time to disposition decision. Statistical analysis was carried out using R version 4.3.0. Our results showed that the presence of a triage physician significantly decreased the number of LWBS patients (p<0.001) and the time taken to encounter an ED physician (p<0.001). However, it did not have any significant impact on the length of hospital stay (p=0.5) or time to disposition decision (p=0.9). The appointment of a triage physician has streamlined patient flow and decreased LWBS rates in the ED, demonstrating the need for more thorough research in this area.

Factors affecting emergency department use among pediatric immigrants and refugees: A qualitative narrative review

Purpose: To identify factors affecting emergency department (ED) use by immigrant and refugee children under the age of 18 years in North America and Europe, where similar primary, secondary, and tertiary healthcare structures exist. Methods: A narrative review methodology was used to complete a search of three databases including CINAHL, MEDLINE, and SCOPUS. Inclusion criteria and exclusion criteria were applied following screening and full-text review, resulting in the 8 articles that were selected for this review. Results: Six central themes were identified for presentation to ED’s including: (1) financial accessibility; (2) health insurance; (3) presence of a primary care provider; (4) language barriers; (5) transportation; and (6) health literacy, with health literacy further being divided into a lack of knowledge and parental perception and understanding of illness. Implications and Conclusion: Factors that influence ED use by pediatric immigrant and refugee patients are multi-factorial and interconnected. Recommendations are made to encourage informed changes based on population healthcare needs, with the overall goal to reduce non-essential ED use and improve patient health outcomes. While this review identifies and evaluates the limited research available in this area, further studies need to be completed before generalizations can be made for all pediatric immigrant and refugee populations.

Factors affecting the length of stay in the emergency department for critically Ill patients transferred to regional emergency medical center.

To identify the factors affecting Emergency Department Length of Stay for transferred critically ill patients. The Length of Stay of the transferred patients is an important indicator of Emergency Department service quality; thus, understanding the factors affecting the Emergency Department Length of Stay of transferred critically ill patients is essential. Using the electronic medical records of 968 transferred critically ill Emergency Department patients of a tertiary hospital in Korea, prediction models for Emergency Department Length of Stay were built using various machine learning algorithms. The logistic regression (AUROC 0.85) models showed the best performance, followed by random forest (AUROC 0.83) and Naive Bayes (AUROC 0.83). The logistic regression model indicated that fewer consultations, the highest acuity level, need for an emergency operation or angiography, need for ICU admission, severe emergency disease and fewer diagnoses were the statistically significant predictors for Emergency Department Length of Stay of 6h or less. The transferred critically ill patients analysed in this study who required immediate or specialized care tended to receive needed care on time at the study site. Understanding the factors affecting the Emergency Department Length of Stay of transferred critically ill patients is crucial for developing strategies to manage the nursing resource of Emergency Department successfully.

Factors Affecting Emergency Department Visits, Readmissions, and Reoperations within 30 Days of Ankle Fracture Surgery: An Institutional Retrospective Study

Category:Ankle; TraumaIntroduction/Purpose:With the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery.Methods:This retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015-2018). The outcome measures assessed were emergency department visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes. P-values less than 0.05 were considered significant.Results:A total of 619 patients were identified. After exclusion of concurrent pilon fractures, 596 patients were eligible for final analysis. Forty-three (7.2%) patients visited the emergency department within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring unplanned return to the OR within thirty days. Sex, insurance status, comorbidities such as pulmonary disease, diabetes mellitus, psychiatric disease, and chronic kidney disease, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p=0.02). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p<0.01).Conclusion:Age less than 45 years old was a risk factor for early ED visits. Open fractures were found to be at increased risk of needing unplanned reoperation. While further investigation into these risk factors is necessary to fully delineate a causal relationship, these findings can help physicians identify ‘at-risk’ populations after ankle fracture surgery and provide the necessary care to minimize early postoperative events.

Factors affecting emergency department visits, readmissions, and reoperations within 30 days of ankle fracture surgery- an institutional retrospective study

IntroductionWith the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This large single institution study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery. MethodsThis retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015–2018). A total of 596 patients were included in final analysis. The primary outcome measures assessed were emergency department (ED) visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes. ResultsForty-three (7.2%) patients visited the ED within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring reoperation within thirty days. Sex, insurance status, several comorbidities, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p = 0.016). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p<0.01). Fifty-four percent of ED visits were for postoperative pain, while 37% of ED visits and 60% of readmissions within 30 days were for issues unrelated to the ankle fracture. ConclusionsAge less than 45 years old was a risk factor for early ED visits, highlighting a potential “at-risk” population after ankle fracture surgery. Furthermore, many of the ED visits (37%) and readmissions (60%) were unrelated to the ankle fracture suggesting unnecessary healthcare utilization may be avoided with protocols that increase emphasis on reconditioning and optimization of comorbidities.

Patient Factors Affecting Emergency Department Utilization and Hospital Readmission Rates After Primary Anterior Cervical Discectomy and Fusion: A Review of 41,813 cases.

Retrospective database analysis. To identify preoperative risk factors for emergency department (ED) visit and unplanned hospital readmission after primary anterior cervical discectomy and fusion (ACDF) at 30 and 90 days. Limited data exist to identify factors associated with ED visit or readmission after primary ACDF within the first 3 months following surgery. Patients undergoing ACDF from 2005 to 2012 were identified in the Statewide Planning and Research Cooperative System database. Multivariable regression models were created based on patient-level and surgical characteristics to identify independent risk factors for hospital revisit. Of 41,813 patients identified, 2514 (6.0%) returned to the ED within 30 days of discharge. Risk factors included age < 35, black race (OR 1.19), Charlson Comorbidity index score > 1, length of stay (LOS) greater than 1 day (OR 1.23), and fusion of > 2 levels (OR 1.17). Four thousand six hundred nine (11.0%) patients returned to the ED within 90 days. Risk factors mirrored those at 30 days. Patients having private insurance or those discharged to rehab were less likely to present to the ED. One thousand three hundred ninety-four (3.3%) patients were readmitted by 30 days. Risk factors included male sex, Medicare, or Medicaid insurance (OR 1.71 and 1.79 respectively), Charlson comorbidity index > 1, discharge to a skilled nursing facility (OR 2.90), infectious/pathologic (OR 3.296), or traumatic (OR 1.409) surgical indication, LOS > 1 day (OR 1.66), or in-hospital complication. 2223 (5.3%) patients were readmitted by 90 days. Risk factors mirrored those at 30 days. No differences in readmission were seen based on race or number of levels fused. Patients aged 18 to 34 were less likely to be readmitted versus patients older than 35. Insurance status, comorbidities, and LOS consistently predicted an unplanned hospital visit at 30 and 90 days. Although nondegenerative surgical indications and in-hospital complications did not predict ED visits, these factors increased the risk for readmission. 3.

Factors Affecting Emergency Department Computed Tomography Use in Children

BackgroundVariability in computed tomography (CT) use during pediatric emergency department (ED) visits has been reported. Our objective was to identify patient and hospital characteristics associated with CT use during pediatric ED visits. MethodsPatients <18 y treated and released from EDs in the 2006-2012 Nationwide Emergency Department Sample were included. Associations were evaluated between pediatric CT scan rate and patient/hospital factors using logistic mixed effects models. Independent predictors of being a high outlier (having a pediatric CT scan rate in the top 10%) were also evaluated using logistic regression models. ResultsThere were 1543 EDs and 20,703,273 visits included. CT scans were prescribed in 4.7% of pediatric ED visits; the highest 10% of EDs prescribed CT scans in >7.63% of all pediatric visits. In multivariable analysis, older age, male gender, private insurance, higher zip code level median income, and higher injury severity were all associated with an increased probability of receiving a CT scan (all P < 0.001). The chance of receiving a CT scan also varied by diagnosis and was independently associated with geographic location and annual pediatric ED volume. Rates of CT use increased with increasing pediatric volume up to approximately 5400 annual pediatric visits, and then decreased with volume >5400 annual visits. ConclusionsSeveral patient-level and ED-level characteristics, including annual pediatric volume, are associated with the probability of a child having a CT scan during an ED visit. Future work should focus on determining drivers behind these associations to develop intervention strategies to decrease pediatric CT use.

Population and patient factors affecting emergency department attendance in London: retrospective cohort analysis of linked primary and secondary care records.

Population factors, including social deprivation and morbidity, predict the use of emergency departments (EDs). To link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record. Retrospective cohort study based in East London. Primary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices. Adjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance. Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.

Factors Affecting Emergency Department Use by a Chronically Homeless Population.

Homeless adults make extensive use of emergency department (ED) services. This study examined factors associated with moderate and high ED use in a cohort of chronically homeless individuals. A cross-sectional analysis identified factors related to ED use in a cohort of 755 individuals at 11 sites at entry into the Collaborative Initiative to Help End Chronic Homelessness (CICH). Bivariate analyses identified sociodemographic, housing status, health status, and service-related factors associated with moderate and high ED use. Independent risk factors were then identified by using a multivariate multinomial model. Hierarchical regression was used to compare the strengths of association between ED use and blocks of factors composed of sociodemographic, housing, health, and service-related characteristics. In a three-month period, 30% of participants visited the ED one or two times (moderate ED use) and 12% visited three or more times (high-ED use). ED use was most strongly associated with poor health and utilization of other non-ED services and to a lesser extent with housing status. Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services. Thus ED use was related to high need and acuity and was not ameliorated by use of other services. Housing instability and homelessness contributed less robustly to increased ED use. More coordinated services may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.

Analyzing Factors Affecting Emergency Department Length of Stay-Using a Competing Risk-accelerated Failure Time Model.

Emergency department (ED) length of stay (LOS) is associated with ED crowding and related complications. Previous studies either analyzed single patient disposition groups or combined different endpoints as a whole. The aim of this study is to evaluate different effects of relevant factors affecting ED LOS among different patient disposition groups.This is a retrospective electronic data analysis. The ED LOS and relevant covariates of all patients between January 2013 and December 2013 were collected. A competing risk accelerated failure time model was used to compute endpoint type-specific time ratios (TRs) for ED LOS.A total of 149,472 patients was included for analysis with an overall medium ED LOS of 2.15 [interquartile range (IQR) = 6.51] hours. The medium LOS for discharged, admission, and mortality patients was 1.46 (IQR = 2.07), 11.3 (IQR = 33.2), and 7.53 (IQR = 28.0) hours, respectively. In multivariate analysis, age (TR = 1.012, P < 0.0001], higher acuity (triage level I vs level V, TR = 2.371, P < 0.0001), pediatric nontrauma (compared with adult nontrauma, TR = 3.084, P < 0.0001), transferred patients (TR = 2.712, P < 0.0001), and day shift arrival (compared with night shift, TR = 1.451, P < 0.0001) were associated with prolonged ED LOS in the discharged patient group. However, opposite results were noted for higher acuity (triage level I vs level V, TR = 0.532, P < 0.0001), pediatric nontrauma (TR = 0.375, P < 0.0001), transferred patients (TR = 0.852, P < 0.0001), and day shift arrival (TR = 0.88, P < 0.0001) in the admission patient group.Common influential factors such as age, patient entity, triage acuity level, or arrival time may have varying effects on different disposition groups of patients. These findings and the suggested model could be used for EDs to develop individually tailored approaches to minimize ED LOS and further improve ED crowding status.

Evaluation of Factors Affecting Emergency Department Handovers; Experience of a Military Hospital

Evaluation of Factors Affecting Emergency Department Handovers; Experience of a Military Hospital

333 Factors Affecting Emergency Department Opioid Prescribing Decisions Vary by Provider Type: A Cross-Sectional Survey at an Urban Academic Center

Commensurate with the trend of rising overdose deaths related to prescription opioid analgesics is a trend of increasing opioid prescription by clinical practitioners. Prior studies have shown that opioid prescribing decisions vary greatly among emergency department (ED) providers, but little is known about the factors that underlie these decisions. The main aim of this study was to describe the self-reported importance of different factors in a provider’s decision to prescribe opioid medications.

Universal Factors Affecting Emergency Department Crowding

Dear Editor, I read with great interest the article entitled “Application of Queuing Analytic Theory to Decrease Waiting Times in Emergency Department: Does it Make Sense?” in the autumn issue of Archives of Trauma Research (1). As an emergency physician in the United States, I can share the frustration of the authors that throughput of patients in the emergency department can often be hindered by numerous medical and logistical factors. In the United States, unlike most countries, emergency department care is not reserved to patients with acute severe conditions alone. Rather, under US law, emergency departments regularly provide care to patients who often do not have access to health care in other settings (2). I believe most emergency physicians in the United States would presume that the lack of such legal mandates would result in less crowding and difficulties in patient flow in emergency departments outside of the US. As this article clearly shows, unfortunately, there are common factors that emergency departments worldwide share in the challenge to improve patient waiting times. Similar to the US, the Iranian emergency department analyzed in this article faces obstacles in the form of personnel, lab processing and results and critical care bed availability. The authors chose a very appropriate simulation method to analyze how their emergency department staffing and procedures could be improved. I would be very curious to see in a follow-up article from the authors whether the implementation of potential solutions to the challenges identified was successful in reducing their emergency department waiting and patient holding times. Such solutions would be of great interest not only in Iranian emergency departments but also in emergency departments worldwide.

Community Characteristics Affecting Emergency Department Use by Medicaid Enrollees

In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr. Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

Analysis of the outcomes of cardiopulmonary resuscitation in an emergency department

Objective — The aim of this study is to analyse the factors affecting emergency department (ED) cardiopulmonary resuscitation (CPR) outcome.Methods — A standard CPR protocol was performed in all patients and certain pre and postresuscitation parameters including age, sex, initial arrest rhythm, primary underlying disease, initiation time of advanced cardiac life support, duration of return of spontaneous circulation were recorded. Patients were followed up to determine rates of successful CPR, survival and one-year survival.Results — From December 1999 to May 2001, 80 consecutive adult patients in whom a standard CPR was performed in the ED were prospectively included in the study.The overall rate for successful CPR, survival and one-year survival were found to be 58.8% (47/80), 15% (12/80) and 10% (8/80), respectively. Survival and one-year survival rates were better in patients with an initial arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) than both pulseless electrical activity (pEA) and asystole; survival and one-year survival rates were better in patients with a primary underlying disease of cardiac origin than non-cardiac origin. Acute myocardial infarction had the best prognosis among conditions causing arrest. Presence of sudden death was found to have a better survival and one-year survival rate.Conclusion — Initial cardiac rhythm of VF/pVT, cardiac origin as the primary disease causing cardiopulmonary arrest and presence of sudden death were found to be good prognostic factors in CPR.

Factors Affecting Emergency Department Assessment and Management of Pain in Children

To evaluate statewide emergency department assessment and management of pain in pediatric patients as a quality improvement initiative. 2002 Survey of Illinois Hospital emergency department's pediatric pain assessment and management strategies, in conjunction with a retrospective chart review of children, ages 0 to 15 years, treated for an extremity fracture. Survey results were available for 123 (59.4%) hospitals; 933 charts (107 hospitals) were reviewed for pain management. Survey results were compared with practices identified by chart review. Use of a pain assessment scale estimated by the survey was 92%, compared with 59% use by chart review. Use of pain assessment scales for infants was limited. Fifty percent of patients in moderate to severe pain would be offered an analgesic. Six- to 15-year-old children would be offered opioids more often than children aged 0 to 1 and 2 to 5 years. Offering higher potency narcotic analgesics was associated with patient's age, geographic location of the facility, and emergency department volume. Providing an analgesic (odds ratio 4.53, 95% confidence interval 2.89-7.10), offering supportive care (odds ratio 2.37, 95% confidence interval 1.44-3.89), and pediatric-focused annual nurse competencies (odds ratio 1.90, 95% confidence interval 1.18-3.06) correlated with reduction of the patient's pain. Disparity exists between perceived and documented emergency department pain management practices for children. Quality improvement initiatives should focus on improving pain assessment in infants, treating moderate to severe pain in children of all age groups, and education of health care providers in pain management strategies. Resources should target health care processes effective in decreasing pediatric pain.

Factors Affecting Emergency Department Opioid Administration to Severely Injured Patients

Factors Affecting Emergency Department Opioid Administration to Severely Injured Patients

Factors Affecting Emergency Department Opioid Administration to Severely Injured Patients

Studies of emergency department (ED) pain management in patients with trauma have been mostly restricted to patients with fractures, yet the potential for undertreatment of more severely injured patients is great. The authors sought to identify factors associated with failure to receive ED opioid administration in patients with acute trauma who subsequently required hospitalization. At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study of trauma team activation patients requiring hospitalization between January 1 and December 31, 1999, was conducted. The authors excluded patients receiving opioids only within ten minutes of chest tube insertion or fracture manipulation. The main outcome measure was ED opioid administration. A total of 540 charts of hospitalized first-tier trauma team activation patients were reviewed. A total of 258 (47.8%) received intravenous opioid analgesia within three hours of ED arrival. The median time to receiving the first dose of opioids was 95 minutes. Patients were independently less likely to receive opioids if they were younger or older, were intubated, had a lower Revised Trauma Score, or did not require fracture manipulation. Patients with these factors were less likely to receive opioids independent of the amount of time they spent in the ED. Many trauma activation patients requiring hospitalization do not receive opioid analgesia in the ED. Patients at particular risk for oligoanalgesia include those who are younger or older and those who are more seriously injured, as defined by a lower Revised Trauma Score, lower Glasgow Coma Scale score, and intubation.

Physician knowledge and attitudes toward an emergency medical services system

A survey was conducted to measure the knowledge, attitudes, and practices concerning emergency medical services (EMS) of physicians practicing in a suburban-rural county on Long Island, New York. Two hundred fifty-four physicians responded to a questionnaire formulated to determine the following: knowledge of the existing system; perceived changes in system components; opinions about factors affecting emergency department visits; physician recommendations to patients in hypothetical situations; reasons for choosing a particular hospital for emergency patients; interest in involvement in the county EMS training program; and physician socio-demographic characteristics. Such information is valuable in the planning of EMS programs.