Left Without Being Seen Rates Research Articles

The effect of long holidays on emergency department visits and cardiac emergencies

Aims: Patients who visit the emergency department (ED) on holidays have delays in diagnosis and treatment due to a lack of personnel and equipment, and these holiday periods may result in increased morbidity and mortality. In this study, we aimed to investigate the impact of a nine-day holiday on ED admissions and admissions due to cardiac complaints in our country, Turkey. Methods: This was a retrospective study. Patients were analyzed in 4 periods: Pre-Eid-El-Fitr, Eid-El-Fitr, pre-Eid al-Adha, and Eid al-Adha. Waiting times in the ED, the left without being seen (LWBS), consultations, admission diagnoses of cardiac patients, referral status of cardiac patients, and hospitalization were examined. Results: The most frequent visits to the ED were on Eid al-Adha (n=6581, 40.1 %). The waiting time before the ED examination increased with the crowd, and the longest waiting time was observed during Eid al-Adha (38.09 ±51.74 min, p<0.001). LWBS rate was the highest during the Eid al-Adha (15.4%). It was observed that cardiac emergencies had shorter waiting times. Among the cardiac emergency patients, all NSTEMI patients could not be referred from the ED during the Eid al-Adha period due to the fullness of the angiography centers, and the patients were transferred to the intensive care unit when the beds became available. Conclusion: Due to the crowded EDs during extended holiday periods, the triage system gains importance for the early detection and treatment of cardiac patients. A regular patient flow chart should be established on a provincial basis to avoid delays in the treatment process of patients needing angiography.

Assessment of Emergency Department Key Performance Indicators about Surge Response Actions Across Three Periods of the COVID-19 pandemic in an Italian Hospital

Introduction:At the beginning of the COVID-19 pandemic, Italian emergency departments (EDs) had to hastily implement current surge response plans or create new ones. The objectives of this study are to quantitatively assess ED performance improvements between selected non-pandemic and pandemic periods at Sant’Anna hospital in Como, Italy, and to relate these to adopted and adapted surge response actions.Method:The average length of stay (LOS), time-to-physician initial assessment (TPIA) and left-without-being seen (LWBS) rates were calculated during two ED periods prior to the pandemic and then three periods during the pandemic in the COVID ED (C-ED) dedicated to treat COVID patients, and the COVID-free ED (NC-ED) dedicated to treat all other patients. Then quantitative data analysis based on hypothesis testing was performed.A qualitative theme and subtheme data analysis based on the Hospital Surge Preparedness and Response Index (HSPRI) was performed on baseline strategies before each pandemic period and on the actions implemented in the subsequent period.Results:The LOS increased across all periods, while the TPIA decreased in the first two pandemic periods in comparison to pre-pandemic periods. The NC-ED LOS was lower than the C-ED LOS, and the C-ED TPIA was lower than the NC-ED TPIA in all three pandemic periods. The LWBS decreased between pre-pandemic and pandemic periods, with an increasing trend towards pre-pandemic levels in the last pandemic period. Of the 20 action items listed in the HSPRI, six were implemented in the first pandemic period, eight in the second and one in the third.Conclusion:The LOS, TPIA and LWBS rates are useful indicators to rapidly obtain an overview of ED performance but failed to provide an exhaustive assessment because ED performance depends on countless external and internal variables. Close collaboration of ED leaders with other healthcare agencies is critical to respond to a pandemic surge.

ATA2023Annual Conference & ExpoMarch 4–6, 2023San Antonio, Texas

ATA2023Annual Conference & ExpoMarch 4–6, 2023San Antonio, Texas

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.

The association between day of arrival, time of arrival, daily volume and the rate of patients that “left without being seen”

IntroductionPatients' left without being seen (LWBS) rate is used as an emergency department (ED) quality indicator. Prior research has investigated characteristics of these patients, but there are minimal studies assessing the impact of departmental variables. We evaluate the LWBS rate at a granular level, looking at its relationship to day of week, hour of arrival and total patient volume. MethodsRetrospective cohort analysis of 109,983 cases from a single academic center. We captured patient disposition, day of week and hour of day of arrival, and total daily volume.Chi-squared test was performed to determine the difference in LWBS rates based on arrival variables. We ran a polynomial regression for LWBS rates by decile of daily patient volume. ResultsThe overall LWBS rate was 1.82% over 2 years. This varied significantly by day of week and hour of day (p < 0.001). Day of week rates ranged from 0.73% on Sunday to 2.45% on Wednesday. Hour of day rates ranged from 0.26% between 8 AM–9 AM, to 3.71% between 10 PM–11 PM.As total daily patient volume increased, LWBS rates gradually increased until the 70th percentile, followed by significant exponential growth afterwards. DiscussionLWBS rates are not static measurements, and vary greatly depending on ED circumstances. Weekdays and evenings have significantly higher rates. Additionally, LWBS rates climb above 2% as daily registrations reach the 70th percentile, increasing exponentially at each subsequent decile. Understanding these effects will allow for more effective, targeted interventions to minimize this rate and improve throughput.

Impact of a Teletriage program on left without being seen rates and cost

Objective: Emergency Departments (EDs) experience throughput constraints for various reasons, such as space, resources, staffing, and bed placement. These throughput constraints are known to increase the volume of patients who leave without being evaluated. TeleTriage is a method implemented shortly after the arrival of the patient to the ED, as a means to expedite evaluation of patients. The project aimed to implement a TeleTriage program and analyze any impact on Left Without Being Seen (LWBS) rates and cost.Methods: A TeleTriage program was developed within a large, nonprofit, academic health care delivery system. The program was piloted at several campuses and subsequently implemented at multiple sites within the health system. Data on LWBS rates were collected for patients evaluated by the TeleTriage process and those who were not. An analysis of staffing utilization and cost-savings was also performed.Results: The TeleTriage program resulted in an average LWBS rate of 0.12% post-implementation, versus 0.79% for patients who were not in the TeleTriage group. In addition, the staffing consolidation resulted in cost-savings.Conclusions: The use of a TeleTriage program results in decreased LWBS rates, as well as cost-savings.

Telemedicine Rapid Assessment in the Emergency Department: A Pilot Study.

Background: The objective of this study is to evaluate a rapid assessment telemedicine system in the emergency department for safety, workflow disruption, and satisfaction level by clinicians, staff, and patients.Methods: After consent is obtained, the patient and telemedicine emergency physician are connected on a Health Insurance Portability and Accountability Act-compliant video conference for a rapid assessment, including history of present illness, review of systems, and past medical history. The telemedicine physician initiates orders based on these data. Patient data collected include age, gender, chief complaint, Emergency Severity Index, door to telemedicine physician time, door to in-person physician time, length of stay, left without being seen (LWBS) status, and satisfaction scores. Nurses were assessed for workflow interruptions and communication gaps. In-person physicians were assessed regarding perceived missed information in patient management, perceived workflow interruptions, and satisfaction.Results: Convenience sampling when participating physicians were on-shift resulted in 22 patients enrolled out of 25 approached over 2 months. No patients LWBS, and no in-person physicians perceived missed information in management. Satisfaction was well scored in all evaluated parties, with no score below a 4.77 out of 5 for any of the categories evaluated. Only one case interrupted the workflow of the on-site physician.Discussion: Telemedicine rapid assessment was found to be safe, efficient, and associated with high satisfaction. These results warrant study on a larger scale with a control group to statistically assess differences in outcome metrics such as LWBS rates. If effective, this approach could provide a novel and flexible physician-staffing tool.

Implementation of a Multifactorial Strategy Including Direct Bedding Is Associated With a Rapid and Sustained Reduction in Left Without Being Seen.

ObjectiveImprove left without being seen (LWBS) in our high volume, tertiary care trauma center. Prior to intervention, our LWBS rate was 4.4%. Including a direct bedding strategy, we successfully reduced our LWBS to <1%.Design and methodWe utilized a retrospective before and after model. We hired a clinical documentation specialist and tracked several metrics. These included daily census, admission rates, and door to provider, door to room, average boarding, and door to disposition times. Data were collected and disseminated daily. Reports were shared at organization quality meetings. Simultaneously, we implemented the direct bedding initiative in conjunction with quick registration. To accommodate higher numbers of patients and expediate movement to care spaces, all patient spaces were clearly designated and labeled.ResultsDirect bedding began in September 2015 and our LWBS was 4.4%. One-year post-intervention, our LWBS was <2%. Within four years, it was <0.5%. The LWBS rate for each year, 2016 to 2019, was significantly lower than the control period (p < 0.01) (2015 up to September). Improvement was also seen in door-to-provider time and with patient experience scores.ConclusionOur multifactorial approach was associated with a profound and sustained reduction in LWBS over a short time period.

The Effects of Implementing a "Waterfall" Emergency Physician Attending Schedule.

IntroductionIncreases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies.MethodsThis study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits.ResultsThe change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001).ConclusionImplementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.

Comparison of the Demographics and Visit Characteristics of Patients Who Left the Pediatric Emergency Department Without Being Seen With Those Who Were Evaluated in the Emergency Department.

We compared those patients who left without being seen (LWBS) with those who stay for evaluation and determined which subsets were more likely to depart prematurely in the largest pediatric population studied to date. We retrospectively extracted data from the electronic medical records of all pediatric patients who visited the emergency department between January 1, 2013, and December 31, 2015. The demographics and visit characteristics were compared between patients who LWBS and those seen by a provider. Bivariate and multivariate analyses were used to determine the odds for premature departure of specific groups within the population. Of the 271,364 pediatric patients visiting the emergency department during the 3-year study period, 3835 (1.4%) LWBS by a provider. The mean age of those LWBS was younger, and the odds of leaving slightly decreased as the patient's age increased (odds ratio [OR], 0.98). Those triaged as having "nonurgent" medical conditions had a statistically significant increase in odds of premature departure when compared with those with "urgent" medical conditions (OR, 1.16). Patients arriving during the evening and overnight hours had a much greater odds of LWBS (OR, 6.7 and 7.3, respectively). Our findings demonstrated and confirmed that age, time of arrival, and acuity level upon presentation were predictors of patients leaving before evaluation. This can guide institutions with staffing and flow processes as they attempt to reduce LWBS rates but also raises further questions as to whether these subsets go forward to have worse clinical outcomes after leaving prematurely.

P117: A multicenter analysis of an emergency physician lead on department flow and the provider experience

Introduction: Emergency department (ED) flow is a strong predictor of patient safety, quality of care and provider satisfaction. Throughput interventions have been shown to improve flow metrics, yet few studies have considered MD leadership roles and evaluated provider experience. Our objective was to evaluate the emergency physician lead (EPL) role, a novel MD staffing initiative. Methods: This mixed-method observational time series analysis evaluated ED metrics at two tertiary EDs including ED length of stay (LOS), EMS Park LOS and physician initial assessment (PIA) time as well as 72-hour readmit and left without being seen (LWBS) rates. Data was collected from the ED information system database for control (Dec 6, 2017-Feb 28, 2018 SITE1 and Mar 1–May 31, 2018 SITE2), pre (Sept 3-Nov 30, 2018 SITE 1 and Dec 3, 2018-Feb 28, 2019 SITE2) and post (Dec 3, 2018 –Feb 28, 2019 SITE1, Mar 1- May 31, 2019 SITE2) periods for adult patients presenting to each site. Site data was analyzed independently using descriptive and inferential statistics to calculate differences in means, and means were compared using t-tests. A survey elicited provider feedback from ED physicians, nurses, and EMS professionals on the effect of the EPL on throughput, timeliness of admissions and discharges, provider workload, and the EPL as a resource to other professionals. Results: The number of ED visits at SITE1 were 13136 (Ctrl), 13236 (Pre) and 13137 (Post), and at SITE2 were 14371(Ctrl), 13866 (Pre) and 14962 (Post). Mean ED LOS was decreased by 17 min in post vs control and 20 min vs pre at SITE1 (p &lt; 0.01). SITE2 saw an increase in ED LOS by 7 min vs control and 8 min vs pre (p &lt; 0.01). EMS LOS at SITE1 was decreased by 21 min vs control and 22 min vs pre (p &lt; 0.01), but was increased at SITE2 by 2 min vs control (p = 0.09) and 14 min vs pre (p &lt; 0.01). PIA time at SITE1 was decreased by 15 min vs control (p &lt; 0.01) and 13 min vs pre and increased by 5 min vs control and 12 min vs pre at SITE2 (p &lt; 0.01). 72 hour readmit and LWBS rates were unchanged at both sites. Qualitative feedback from ED providers highlighted the early provision of treatments and investigations by the EPL, and many felt the EPL was an important resource. Conclusion: The inclusion of both quantitative and qualitative data in this study provided a robust analysis of the impact of the EPL role and demonstrated modest but important improvements. A site-dependent, carefully considered implementation of the EPL role may improve ED metrics and provider experiences.

The Impact of On-duty Emergency Medicine Trainees on Left-Without-Being-Seen Rates in an Academic Emergency Department.

Objectives: One of the endpoints for assessing the emergency department (ED) performance is the left-without-being-seen (LWBS) proportion. This study aimed to evaluate the impact of increasing proportions of on-duty emergency medicine (EM) trainees on LWBS rates in clinical shifts. Methods: The study was conducted at an urban-academic-ED (annual census: 452,757) over a period of one year. We employed multivariate linear regression (p < 0.05) defining significance to identify and adjust for multiple LWBS influencers related to patient care. Results: After analyzing over 1098 shifts, the median LWBS rate was 8.9% (interquartile range 5.3% to 13.5%). The increasing number of EM trainees in the ED did not adversely impact the LWBS; the opposite was noted. In univariate analysis, the increasing proportion of on-duty EM trainee physicians was significantly (p < 0.001) associated with a decrease in the LWBS rates. The multivariate model adjusted for the statistically significant and confounding LWBS influencers, with an absolute increase of 1% in trainees’ proportion of overall on-duty physician coverage, was associated with an absolute decrease of 2.1% in LWBS rates (95% confidence interval 0.43% to 3.8%, p = 0.014). Conclusions: At the study site, there was a statistically and operationally significant improvement in LWBS associated with partial replacement of board-certified specialist-grade EM physicians with EM residents and fellow trainees.

A Front-end Redesign With Implementation of a Novel "Intake" System to Improve Patient Flow in a Pediatric Emergency Department.

Introduction:Children’s Hospital Colorado is an academic, tertiary-care Level 1 Trauma Center with an emergency department (ED) that treats >70,000 patients/year. Patient volumes continue to increase, leading to worsening wait times and left-without-being-seen (LWBS) rates. In 2015, the ED’s median door-to-provider time was 49 minutes [interquartile range (IQR) = 26–90], with a 3.2% LWBS rate. ED leadership, staff, and providers aimed to improve patient flow with specific goals to (1) decrease door-to-provider times to a median of <30 minutes and (2) decrease annual LWBS rate to <1%.Methods:An inter-professional team utilized quality improvement and Lean methodology to study, redesign, and implement significant changes to ED front-end processes. Key process elements included (1) new Flow Nurse/EMT roles, (2) elimination of traditional registration and triage processes, (3) immediate “quick registration” and nurse assessment upon walk-in, (4) direct-bedding of patients, and (5) a novel “Intake” system staffed by a pediatric emergency medicine physician.Results:In the 12 months following full implementation of the new front-end system, the median door-to-provider time decreased 49% to 25 minutes (IQR = 13–50), and the LWBS rate decreased from 3.2% to 1.4% (a 56% relative decrease). Additionally, the percentage of patients seen within 30 minutes of arrival increased, overall ED length-of-stay decreased, patient satisfaction improved, and no worsening of the unexpected 72-hour return rate occurred.Conclusions:Using quality improvement and Lean methodology, an inter-professional team decreased door-to-provider times and LWBS rates in a large pediatric ED by redesigning its front-end processes and implementing a novel pediatric emergency medicine-led Intake system.

31 Impacting Emergency Department Left Without Being Seen Rates Through Physician Resourcing

Patients who leave the emergency department (ED) without being seen and evaluated, or left without being seen (LWBS), pose a continual challenge for all EDs. This population poses the moral and ethical dilemma of not providing care to those who present for it. They also carry significant risk associated with the missed opportunities, for the patient and the institution. Also, LWBS rates are nationally reported metrics for institutions and generate no reimbursement. As such, EDs nationally are continually trying to implement initiatives to quickly evaluate and treat patients.

Using modified triage system to improve emergency department efficacy: A successful Lean implementation

ABSTRACT Introduction: Most emergency departments in rural hospitals practice single-tier triage system. We propose adding a secondary triage, a 2-tier triage system that can improve the department efficacy. Methods: This was a single-centre pre–post-interventional study conducted in a district emergency department. During pre-interventional phase, patients were triaged by usual practice using single-tier system. For post-interventional phase, a secondary triage was added. A physician was also added to the secondary triage during peak hours. All patients who came during pre- and post-intervention phases were recruited for analysis. The primary outcomes were department length of stay (LOS) and left without being seen (LWBS) rate. Results: There were 5007 patients (pre-intervention period) and 4970 patients (post-intervention period) recruited for data analysis. Intervention had reduced the overall LOS from 106 to 85 min (mean, p < 0.001). Subgroup analysis showed reduced LOS for non-critical cases from 72 to 45 min (mean, p < 0.001), but no significant improvement for critical and semi-critical cases. The LWBS rate was also reduced from 4.1% to 2.0% (p < 0.001). Conclusions: Secondary triage system with an addition of physician during peak hours has been proven to improve emergency department LOS and LWBS rate.

Characterization of emergency department abandonment using a real-time location system

BackgroundPatients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting. ObjectiveCompare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates. MethodsThis is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included. ResultsOur study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5). ConclusionCompared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.

Freestanding emergency departments in Texas do not alleviate congestion in hospital-based emergency departments

ObjectivesEver since the passage of the Texas Freestanding Emergency Medical Care Facility Licensing Act in 2009, freestanding Emergency Departments (FrEDs) have spread throughout Texas. This study aims to determine whether the entry of FrEDs has been associated with less congestion in hospital-based EDs. MethodsThe dependent variables of interest were hospital-based ED annual visit volume, median wait time, length of visit for discharged patients and the percent of patients who left without being seen (LWBS). The explanatory variables of interest were the numbers of FrEDs within the same local market of each hospital-based ED, and an indicator variable for whether the hospital owned satellite FrEDs in outlying areas. ResultsHospital ED visits, wait times, length of visit for discharged patients, and LWBS rates were not associated with the number of competitor FrEDs in the local market. Hospitals that opened satellite FrEDs had significantly higher visit volume in general, but did not experience shorter wait times, length of visit or LWBS rates if located in large metropolitan areas. ConclusionsThe entry of FrEDs did not help relieve congestion in nearby hospitals in major metropolitan areas in Texas. By offering more treatment options to patients, FrEDs are associated with increased usage of emergency services.

MP03: Strategies to minimize impact of electronic health record implementation on emergency department flow

Introduction: Electronic health record (EHR) implementation can be associated with a slowdown in performance and delayed return to pre go-live productivity. The objective of this study is to describe the impact of a go-live strategy including diversion, public advertising of the go-live, and extra physician staffing to mitigate productivity loss. Methods: Lions Gate Hospital (LGH), an urban community hospital and rural referral centre with 250 beds and 65,000 annual ED visits went live with Cerner HER (Cerner Corporation, Kansas, MO) on April 28, 2018. The implementation included complete electronic ordering and electronic physician documentation. We compared patients seen per hour, time to physician (TTMD), ED length of stay (EDLOS), patients per hour left without being seen (LWBS), and admission rate (AR) for the 6 weeks prior to implementation (Pre), 2 weeks during (Imp), and 6 weeks after (Post) for LGH and a control hospital (Richmond Hospital – comparable in size/acuity) for the same periods. Medians were compared using the Mann-Whitney test for patients/hour, EDLOS and TTMD, and chi-square for AR and LWBS. Results: Patients/hour seen went from 2.1/hour in the pre phase, but dropped to 1.7/hr in the 2 week period following implementation (P &amp;lt; 0.05). During weeks 2-8 post implementation, 2,3 patients per hour were seen (P = 0.38 compared to Pre phase). At the control hospital, patients per hour were comparable across all time periods (Ps &amp;gt; 0.3). Median time to physician was 54, 56, and 54 minutes at LGH for the Pre, Imp, and Post time periods (Ps &amp;gt; 0.3). Median EDLOS was 184, 196, and 184 minutes in the pre, Imp, and post phases (P Imp versus pre = 0.11; Pre versus post = 0.54). LWBS rate was 1.3%, 2.9, and 2.4% (Ps for Imp and Post versus pre &amp;lt;0.05) at LGH, but the pattern was similar for the control hospital (2.9%, 4.1% and 4.0%’ Ps &amp;lt;0.05). There was no significant change in ambulance arrivals or admission rate at either hospital (Ps &amp;gt; 0.2). Conclusion: A deliberate implementation strategy that focuses on ED physician upstaffing and visit diversion can smooth the impact of the implementation of an EHR so that patient care is not impacted significantly. Return to normal productivity occurred by 8 weeks post go-live. We demonstrate a strategy that may support easier implementation at other sites.

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.

Trends and Characterization of Academic Emergency Department Patient Visits: A Five-year Review.

To meet the unique comparative data needs of academic emergency departments (EDs), we describe the recent 5-year national and regional trends for adult emergency patients' characteristics and operational parameters at academic emergency medical centers. Data collected from the recent 5-year period academic year (AY) 2012 through AY 2016 of the Academy of Administrators in Academic Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) Academic Emergency Medicine Benchmarking Survey were analyzed for trends in 1) ED volumes and modes of arrival, 2) triage acuity level, 3) trends in ED professional fee billing, and 4) disposition patterns of ED patients including admission rates and walkouts. The AY spanned the 12-month period of July 1 through June 30. Only primary academic or academic affiliate hospitals data were included. Community and freestanding affiliated EDs were excluded. Institutional-specific data were stratified into four cohorts based on the following annual ED visit volumes: under 40,000, 40,000 to 60,000, 60,000 to 80,000, and over 80,000. Triage acuity levels were based on the Emergency Severity Index (ESI). Professional fee billing was analyzed specifically for CPT codes 99284, 99285, and 99291 (critical care). Left without being seen (LWBS), defined as leaving before a screening examine by a licensed medical provider, and screened and left (SAL), i.e., patients who were screened by a provider, but left before definitive evaluation and management, were similarly evaluated. Total walkouts were defined as the sum of LWBS and SAL. Forty-four primary academic and academic affiliate sites completed the survey for all 5 years. The mean annual patient census increased 13.4% over the study period, with the majority (80%) of sites experiencing volume growth. Acuity/illness severity, measured as ESI 1 and 2, and CPT codes 99284, 99295, and 99291 increased an aggregate 18.2 and 8.4%, respectively. Large-volume hospitals (>60,000-80,000, >80,000) admissions increased by 15 and 21.6%, respectively, primarily due to surge in 2016. Overall emergency medical services (EMS) arrivals increased 7.3% although admissions from EMS remained relatively stable. LWBS rates decreased 19.5%, but total walkouts did not appear to change. With a focus on larger academic institutions, differences were noted in the overall increases in volume and acuity. In this survey, participating institutions experienced increased volumes of patients with seemingly higher illness severity. While inroads have been made in LWBS rates, there has not been an overall decrease in total walkouts. The data reported here differed in many aspects compared to other benchmark surveys.