Mean Emergency Department Length Of Stay Research Articles

The use of a psychiatric overflow unit in a large urban community hospital to improve process outcomes

BackgroundThe United States is experiencing a mental health (MH) crisis with limited resources to meet demands. We established a 5-bed psychiatric overflow unit (POU) within the emergency department (ED) as a care alternative. ObjectiveDetermine the clinical utility and safety of a POU in care delivery to patients in a MH crisis compared to the main ED (controls). MethodsRetrospective study using data from electronic health record/chart review [October 1, 2021–May 31, 2022 (POU established January 2022)] for all ED patients ≥12 years admitted with MH crisis. Per triage nurse, patients for potential hospital admission were POU admitted when medically cleared. Clinical utility definition: ED length of stay (LOS); patient safety definition: return to ED within 72 ​h for same complaint. ResultsPatients (n ​= ​919; POU ​= ​302, main ED ​= ​617) were 61.4% male, mean age 39.7 ​± ​15.6 years, 84.2% ESI 2, 61.7% admitted/transferred, average ED LOS was 932.3 ​± ​804.7 ​min and no returns within 72 ​h. POU had longer ED LOS (1058.7 ​± ​736.5 vs 884.6 ​± ​824.6, P ​< ​0.0001) but no differences among admitted/transferred patients comparing POU vs controls (P ​> ​0.05); Among discharged patients POU compared to main ED had a longer mean ED LOS (819.9 ​± ​779.8 vs 486.4 ​± ​577.3, P ​< ​0.0001); Removal of police escort patients did not change POU ED LOS (P ​< ​0.05). ConclusionsAn ED POU, staffed with behavioral health nurses, had equivocal safety and clinical utility as the main ED potentially providing an alternative care-delivery option when ED space and MH resources are limited.

130 CHARACTERISTICS AND OUTCOMES OF OLDER NURSING HOME RESIDENTS ATTENDING AN EMERGENCY DEPARTMENT

Abstract Background Older nursing home (NH) residents are among the most vulnerable members of society, often with multiple comorbidities and complex care needs. The Emergency Department (ED) is a common point of access to the acute hospital for NH residents. This study aims to review characteristics and outcomes of older NH residents presenting to ED over one year. Methods A prospective cohort study was carried out. NH residents aged 50 years and older attending ED of a university teaching hospital over one year (01/10/2019-30/09/2020) were included. Data on demographics, comorbidities, functional status, frailty and details of ED attendance were collected. Results There were a total of 515 ED attendances by 341 NH residents over one year. Mean age was 76.3 years (50-103 years; SD ± 10.9). 50.9% (n=262) were female. Mean Charlson Comorbidity Index (CCI) was 5 (0-12; SD ± 2.1). 46.6% (n=240) had a dementia diagnosis. A mean of 12.6 medications (0-31; SD ± 5.3) were prescribed in the NH. Mean Clinical Frailty Score (CFS) was 6.5 (3-9; SD ± 0.9). Mean Barthel Index (BI) was 8.9 (0-20; SD ± 6.0). 38.3% (n=197) of presentations occurred “in-hours”. Mean Manchester Triage Score (MTS) was 2.54 (1-5; SD ± 0.7) with 92.0% (n=474) scoring 1-3. Delirium was documented in 31.8% (n=164). Mean ED Length of Stay (LOS) was 13.7hours (0-80hours; SD ± 11.0). 14.6% (n=75) were discharged without follow-up. 61.2% (n=315) were admitted to hospital. Mean hospital (LOS) was 9.7days (0-191 days) and 8.7% (n=47) of those admitted died in hospital. 12 months after ED presentation, 40.4% (n=138) of the cohort had died. Conclusion NH residents are a frail group, with high levels of multimorbidity, polypharmacy and significant care needs. This complexity is reflected in the numbers requiring urgent review on attendance, rates of delirium, ED LOS and hospital admission rates. Dedicated NH liaison teams may enhance care and improve outcomes for this cohort.

Intra-Articular Lidocaine versus Procedural Sedation for Shoulder Dislocation Reduction: A Randomized Trial.

Two common ways of providing anesthesia for shoulder dislocation reductions in the emergency department (ED) are intra-articular lidocaine (IAL) injections and procedural sedation (PS). We sought to compare PS with propofol or etomidate to IAL for shoulder dislocation reductions in the ED. This was an open-label, randomized controlled trial of patients aged 18-70 years with anterior shoulder dislocations who presented to a single ED. We randomized patients to either PS or IAL for their shoulder dislocation reduction. The primary outcome measure was ED length of stay (LOS). Secondarily, we assessed patient satisfaction and the number of attempts required for successful reduction. We identified 60 patients who met the criteria for enrollment, and were able to enroll 43. We randomized 23 patients to IAL and 20 to PS. In the IAL group, the mean ED LOS was 133 min as compared to 124 min for the PS group (difference 9 min [95% confidence interval (CI)-22-41], P = 0.54). Patients in the IAL group required an average of 1.9 reduction attempts as compared to 1.2 in the PS group (difference of 0.7 [95% CI 0.2-1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and PS groups, respectively. This study lacked a sufficient sample size to detect small differences but found no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL as compared to PS. Patients in the PS group required fewer attempts for successful reduction.

Factors associated with emergency department length of stay of internal medicine patients

Emergency Department (ED) Length Of Stay (ED-LOS) is associated with quality of care, patient safety and treatment outcome. The aim of this study is to identify factors associated with ED-LOS of internal medicine patients and provide recommendations to shorten ED-LOS. A retrospective cohort study was conducted in a single center in the Netherlands. Anonymised data of 7,380 ED attendances from January 2016 to January 2018 were analyzed. Data included time of ED arrival and departure, sex, age, source of referral, triage category, first or consecutive visit and number of radiological examinations. Univariate analyses were used. Mean ED-LOS was 220 minutes. Factors which significantly prolonged ED-LOS were older age, source of referral, triage category, need for admission, first visit, number of radiological examinations, presentation in winter or spring and time of arrival (day and evening). Several patient and circumstantial factors are associated with ED-LOS. To shorten ED-LOS, we recommend to anticipate need for admission for older patients who arrive by ambulance and to create time slots in the radiology program and to restructure the morning report.

Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study.

Overcrowding in the emergency departments (ED) is a significant issue associated with increased morbidity and mortality rates as well as decreased patient satisfaction. Length of stay (LOS) is both a cause and a result of overcrowding. In Israel, as there are few emergency medicine (EM) physicians, the ED team is supplemented with doctors from specialties including internal medicine, general surgery, orthopedics etc. Here we compare ED length of stay (ED-LOS), treatment time and decision time between EM physicians, internists and general surgeons.A retrospective cohort study was conducted examining the Emergency Department length of stay (ED-LOS) for all adult patients attending Sheba Medical Center ED, Israel, between January 1st, and December 31st, 2014. Using electronic medical records, data was gathered on patient age, sex, primary ED physician, diagnosis, eventual disposition, treatment time and disposition decision time. The primary outcome variable was ED-LOS relative to case physician specialty and level (ED, internal medicine or surgery; specialist or resident). Secondary analysis was conducted on time to treatment/ decision as well as ED-LOS relative to patient classification variables (internal medicine vs surgical diagnosis). Specialists were compared to specialists and residents to residents for all outcomes.Residents and specialists in either EM, internal medicine or general surgery attended 57,486 (51.50%) of 111,630 visits to Sheba Hospital's general ED. Mean ED-LOS was 4.12 ± 3.18 hours. Mean treatment time and decision time were 1.79 ± 1.82 hours, 2.84 ± 2.17 hours respectively. Amongst specialists, ED-LOS was shorter for EM physicians than for internal medicine physicians (mean difference 0.28 hours, 95% CI 0.14–0.43) and general surgeons (mean difference 0.63 hours, 95% CI 0.43–0.83). There was no statistical significance between residents when comparing outcomes.Increasing the number of EM specialists in the ED may support efforts to decrease ED-LOS, overcrowding and medical errors whilst increasing patient satisfaction and outcomes.

Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome.

This study examines the feasibility and utility of integrating coronary computed tomography angiography and the HEART Pathway into a novel accelerated diagnostic protocol-called HEART-CT-and assesses its impact as an optional interactive decision support tool (smart form) in the electronic health record. This was a retrospective observational study performed in 2 adult emergency departments (ED) among patients evaluated for suspected acute coronary syndrome. Primary outcomes included the rate of discharge from the ED following HEART-CT Smart Form use, 30-day major adverse cardiac events (MACE), and ED length of stay (LOS). Hypothesis-generating outcomes included the rate of Smart Form use by ED providers and whether adhering to the HEART-CT recommendations was associated with improved outcomes. The study included 672 subjects, 78.1% of whom were discharged from the ED. HEART-CT identified 76.7% of patients with increased risk HEAR scores as safe for discharge. No patients identified as low risk by HEART-CT had MACE within 30 days. Total mean ED LOS was 4.6 hours. ED providers used the HEART-CT smart form in 19.7% of eligible patients. ED providers who followed the HEART-CT recommendations had 3.41 times higher odds of ED discharging patients with increased risk HEAR scores than nonadherent providers (95% CI, 2.20-5.27). HEART-CT reclassified a large proportion of patients as safe for discharge, maintained a high sensitivity for detecting 30-day MACE, and had an acceptable ED LOS. Future studies should test the extent to which more automated clinical decision support improves provider adoption and clinical outcomes of HEART-CT.

Elimination of Routine Screening Laboratory Tests for Psychiatric Admission: A Quality Improvement Initiative.

Research has shown that routine screening laboratory tests for patients with mental health symptoms admitted to psychiatry units find little unexpected clinical abnormalities. This study examined the effects on cost of care and patient safety measures of a hospital change in policy in which such routine tests were no longer required. This retrospective cohort study analyzed data from all patients admitted from the emergency department (ED) to inpatient psychiatry at a tertiary care hospital 4 months before and 4 months after the policy change. Primary outcome measures were number and costs of laboratory tests ordered in the ED and during the inpatient stay. Secondary measures included length of stay (LOS) and number of hospital consultations during admission, patient transfers to nonpsychiatry services, and inpatient deaths. Chi-square tests and Wilcoxon rank sum tests were used to examine group differences. In total, data from 1,910 patients were included (886 preimplementation and 1,024 postimplementation). The median number of lab tests ordered during the hospital stay decreased from three (interquartile range [IQR]=3) to two (IQR=3). The median total lab charges decreased from $445 (IQR=$291) to $312 (IQR=$497). Mean ED LOS decreased by 5.5 hours, and the proportion of patients with no blood lab orders increased from 22% to 40%. No increases in consultations or transfers were noted. No patients died at any point. A policy that avoids routine laboratory screening tests for patients admitted to inpatient psychiatry can save money, improve patient care, and decrease LOS, without increasing adverse outcomes.

77 Intra-articular Lidocaine versus Procedural Sedation for Anterior Shoulder Dislocations

Shoulder dislocations are the most common dislocations presenting to emergency departments (EDs). Due to the large groups of muscles involved, shoulder dislocation reductions are difficult to achieve for the provider if the patient's pain is not adequately controlled. There are several ways of providing anesthesia for shoulder dislocation reductions, and two of the most common are intra-articular lidocaine (IAL) injections and procedural sedation. Prior studies have found that the use of IAL is safer and results in a shorter ED length of stay (LOS) as compared to procedural sedation, but those studies used sedative medications that have fallen out of favor. The purpose of this study was to compare IAL to procedural sedation with propofol or etomidate for closed reduction of anterior shoulder dislocations. This was a single center, open label, randomized controlled trial. ED patients from 18 to 70 years old who had an anterior shoulder dislocation without an associated fracture (other than a Hill-Sachs) were eligible for enrollment. Consenting patients were randomized to either procedural sedation (with provider’s choice of propofol or etomidate) or IAL. The dose of procedural sedation medication was per provider discretion. The initial study protocol stated that patients randomized to the IAL group would receive 20mL of 1% lidocaine into the glenohumeral joint, but due to a shortage of 1% lidocaine, injections with 10mL of 2% lidocaine were also allowed. The primary outcome measure was ED LOS. Secondarily the number of attempts required for successful reduction and patient satisfaction were compared between groups. In total, 43 patients were enrolled with 23 randomized to the IAL group and 20 to the procedural sedation group. Three patients randomized to the IAL group ended up getting procedural sedation after failed attempts at reduction. In those randomized to the IAL group, the mean ED LOS was 133 minutes as compared to 124 minutes for the procedural sedation group. The difference of 9 minutes (95% CI -22 to 41) was not statistically significant (p = 0.54). Patients in the IAL group had a higher mean number of reduction attempts at 1.9 as compared to 1.2 in the procedural sedation group (difference 0.7 [95% CI 0.2 to 1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and procedural sedation groups, respectively (difference 0.1 [95% CI -0.3 to 0.4]). Although this study was underpowered to detect small differences, there was no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL for their shoulder dislocation reduction as compared to those who received procedural sedation. Patients randomized into the procedural sedation group required less number of attempts for successful reduction compared to those randomized into the IAL group.

How Standardization of Diagnosing and Treating Decompensated Heart Failure Affects Emergency Department and Hospital Length of Stay Across a Large Healthcare System

Introduction Heart failure (HF) affects more than 6 million Americans and is the most common discharge diagnosis-related group (DRG) among Medicare patients. As greater than 80% of these patients present via the emergency department (ED), it is imperative that decompensated HF (DHF) be differentiated from other medical conditions as quickly as possible to allow for efficient treatment initiation. In this study, we examined the effect of an ED HF protocol involving the triage, diagnosis, and management of DHF with the goal of improving diagnostic accuracy, time to initial diuresis, and length of stay (LOS). Methods : All patients diagnosed with DHF during an ED visit were studied over a 3-month period at two EDs across the Scripps Healthcare system. Quality metrics collected are listed in the accompanying table. Values were compared to a pre-intervention cohort that was treated for DHF at the same sites the year prior. Patients were evaluated in triage, and the HF protocol was initiated if the patient met screening criteria, which included specific complaints such as shortness of breath and/or leg swelling. Once initiated, “Code CHF” was announced. The protocol included a nurse-driven order set, medication reconciliation, and a prompt to the physician to utilize point of care ultrasound (POCUS). If DHF was diagnosed, a protocol dose of diuretic was ordered. The aforementioned metrics were then calculated post discharge. Results : A total of 485 patients were evaluated using the DHF protocol, and 377 patients were evaluated from the year prior. Mean door-to-diuretic (D2D) time decreased by 35 minutes. Mean ED LOS decreased by 1 hour and 34 minutes. Mean hospital LOS decreased by 5 hours. POCUS use increased by 23%. Lasix dose increased by a mean of 13 mg. Medication reconciliation did not change dramatically between the pre and post period. Conclusions/Discussion : This pilot study demonstrates that implementation of a HF protocol aimed at improving diagnostic accuracy and treatment of DHF is feasible in a real-world community ED. Crucially this translates into important quality, patient experience, and cost metrics. Our results are consistent with prior studies showing that a decrease in D2D time, and increase in initial diuretic dosing, are associated with improved LOS. While promising, the simultaneous implementation of several interventions makes it difficult to discern which had the biggest impact on improving the evaluated metrics. The question of sustainability and follow-up ED and hospital admissions is currently being assessed in follow up studies.

Seeing Red: Blood Sample Hemolysis Is Associated with Prolonged Emergency Department Throughput.

Hemolyzed emergency department (ED) blood specimens impose substantial burdens on various aspects of delivering care. The ED has the highest incidence of hemolysis among hospital departments. This study assessed the association and potential impact of hemolyzed blood samples on patient throughput time using ED length of stay (LOS) as the primary outcome measure. This study was a secondary analysis of data collected during a performance improvement project aimed at reducing the incidence of hemolysis in ED blood specimens. The electronic medical record was queried for potassium orders and results and for key patient throughput time points. Throughput times were stratified according to hemolysis, ED disposition (admitted vs discharged), and Emergency Services Index (ESI) triage categorization. Two-tailed t tests were used to compare throughput times for patients with and without hemolysis. Potassium values were reported for 11 228 patient visits. The mean ED LOS was 287 minutes for patients with nonhemolyzed samples and 349 minutes for patients who had hemolyzed samples, a mean delay of 62 minutes. The mean throughput time for discharged patients was 92 minutes shorter in the group without hemolysis (337 vs 429 minutes). The mean throughput time for admitted patients was 28 minutes shorter in the group without hemolysis (264 vs 292 minutes). The increased LOS for patients with a hemolyzed blood sample was independent of the most commonly encountered ESI levels. Hemolysis of blood samples obtained in the ED is associated with prolonged patient throughput via delays in patient disposition, independent of various markers of acuity, such as the patients' ultimate disposition or triage categorization.

Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States

ObjectivesThe objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP) in the ED. MethodsWe conducted a secondary analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2014–2015). Adults (age ≥18 years) who presented to the ED with a reason for visit or primary diagnosis of LBP were included in the final study sample. Patient visits were categorized into two groups based on whether they received opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. The primary outcome measure was ED LOS, which was log-transformed (as ED LOS was not normally distributed) for analysis. A multivariable linear regression analysis was used to evaluate the association between opioid use and ED LOS. ResultsThe study sample consisted of a national estimate of approximately 8.6 million ED visits for LBP (during 2014–2015), of which 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 min, respectively; p < 0.001). After adjusting for confounders in the multivariable analysis, patient visits that received opioids had a significantly longer ED LOS (coefficient 0.25; 95% CI 0.11 to 0.38; p < 0.001). ConclusionsIn a nationally representative sample of patient visits to ED due to LBP in the US, use of opioids in the ED was associated with an increased ED LOS.

P139: The impact of a pancreatitis admission algorithm on emergency department length of stay in a tertiary care academic hospital

Background: Emergency department (ED) overcrowding is associated with a broad spectrum of poor medical outcomes, including medical errors, mortality, higher rates of leaving without being seen, and reduced patient and physician satisfaction. The largest contributor to overcrowding is access block – the inability of admitted patients to access in-patient beds from the ED. One component to addressing access block involves streamlining the decision process to rapidly determine which hospital service will admit the patient. Aim Statement: As of Sep 2011, admission algorithms at our institution were supported and formalised. The pancreatitis algorithm clarified whether general surgery or internal medicine would admit ED patients with pancreatitis. We hypothesize that this prior uncertainty delayed the admission decision and prolonged ED length of stay (LOS) for patients with pancreatitis. Our project evaluates whether implementing a pancreatitis admission algorithm at our institution reduced ED time to disposition (TTD) and LOS. Measures &amp; Design: A retrospective review was conducted in a tertiary care academic hospital in Montreal for all adult ED patients diagnosed with pancreatitis from Apr 2010 to Mar 2014. The data was used to plot separate run charts for ED TTD and LOS. Serial measurements of each outcome were used to monitor change and evaluate for special cause variation. The mean ED LOS and TTD before and after algorithm implementation were also compared using the Student's t test. Evaluation/Results: Over four years, a total of 365 ED patients were diagnosed with pancreatitis and 287 (79%) were admitted. The mean ED LOS for patients with pancreatitis decreased following the implementation of an admission algorithm (1616 vs. 1418 mins, p = 0.05). The mean ED TTD was also reduced (1171 vs. 899 mins, p = 0.0006). A non-random signal of change was suggested by a shift above the median prior to algorithm implementation and one below the median following. Discussion/Impact: This project demonstrates that in a busy tertiary care academic hospital, an admission algorithm helped reduce ED TTD and LOS for patients with pancreatitis. This proves especially valuable when considering the potential applicability of such algorithms to other disease processes, such as gastrointestinal bleeding and congestive heart failure, among others. Future studies demonstrating this external applicability, and the impact of such decision algorithms on physician decision fatigue and within non-academic institutions, proves warranted.

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.

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases...

Differences in patient population and length of stay between freestanding and hospital-based emergency departments

BackgroundFreestanding emergency departments (FEDs) represent over 10% of emergency departments (EDs) in the United States. Little is known about differences in encounter characteristics. We compared ED length of stay (LOS) clinical demographics, method of arrival, acuity level, and patient disposition for encounters to FEDs vs. hospital-based EDs (HBEDs). MethodsA multi-center retrospective analysis was performed. Study sites included 6 FEDs and 13 HBEDs from 10/1/2017 to 9/30/2018. Data was abstracted from ED records and discharge summary within the electronic health record. Descriptive statistics were reported with prevalence (95% Confidence Interval [CI]) for categorical variables and mean (standard deviation [SD]) for continuous variables. Multivariable linear regression assessed the relationship between ED facility (FEDs vs. HBEDs) and ED length of stay (LOS). Results1,263,297 encounters were analyzed. Mean ED LOS was shorter at FEDs (146.62 min (±97.04)) vs. HBED (249.70 min (+287.50)). Nine percent of FED encounters arrived via EMS vs. 21% at the HBEDs. FEDs saw 5.47% emergency severity index (ESI) level 2 vs. 13.76% at the HBEDs. Medicaid and Medicare patients were more prevalent in HBEDs (64.2%) than in FEDs (50.6%). FEDs admitted 13% of patients and HBEDs 27%. All results were significant (p < 0.001). After adjusting for potential confounding variables, patients utilizing FEDs had 16.2% shorter ED LOS vs. HBEDs (β = −0.18 [95% CI: −0.18 to −0.17]). ConclusionOverall ED LOS was significantly less for FED vs. HBED patients. Acuity level, insurance status, method of arrival, and patient disposition were significantly different at FEDs vs. HBEDs.

PMS13 ASSOCIATION OF OPIOID ANALGESIC USE ON EMERGENCY DEPARTMENT LENGTH OF STAY AMONG LOW BACK PAIN PATIENTS: A UNITED STATES NATIONAL ANALYSIS

The objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP). Secondary data analysis of the ED component of National Hospital Ambulatory Medical Care Survey (2014-2015), a nationally representative database of the United States (US) was conducted. Adults (age≥ 18 years) with a reason for visit or primary ICD-9-CM diagnosis of LBP were included. Patients were excluded if they had a reason for visit related to motor vehicle collisions, did not receive any analgesics, transferred to psychiatric hospital, nursing home, or other hospital, left against medical advice, admitted for inpatient treatment, or died. Patient visits were categorized into two groups: receipt of opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. ED LOS was log-transformed to improve normality. A multivariable linear regression analysis was used to evaluate the association between opioid use and log-transformed ED LOS. The final study sample consisted of approximately 8.6 million ED visits (US national-level) for LBP during 2014-2015. Of these, 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 minutes, respectively; p<0.001). Using multivariable regression analysis opioid analgesic use was associated with increased log-transformed ED LOS ( =0.25, p<0.001, 95% CI: 0.11 to 0.38). In a nationally representative sample of ED patient visits due to LBP in the US, use of opioids was associated with an increased ED LOS.

Correction: Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department.

[This corrects the article DOI: 10.1371/journal.pone.0187662.].

Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department.

BackgroundThe 1-hour (h) algorithm triages patients presenting with suspected acute myocardial infarction (AMI) to the emergency department (ED) towards “rule-out,” “rule-in,” or “observation,” depending on baseline and 1-h levels of high-sensitivity cardiac troponin (hs-cTn). The economic consequences of applying the accelerated 1-h algorithm are unknown.Methods and findingsWe performed a post-hoc economic analysis in a large, diagnostic, multicenter study of hs-cTnT using central adjudication of the final diagnosis by two independent cardiologists. Length of stay (LoS), resource utilization (RU), and predicted diagnostic accuracy of the 1-h algorithm compared to standard of care (SoC) in the ED were estimated. The ED LoS, RU, and accuracy of the 1-h algorithm was compared to that achieved by the SoC at ED discharge. Expert opinion was sought to characterize clinical implementation of the 1-h algorithm, which required blood draws at ED presentation and 1h, after which “rule-in” patients were transferred for coronary angiography, “rule-out” patients underwent outpatient stress testing, and “observation” patients received SoC. Unit costs were for the United Kingdom, Switzerland, and Germany. The sensitivity and specificity for the 1-h algorithm were 87% and 96%, respectively, compared to 69% and 98% for SoC. The mean ED LoS for the 1-h algorithm was 4.3h—it was 6.5h for SoC, which is a reduction of 33%. The 1-h algorithm was associated with reductions in RU, driven largely by the shorter LoS in the ED for patients with a diagnosis other than AMI. The estimated total costs per patient were £2,480 for the 1-h algorithm compared to £4,561 for SoC, a reduction of up to 46%.ConclusionsThe analysis shows that the use of 1-h algorithm is associated with reduction in overall AMI diagnostic costs, provided it is carefully implemented in clinical practice. These results need to be prospectively validated in the future.

Clinical Pathway Produces Sustained Improvement in Acute Gastroenteritis Care.

Despite widespread use of the rotavirus vaccine in the last decade, dehydrating illnesses impact almost 2 billion children worldwide annually. Evidence supports oral rehydration therapy as a first-line treatment of mild to moderate dehydration. Ondansetron has proven to be a safe and effective adjunct in children with vomiting. We implemented a clinical pathway in our pediatric emergency department (ED) in January 2005 to improve care for this common condition. Our objective in this study was to determine the long-term impact of the pathway for acute gastroenteritis (AGE) on the proportion of patients receiving intravenous (IV) fluids and ED length of stay (LOS) for discharged patients. Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. We used statistical process control to analyze process and outcome measures for 2 years before and 10 years after pathway implementation. We included 30 519 patients. We found special cause variation with a downward shift in patients receiving IV fluids after initiation of the pathway and later with addition of ondansetron to the pathway from 48% to 26%. Mean ED LOS for discharged patients with AGE decreased from 247 to 172 minutes. These improvements were sustained over time. Implementation of a clinical pathway emphasizing oral rehydration therapy and ondansetron for children with AGE led to decreased IV fluid use and LOS in a pediatric ED. Improvements were sustained over a 10-year period. Our results suggest that quality-improvement interventions for AGE can have long-term impacts on care delivery.

Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project.

To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain. Quasi-experimental design, with interrupted time series analysis for the period October 2013 - November 2015. Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland. Implementation of the ADP by structured clinical re-design. Primary outcome: hospital LOS. ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS). Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74-0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72-0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3-78.5%) to 54.9% (95% CI, 44.7-67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions. Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.