Median Emergency Department Length Of Stay Research Articles

The Impact of an Accelerated Diagnostic Protocol Using Conventional Troponin I for Patients With Cardiac Chest Pain in the Emergency Department

BackgroundThis study strove to assess the impact of the implementation of an accelerated diagnostic protocol (ADP), using shortened serial-testing intervals and a conventional troponin I (c-TnI) test, on emergency department (ED) length of stay (LOS). MethodsThis retrospective cohort study included adults (aged ≥ 18 years) presenting to a Canadian ED with a primary complaint of cardiac chest pain between January 14, 2017 and January 15, 2019. For non-high-risk patients, the troponin delta timing decreased from 6 hours to 3 hours, and a different conventional troponin I level cut-point was implemented on January 15, 2018. The primary outcome was ED LOS. Secondary outcomes included disposition status, consultation proportions, and major adverse cardiac events within 30 days. ResultsA total of 3133 patient interactions were included. Although the overall decrease in median ED LOS was not significant (P = 0.074), a significant reduction occurred in ED LOS (-33 minutes; 95% confidence interval: -53.6 to -12.4 minutes) among patients who were discharged in the post-ADP group. Consultations were unchanged between groups (36.1% before vs 33.8% after; P = 0.17). The major adverse cardiac events outcomes were unchanged across cohorts (15.9% vs 15.3%; P = 0.62). ConclusionsThe implementation of an ADP, with a conventional troponin I test, for cardiac chest pain in a Canadian ED was not associated with a significant reduction of LOS for all patients; however, a significant reduction occurred for patients who were discharged, and the strategy appears safe.

Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study

BackgroundThe objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. MethodsWe conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. ResultsA total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). ConclusionsThe implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.

Coronary CTA for Acute Chest Pain in the Emergency Department: Comparison of 64-Detector Row Single-Source and Third-Generation Dual-Source Scanners.

Background: When performing coronary CTA in the emergency department (ED), a contemporary scanner with improved temporal resolution may eliminate the need to administer beta blockers for heart rate (HR) control, thereby expediting workup. Objective: To compare ED length-of-stay (LOS), image quality, frequency of nondiagnostic examinations, and other clinical outcomes between patients undergoing coronary CTA in the ED by a single-source CT (SSCT) scanner with HR control versus a dual-source CT (DSCT) scanner without HR control. Methods: This retrospective study included 509 patients (mean age, 52.1±15.1 years; 283 men, 226 women) at low-to-intermediate risk for acute coronary syndrome who underwent coronary CTA for acute chest pain during off hours in a single ED from March 1, 2020 to April 25, 2022. A total of 205 patients initially underwent CTA using a 64-detector SSCT with HR control (oral beta-blocker administration if HR was >65 beats per minute); following scanner replacement on April 26, 2021, 304 patients underwent CTA using a third-generation DSCT without HR control. Groups were compared in terms of ED LOS and CT completion time (time from ordering of CTA to completion of acquisition) using propensity score matching, and additional endpoints including image quality and nondiagnostic examinations based on radiology reports. Results: DSCT group, compared with SSCT group, showed no significant difference in median ED LOS (505 vs 457 minutes; P=.37), but shorter median CT completion time (95 vs 117 minutes; P<.001); based on mediation analysis, 89% of reduction in CT completion time for DSCT was attributed to absence of HR control. DSCT group, compared with SSCT group, showed higher frequency of examinations with good or excellent image quality (87.8% vs 60.0%, P<.001) and lower frequency of nondiagnostic examinations (1.6% vs 6.3%, P=.01), but no significant difference in frequencies of emergent cardiology consultation, invasive angiography, ED disposition, or coronary revascularization (all P>.05). No patient in either group experienced 30-day all-cause mortality or major adverse cardiovascular event. Conclusion: Use of a DSCT scanner for coronary CTA can eliminate need for beta-blocker administration for HR control while decreasing nondiagnostic examinations. Clinical Impact: A DSCT scanner can expedite clinical processes in the ED.

Assessing Trends and Severity of Emergency Department Access Block by Measuring Median ED Length of Stay for Admitted Patients

Introduction:The Emergency Department (ED) is the hospital’s main gateway, as well as the initial site for diagnosis and emergency medical care. In recent years, ED overcrowding is worsening in Israel and world-wide. Overcrowding has been shown to adversely affect patient service and care, fostering patient and caregiver dissatisfaction, as well as lowering quality of care and even increasing mortality. A main driver of ED overcrowding is ED patient boarding due to limited inpatient bed availability in conjunction with hospital policy. Measuring median length of ED stay (LOS) for admitted vs. discharged patients can serve as a simple indicator for the severity of the access block over time and between facilities.Method:ED operational data from the computerized system of four hospitals in Israel were collected over a year and analyzed. In parallel data was collected regarding hospital capacity and ED volumes. Data were analyzed using SPSS.Results:The Mean ED LOS was significantly higher for ED patients needing admission in all hospitals. Mean ED LOS for admitted vs. discharged patients was 227 min vs.431 in hospital A, 215 min vs. 222 in hospital B, 198 min vs. 440 in hospital C and 167 min vs. 190 in hospital D. The discrepancy in LOS for admitted patients was not related to the total hospital bed capacity or the hospital ED patient volume.Conclusion:ED boarding is a major challenge for ED's and hospitals worldwide and a significant contributor to ED overcrowding. A tool to assess boarding is proposed. The tool calculates the ratio of median ED LOS between patients admitted to the hospital and those discharged. Slightly higher LOS among those admitted is to be expected, considering the fact that they usually present with more complex medical problems. In this study the LOS ratios were 1.03, 1.12, 1.90 and 2.22.

Evaluation of factors affecting the length of stay of geriatric patients in the emergency department.

The emergency department length of stay (EDLOS) is one of the essential parameters of emergency healthcare management efficacy, and prominent factors that contribute to EDLOS are critical in enhancing emergency department (ED) patient care effectiveness, particularly for older patients, which is rarely investigated. This single-center, prospective cohort study was performed in the ED of a tertiary care hospital. The patients were classified into two groups according to EDLOS (≥4 h vs. <4 h). The chief complaints, consultant branches, the patients' comorbidities, polypharmacy status, time of presentation, laboratory, imaging investigations, EDLOS, Clinical Frailty Score (CFS) score, mini mental examination test, National Early Warning Score 2 (NEWS2), consultations, and outcome of the patients were compared with Spearman and Kendall tau-b correlations. During the 30-day study period, a total of 222 geriatric patients were included in the study. The mean age of study patients was 79.13±9.43 years, and 47.05% of patients were male. The Median EDLOS was 250 (range, 60-1440) min. The patients who arrived on the night shift (p=0.047), who had chronic heart failure (p=0.025), chronic obstructive pulmonary disease (p=0.03), severe dementia according to the MMSE (p=0.008), higher CFS frailty scores (p=0.03), and higher clinical acuity according to the NEWS2 score, were found to be positively correlated to an EDLOS of >4 h. (p=0.001) Any specialty consultation and specialty consultation number, along with hospitalization, were also positively correlated to an EDLOS of >4 h. (p=0.001). High-acuity patients with frailty and dementia are at increased risk for increased EDLOS via consultations. Emergency and consultation physicians should communicate better about which patients are vulnerable to EDLOS case by case, and the patient outcome must be decided as soon as possible.

Shorter laboratory turnaround time is associated with shorter emergency department length of stay: a retrospective cohort study

BackgroundA longer emergency department length of stay (EDLOS) is associated with poor outcomes. Shortening EDLOS is difficult, due to its multifactorial nature. A potential way to improve EDLOS is through shorter turnaround times for diagnostic testing. This study aimed to investigate whether a shorter laboratory turnaround time (TAT) and time to testing (TTT) were associated with a shorter EDLOS.MethodsA retrospective cohort study was performed, including all visits to the emergency department (ED) of an academic teaching hospital from 2017 to 2020 during which a standardized panel of laboratory tests had been ordered. TTT was calculated as the time from arrival in the ED to the ordering of laboratory testing. TAT was calculated as the time from test ordering to the reporting of the results, and was divided into a clinical and a laboratory stage. The outcome was EDLOS in minutes. The effect of TTT and TAT on EDLOS was estimated through a linear regression model.ResultsIn total, 23,718 ED visits were included in the analysis. Median EDLOS was 199.0 minutes (interquartile range [IQR] 146.0–268.0). Median TTT was 7.0 minutes (IQR 2.0–12.0) and median TAT was 51.1 minutes (IQR 41.1–65.0). Both TTT and TAT were positively associated with EDLOS. The laboratory stage comprised a median of 69% (IQR 59–78%) of total TAT.ConclusionLonger TTT and TAT are independently associated with longer EDLOS. As the laboratory stage predominantly determines TAT, it provides a promising target for interventions to reduce EDLOS and ED crowding.

Impact of the 24-hour time target policy for emergency departments in South Korea: a mixed method study in a single medical center

BackgroundIn South Korea, after the spread of the Middle East Respiratory Syndrome epidemic was aggravated by long stays in crowded emergency departments (EDs), a 24-hour target policy for EDs was introduced to prevent crowding and reduce patients' length of stay (LOS). The policy requires at least 95% of all patients to be admitted, discharged or transferred from an ED within 24 hours of arrival. This study analyzes the effects of the 24-hour target policy on ED LOS and compliance rates and describes the consequences of the policy.MethodsA mixed-methods approach was applied to a retrospective observational study of ED visits combined with a survey of medical professionals. The primary measure was ED LOS, and the secondary measure was policy compliance rate which refers to the proportion of patient visits with a LOS shorter than 24 hours. Patient flow, quality of care, patient safety, staff workload, and staff satisfaction were also investigated through surveys. Mann–Whitney U and χ2 tests were used to compare variables before and after the introduction of the policy.ResultsThe median ED LOS increased from 3.9 hours (interquartile range [IQR] = 2.1–7.6) to 4.5 hours (IQR = 2.5–8.5) after the policy was introduced. This was likely influenced by the average monthly number of patients, which greatly increased from 4819 (SD = 340) to 5870 (SD = 462) during the same period. The proportion of patients with ED LOS greater than 24 hours remained below5% only after 6 months of policy implementation, but the number of patients whose disposition was decided at 23 hours increased by 4.84 times. Survey results suggested that patient flow and quality of care improved slightly, while the workload of medical staff worsened.ConclusionsAfter implementing the 24-hour target policy, the proportion of patients whose ED LOS exceeded 24 hours decreased, even though the median ED LOS increased. However, the unintended consequences of the policy were observed such as increased medical professional workload and abrupt expulsion of patients before 24 hours.

A customized early warning score enhanced emergency department patient flow process and clinical outcomes in a COVID-19 pandemic.

ObjectivePatient crowding and boarding in the emergency department (ED) is associated with adverse outcomes and has become increasingly problematic in recent years. We investigated the impact of an ED patient flow countermeasure using an early warning score.MethodsWe conducted a cross‐sectional analysis of observational data from patients who presented to the ED of a Level 1 Trauma Center in Pennsylvania. We implemented a modified version of the Modified Early Warning Score (MEWS), called mMEWS, to address patient flow. Patients aged ≥18 years old admitted to the adult hospital medicine service were included in the study. We compared the pre‐mMEWS (February 19, 2017–February 18, 2019) to the post‐mMEWS implementation period (February 19, 2019–June 30, 2020). During the intervention, low MEWS (0–1) scoring admissions went directly to the inpatient floor with expedited orders, the remainder waited in the ED until the hospital medicine admitting team evaluated the patient and then placed orders. We investigated the association between mMEWS, ED length of stay (LOS), and 24‐hour rapid response team (24 hour‐RRT) activation. RRT activation rates were used as a measure of adverse outcome for the new process and are a network team response for admitted patients who are rapidly decompensating. The association between mMEWS and the outcomes of ED length of stay in minutes and 24 hour‐RRT activation was assessed using linear and logistic regression adjusting for a priori selected confounders, respectively.ResultsOf the total 43,892 patients admitted, 19,962 (45.5%) were in the pre‐mMEWS and 23,930 (54.5%) in the post‐mMEWS implementation period. The median post‐mMEWS ED LOS was shorter than the pre‐mMEWS (376 vs 415 minutes; P < 0.01). After accounting for potential confounders, there was a 4.57% decrease in the ED LOS after implementing mMEWS (95% confidence interval [CI], 4.20–4.94; P < 0.01). The proportion of 24 hour‐RRT did not differ significantly when comparing pre‐ and post‐mMEWS (33.5% vs 34.4%; P = 0.83).ConclusionThe use of a modified MEWS enhanced admission process to the hospital medicine service, even during the COVID‐19 pandemic, was associated with a significant decrease in ED LOS without a significant increase in 24 hour‐RRT activation.

An Initiative to Improve Efficiency of Emergency Department Adolescent Behavioral Health Visits.

Pediatric mental illnesses are quite prevalent in the United States and worldwide. Prevalence has been increasing, and it is estimated that 13% to 20% of US children have a mental illness that costs an estimated $247 billion per year and affects children's social, emotional, and cognitive development (Perou et al. MMWR Suppl. 2013;62:1-35). Pediatric behavioral health visits to the emergency department (ED) have been on an exponential rise constituting 5% to 7% of ED visits (Kalb et al. Pediatrics. 2019;143(4):e20182192). This requires pediatric emergency physicians to frequently manage pediatric mental health illnesses and interact with pediatric psychiatrists to create an integrated system.There is no universally accepted protocol for medical clearance of psychiatric patients (Corl et al. Med Health R I. 2008 91(11):339-341). Our medical clearance protocol comprised complete blood counts, complete metabolic panel, thyroid panel, urine toxicology screen, blood alcohol, urine human chorionic gonadotropin for females, and electrocardiogram for patients 16 years and older. These tests are obtained and have to result in pediatric ED before admission to the adolescent psychiatry unit, therefore occupying space and contributing to pediatric ED overcrowding. In an attempt to decrease our length of stay (LOS), we worked with multiple stakeholders to modify this protocol.Based on results of the data extrapolated from adult psychiatry studies (Olshaker et al. Acad Emerg Med. 1997;4(2), 124-128; Parmar et al. West J Emerg Med. 2012;13(5), 388-393; Janiak and Atteberry. J Emerg Med. 2012;43(5), 866-870). The medical clearance process was adjusted, and laboratory tests, electrocardiogram, and other ancillary studies were waived. The new protocol indicates testing based on a detailed history, physical examination, and clinical judgment. The new medical clearance protocol was initiated in December 2018. The median ED LOS for patients seen in the ED and admitted to our inpatient unit from January to November 2018 was 290 minutes in comparison with median LOS for December 2018 to December 2019 period, which was 204 minutes, showing a median reduction of 86 minutes with no adverse outcomes.The median number of encounters requiring admission in both these periods was comparable. A downstream effect of this process was also cost savings. The estimated cost savings ranged from $37.45 to $47.5 per patient, not including labor and other indirect costs. The medical clearance process is a daunting process for both patients and their families and emerging data questioning its use. Goal-directed medical clearance may be an efficient and cost-saving medical clearance for patients requiring emergent psychiatric evaluation.

Impact of rubidium imaging availability on management of patients with acute chest pain

ObjectiveEvaluate the impact of 82-Rubidium positron emission tomography (PET) myocardial perfusion imaging (MPI) availability on patient management presenting at the emergency department (ED) with chest pain (CP). MethodsThis is a single-center retrospective study of clinical databases. Patients presenting with CP with a non-definitive suspicion of acute coronary syndrome (ACS) at the ED between April 2016 and February 2020 were divided into 2 groups based on PET availability. The proportion of invasive coronary angiography (ICA) without significant coronary artery disease (CAD), length of stay (LoS), and additional downstream testing were evaluated. ResultsThere were 21,242 ED visits for CP without definitive ACS: 5,492 when PET is not available and 15,750 when PET is available. When PET is available, proportion of patients undergoing a MPI study was greater (20.7% vs 17.6%, P<0.0001), proportion of ICA without significant CAD was similar (18.5% vs 21.4%, P=0.24), and median ED LoS was shorter (16.6 vs 18.1 hours, P=0.03). Patients undergoing SPECT MPI had significantly more downstream testing (8.9% vs 6.4%, P=0.003) and a higher rate of coronary angiogram without significant CAD (21.2% vs 14.2%, P=0.09) compared to those who underwent PET MPI. ConclusionAvailability of PET MPI was associated with an increased number of MPI referral from the ED, similar rates of ICA without significant CAD, decreased LoS, and fewer downstream testing.

Emergency department length of stay and outcomes of emergency department-based intensive care unit patients.

ObjectiveEmergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED‐based intensive care units (ED‐ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED‐ICU on patient outcomes.MethodsWe retrospectively analyzed adult ED patients managed in the ED‐ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48‐hour mortality, and hospital mortality. Multivariable analyses’ covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3).ResultsWe included 5859 ED visits with subsequent care in the ED‐ICU. Median age, CCI, eSAPS3, ED LOS, and ED‐ICU LOS were 62 years (interquartile range [IQR], 48–73 years), 5 (IQR, 2–8), 46 (IQR, 36–56), 3.6 hours (IQR, 2.5–5.3 hours), and 8.5 hours (IQR, 5.3–13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = −3.4; 95% confidence interval [CI], −5.9 to −1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84–0.88), 48‐hour mortality (OR, 0.89; 95% CI, 0.82–0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85–0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88–0.93), but no associations with other outcomes.ConclusionsWe observed no significant associations between ED LOS before ED‐ICU transfer and worsened outcomes, suggesting an ED‐ICU may mitigate the risks of ED boarding of patients who are critically ill.

Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study.

ObjectiveTo investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).Materials and MethodsThis retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.ResultsAccording to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).ConclusionQIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.

Factors associated with emergency department length of stay of foreign patients visiting a regional core hospital in Japan.

AimThis study aims to elucidate the foreign patient‐specific factors associated with emergency department length of stay (EDLOS) in a regional core hospital emergency department (ED) in Japan.MethodsThis retrospective observational study included non‐Japanese patients who visited the ED in a Japanese regional core hospital between April 1, 2018, and March 31, 2020. The effects on EDLOS were assessed using multivariate linear regression analysis, which included factors such as age, sex, consultation language, interpreter usage, arrival time, day of visit, mode of arrival, underlying disease, triage level, diagnosis of injury/noninjury, diagnostic investigations, consultation with specialists, and treatments or procedures.ResultsOf 65,297 ED patients, there were 777 study patients, with a median age of 37 years (interquartile range [IQR], 24.0–50.0). The median EDLOS was 101 min (IQR, 63.0–153.0). Multivariate linear regression analysis indicated that an extended EDLOS was associated with: language apart from Japanese, Chinese, or English (51.7 min; 95% confidence interval [CI], 17.8–85.6), helicopter arrival (115.6 min; 95% CI, 48.8–182.5), blood testing (60.5 min; 95% CI, 34.6–86.4), computed tomography (23.8 min; 95% CI, 3.7–43.9), consultation with specialists (36.2 min; 95% CI, 11.8–60.6), intravenous fluid/medication (29.7 min; 95% CI, 3.3–56.1), and surgical procedure/reduction/fixation in the ED (38.8 min; 95% CI, 14.2–63.4).ConclusionsConsultation in a language other than Japanese, English, or Chinese was associated with a longer EDLOS in a regional core hospital in Japan. Devising ways to accommodate patients who speak various languages could be important.

Emergency Department Management of Chest Pain With a High-Sensitivity Troponin-Enabled 0/1-Hour Rule-Out Algorithm.

The analytical sensitivity of high-sensitivity cardiac troponin T (hsTnT) assays has enabled rapid myocardial infarction rule-out algorithms for emergency department (ED) presentations. Few studies have analyzed the real-world impact of hsTnT algorithms on outcomes and operations. Comparison of ED length of stay (LOS) and 30-day outcomes (return to ED, inpatient admission, and mortality) for patients presenting with chest pain during 2 separate 208-day periods using a 0/1-hour hsTnT-enabled algorithm or fourth-generation TnT. Discharge, 30-day readmission, and 30-day mortality rates were not significantly different with fourth-generation TnT vs hsTnT. Thirty-day return rates were significantly decreased with hsTnT (17.4% vs 14.9%; P < .01). For encounters with TnT measured at least twice and resulting in discharge, median ED LOS decreased by 61 minutes with the use of hsTnT (488 vs 427 minutes; P < .0001). Median time between first and second TnT results decreased by 82 minutes with hsTnT (202 vs 120 minutes; P < .0001), suggesting that the 0/1-hour algorithm was incompletely adopted. Implementation of the hsTnT algorithm was associated with decreased 30-day return rates and decreased ED LOS for a subset of patients, despite incomplete adoption of the 0/1-hour algorithm.

The Impact of Extreme Heat Events on Emergency Departments in Canadian Hospitals.

Mean daily temperatures in Canada rose 1.7°C between 1948 and 2016, and the frequency, severity, and duration of extreme heat events has increased. These events can exacerbate underlying health conditions, bringing patients to emergency departments (EDs). This retrospective analysis assessed the impact of temperature and humidex on ED volume and length of stay (LOS). LOS is an indicator of ED overcrowding and system performance. Using daily maximum temperatures and humidex values, this study investigated the impact of mean 3-d temperatures and humidex preceding ED presentation on the median and maximum ED LOS and patient volume in 2 community hospitals in Montreal, Quebec, during the summer months of 2016 to 2018. Data were analyzed with 1-way analysis of variance with post hoc Fisher least significant difference tests and Spearman correlation tests. The mean maximum temperature and humidex were 26.1°C and 30.4°C, respectively (n=276 d). Mean 3-d temperatures ≥30°C were associated with higher daily ED volumes in both hospitals (138 vs 121, P=0.002 and 132 vs 125, P=0.03) and with increased median LOS at 1 hospital (8.9 vs 7.6 h, P=0.03). Mean 3-d humidex ≥35 was associated with higher daily ED volumes at both hospitals as well (136 vs 123, P=0.01 and 133 vs 125, P=0.009) with an increased median LOS at 1 hospital (8.6 vs 6.9 h, P=0.0001) with humidex values of 25 to 29.9°C. Heat events were associated with increased ED presentations and LOS. This study suggests that a warming climate can impede emergency service provision by increasing the demand for and delaying timely care.

159 Modified Early Warning Score (MEWS)-Enhanced Emergency Department Flow Process

Emergency Department (ED) crowding is a longstanding problem in the US. Admission to the inpatient floors can be a bottleneck in ED patient flow, due to the need for hospitalist assessment of patient clinical stability. Early Warning Systems (EWS) have been proposed that use vital signs to detect early signs of clinical deterioration. We set out to determine whether the use of a modified version of the EWS score (MEWS) could be used to discriminate patients in which ED streamlined admission orders could be placed prior to being seen by the hospitalist-- with a goal of improving ED length of stay (LOS) without increasing adverse events. We conducted an IRB approved retrospective, observational, cross-sectional analysis of inpatient admissions from the ED at a Level 1 Trauma Center in NE PA with an annual census of approximately 90,000 visits. Subjects were included if they were ≥18 yo and admitted to the hospital medicine service. The study design compared a time period prior to implementation to a MEWS-enhanced ED admission patient flow process (Pre-MEWS: 2/19/2017-2/19/2019) with the post implementation period (Post-MEWS: 2/19/2019-2/19/2020). Post-MEWS implementation, patients with a low MEWS score (0-1) were admitted with an abbreviated order set to expedite the admission process. Those with higher MEWS scores remained in the ED until they were seen by the admitting team. Metrics such as demographics, ED LOS (minutes) and need for a Rapid Response Team (RRT) were collected. A total of 44,986 admissions occurred; 28,624 (63.63%) were Pre-MEWS while 16, 362 (36.37%) were Post-MEWS. The average patient age was 68.53±17.27 with a younger mean age among those in the Pre-MEWS as compared to Post-MEWS (68.66±17.31 vs 68.30±17.21; p=0.03). Over half (51.8%) the patients were female without a significant difference; Pre- vs Post-MEWS periods (51.78% vs 51.85%; p=0.88). The median ED LOS was 371 minutes (Inter-Quartile Range 0(IQR): 288 to 509) with a statistically significantly shorter median ED LOS in the post-MEWS (358; IQR, 273 to 478) as compared with Pre-MEWS period (379; IQR, 288 to 509). The ED LOS in the post-MEWS did not differ when comparing those with MEWS > 1 (354; IQR, 271 to 476) with MEWS ≤ 1(360; IQR, 275 to 479) (p=0.12) while in the Pre-MEWS period the ED LOS was significantly longer among those with MEWS ≤ 1 (384(IQR, 292 to 514) vs 372(IQR, 282 to 501); p<0.0001). There was total of 681 Rapid Responses events of which 236 (34.65%) were within the first 24 hours of admission (RRT-24hr). When comparing the pre-MEWS to post-MEWS periods there was no significant difference in RRT-24hr (143(33.26%) vs 93(37.05%); p=0.32). The use of a modified MEWS enhanced admission process to the hospital medicine service was associated with a significant decrease in ED LOS without a significant increase in adverse outcome as measured by RRT events within 24 hours of admission.

Factors associated with paediatric and adolescent Emergency Department presentations involving acute behavioural disturbance events.

AimStudies reporting factors associated with paediatric/adolescent acute behavioural disturbance (ABD) in the Emergency Department (ED) are lacking. The aim of this study is to describe paediatric/adolescent ED presentations involving ABD events.MethodsA retrospective chart review of presentations involving ABD events, identified via hospital security log, to a tertiary referral paediatric ED during the 2017 calendar year. Data reported included: cause of presentation, use of sedation/physical restraint, ED/inpatient length of stay (LOS) and time requiring security staff presence.ResultsFrom 280 reported ABD episodes 26 were excluded leaving 254 events involving 150 patients across 233 presentations of whom 38 (25.3%) presented on multiple occasions. Median age was 14 years (interquartile range (IQR): 13–16), 132/233 (56.7%) were female, 167/233 (71.7%) primary mental health complaints, 30/233 (12.9%) deliberate self‐harm, 18/233 (7.7%) deliberate self‐poisoning, 11/233 (4.7%) acute intoxication and 7/233 (3.0%) other.Transport to hospital involved police and ambulance in 124/233 (53.2%), ambulance only 71/233 (30.5%), police only 16/233 (6.9%), relative or carer 20/233 (8.6%), with self‐presentation in 2/233 (0.9%).Sedation or physical restraint was used in 81/233 (34.8%), both 38/233 (16.3%), restraint only 26/233 (11.2%) and sedation only 17/234 (7.3%). Intra‐muscular droperidol accounted for 57/96 (59.4%) sedations, IM/IV benzodiazepines 15/96 (15.6%), IM/IV ketamine 5/96 (5.2%) and 19/96 (19.8%) other.Discharge from ED occurred in 171/233 (73.1%) with median ED LOS 5.1 h (IQR: 3.5–7.7) and median hospital LOS 92.4 h (IQR: 47.5–273.4) for those admitted. The Mental Health Act was utilised in 183/233 (78.5%) presentations.Median security staff time requirement per presentation was 2.4 h (IQR: 1.0–3.9).ConclusionsPaediatric/adolescent ED presentations involving ABD are primarily due to mental health complaints. Less than half require the use of sedation/physical restraint. Time requiring security staff involvement is a significant resource consumption.

Effect of language interpretation modality on throughput and mortality for critical care patients: A retrospective observational study.

ObjectiveLimited data exist describing possible delays in patient transfer from the emergency department (ED) as a result of language barriers and the effects of interpretation services. We described the differences in ED length of stay (LOS) before intensive care unit (ICU) arrival and mortality based on availability of telephone or in‐person interpretation services.MethodsUsing an ICU database from an urban academic tertiary care hospital, ED patients entering the ICU were divided into groups based on primary language and available interpretation services (in‐person vs telephone). Non‐parametric tests were used to compare ED LOS and mortality between groups.ResultsAmong 22,422 included encounters, English was recorded as the primary language for 51% of patients (11,427), and 9% of patients (2042) had a primary language other than English. Language was not documented for 40% of patients (8953). Among encounters with patients with non‐English primary languages, in‐person interpretation was available for 63% (1278) and telephone interpretation was available for 37% (764). In the English‐language group, median ED LOS was 292 minutes (interquartile range [IQR], 205–412) compared with 309 minutes (IQR, 214–453) for patients speaking languages with in‐person interpretation available and 327 minutes (IQR, 225–463) for patients speaking languages with telephone interpretation available. Mortality was higher among patients with telephone (15%) or in‐person (11%) interpretation available compared with patients who primarily spoke English (9%).ConclusionsPatients with primary languages other than English who were critically ill spent a median of 17 to 35 more minutes in the ED before ICU arrival and experienced higher mortality rates compared with patients who spoke English as a primary language.

Morning Discharges and Patient Length of Stay in Inpatient General Internal Medicine.

Many initiatives seek to increase the number of morning hospital discharges to improve patient flow, but little evidence supports this practice. To determine the association between the number of morning discharges and emergency department (ED) length of stay (LOS) and hospital LOS in general internal medicine (GIM). Multicenter retrospective cohort study involving all GIM patients discharged between April 1, 2010, and October 31, 2017, at seven hospitals in Ontario, Canada. The primary outcomes were ED LOS and hospital LOS, and secondary outcomes were 30-day readmission and in-hospital mortality. The number of morning GIM discharges (defined as the number of patients discharged alive between 8:00 AM and 12:00 PM) on the day of each hospital admission was the primary exposure. Multivariable regression models were fit to control for patient characteristics and situational factors, including GIM census. The sample included 189,781 patient admissions. In total, 36,043 (19.0%) discharges occurred between 8:00 AM and 12:00 PM. The average daily number of morning discharges and total discharges per hospital was 1.7 (SD, 1.4) and 8.4 (SD, 4.6), respectively. The median ED LOS was 14.5 hours (interquartile range [IQR], 10.0- 23.1), and the median hospital LOS was 4.6 days (IQR, 2.4-9.0). After multivariable adjustment, there was not a significant association between morning discharge and hospital LOS (adjusted rate ratio [aRR], 1.000; 95% CI, 0.996-1.000; P = .997), ED LOS (aRR, 0.999; 95% CI, 0.997-1.000; P = .307), 30-day readmission (aRR, 1.010; 95% CI, 0.991-1.020; P = .471), or in-hospital mortality (aRR, 0.967; 95% CI, 0.920-1.020; P = .183). The lack of association between morning discharge and LOS was generally consistent across all seven hospitals. At one hospital, morning discharge was associated with a 1.9% shorter ED LOS after multivariable adjustment (aRR, 0.981; 95% CI, 0.966-0.996; P = .013). The number of morning discharges was not significantly associated with shorter ED LOS or hospital LOS in GIM. Our findings suggest that increasing the number of morning discharges alone is unlikely to substantially improve patient throughput in GIM, but further research is needed to determine the effectiveness of specific interventions.

Potentially Inappropriate Medication Usage in Older Adults in a Tertiary Academic Medical Center Emergency Department

Background: The Beers Criteria® medications are potentially inappropriate medications (PIMs) recommended by the American Geriatric Society to be avoided or used with caution in adults 65 years and older. The usage of PIMs in the emergency department (ED) setting is not well characterized. Objectives: The purpose of this study is to evaluate the usage of PIMS in the ED. Methods: This is a single center retrospective observational study of a random sample of patients aged 65 and older who presented to the ED during a 6-month timeframe. The primary outcome was the incidence of ED readmissions in patients administered or prescribed a PIM compared with patients who were not prescribed or administered a PIM. Secondary outcomes included ED length of stay (LOS) and hospital admission. Results: Out of 192 patients, there was a total of 58 patients (30.2%) in the PIM group and 134 patients (69.8%) in the No PIM group. ED re-presentation within 30 days occurred in 10 patients (17%) in the PIM group vs 26 patients (19%) in the No PIM group (p = 0.88). The median ED LOS was 227 minutes vs 208 minutes (p = 0.1679). Hospital admission within 30 days occurred in 4 patients (7%) in the PIM group and 13 patients (10%) in the No PIM group (p = 0.725). Conclusions: This analysis did not show statistically significant differences between patients who received a PIM compared to those who received an alternative medication with regard to re-presentation, admission, and ED LOS. ED LOS trended towards being longer in the PIM group.