National Emergency Department Overcrowding Scale Research Articles

Perceived Work Demands and Emergency Department Crowding as Predictors of Objective Stress Among Emergency Physicians: A Shift-Level Approach.

To understand shift-level determinants of emergency physician (EP) burnout, relationships were tested between EP shift demands, stress, and fatigue. EP ( n = 16) were assessed over 114 shifts that occurred before and during the COVID-19 pandemic. Salivary cortisol (an indicator of stress) and self-reported fatigue were collected prior to and following each shift. An objective crowding score (National Emergency Department Overcrowding Scale) per shift was calculated. Shift demands were assessed at the end of each shift. Multilevel models revealed that shift demands, National Emergency Department Overcrowding Scale, and the pandemic were related to higher levels of end-of-shift cortisol, but not fatigue. Cortisol levels were higher for shifts with a higher number of demands, greater crowding, and during the pandemic. Shift demands predicted objective indicators of stress, but not self-reported fatigue. Interventions are needed to decrease stress and shift demands to reduce EP burnout.

Impact of a new post-emergency teleconsultation procedure on overcrowding.

Saint Vincent de Paul Hospital is using a post-emergency teleconsultation solution (TELESCOPE). Target patients are discharged early, freeing up examination rooms and hospital beds, and the patient's clinical evolution is monitored by teleconsultation 24 hours after discharge. This study aims to evaluate this pioneering procedure, firstly to assess the impact of TELESCOPE on ED overcrowding, and secondarily to evaluate 72-hour post-emergency hospitalization rates, throughput times, and patient satisfaction. This is a prospective, comparative, before/after type study. The National Emergency Department Overcrowding Scale (NEDOCS) score was used to measure the impact of TLC on ED congestion. It was calculated every hour, every day during the two study periods. The 72-hour post-emergency hospitalization rates were cross-compared for the patients who had a TLC, those who did not have a TLC during the same period, and those from the control period. The patient flow was evaluated by comparing the average length of stay of patients invited to a TLC against those from the control period. The patient's satisfaction was measured through a telephone survey. The mean difference in NEDOCS score is -3.1 [-4.14; -1.85]. Compared to the control phase, ED spent an additional 160 hours at a 'normal' level during the test period. The time spent in the 'busy' or 'overcrowded' categories was reduced by 129 and 19 hours. There is a significant reduction in the hospitalization rate between teleconsultation patients and all other patients. The patients discharged and invited to a TLC waited 87 minutes longer on average [56 minutes; 119 minutes]. Patient satisfaction is high (91.8%). Additional statistical strength would be needed to prove a reduction in overcrowding. The low hospitalization rate reflects adequate recruitment. ED visit times were unexpectedly longer. TELESCOPE seems useful for defining a new type of care. A further multicentre study is scheduled for 2024.

The Relationship Between The Implementation of Triage and The Incidence of Overcrowded in the Emergency Department of Adi Husada Kapasari Hospital, Surabaya, Indonesia

Introduction: The emergency department (ED) is at the forefront of hospital healthcare and is expected to provide timely and effective care. The imbalance of the need for emergency care and the availability of hospitals to provide health services has an impact on the occurrence of overcrowded situations. This study aims to determine the relationship between the implementation of triage and the incidence of overcrowded in the ED of Adi Husada Kapasari Hospital. Methods: This study uses a correlation study design with a cross sectional approach. The population in the study were all nurses in the ED of Adi Husada Kapasari Hospital, Surabaya, Indonesia, and 14 nurses were involved as respondents through a total sampling technique. The independent variable is the implementation of triage, the dependent variable is the incidence of overcrowded. Data collection using a questionnaire sheet to measure the implementation of triage, and the NEDOCS scale (National Emergency Department Overcrowding Scale) to measure the incidence of overcrowded. Data was analyzed using Spearman rank correlation test with α = 0.05. Results: The results showed that more than half respondents (64.3%) practice triage in moderate level, and the overcrowded assessment showed all respondents (100%) in the level 1, which means it was in category not busy. Spearman rank correlation test showed that there was no relationship between the implementation of triage and the incidence of overcrowded in the ED of Adi Husada Kapasari Hospital (p-value 0.898 and r=0.038). Conclusion: For non-large-scale emergency departments like the ED of Adi Husada Kapasari Hospital, the implementation of triage is not significantly related to the overcrowded incidence, although some studies and theories state otherwise, that the accuracy of emergency room nurses in triaging can help reduce patients overcrowding and treat patients immediately. Further research could explore this gap through a larger sample or by involving or comparing more populations of various type of EDs.

Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations.

Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding. A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups. Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue. Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.

Association between Covid-19 surge and emergency department patient flow and experience

BackgroundPreparations for Covid-19 in the Netherlands included hospital reconfigurations to increase capacity for the expected surge at the emergency department (ED). We describe patients’ ED length of stay (LOS), crowding and experiences of patients with respiratory complaints during the first Covid-19 peak. MethodsRetrospective analysis of demand, ED LOS, crowding, and a patient experience survey during a 12-week period in 2020 and similar periods in 2018 and 2019. Crowding levels were calculated using the National ED OverCrowding Scale. ResultsThe number of patients with respiratory complaints increased significantly, while total ED numbers were unchanged. Although presentation during the Covid-19 peak and needing hospital admission were associated with a longer ED LOS in patients with respiratory complaints, significantly less crowding occurred compared with the 2018 and 2019 periods. Increased ED LOS was associated with lower patient experience scores. ConclusionAdvanced warning and its associated preparation within the hospital and the community prevented significant delays in ED throughput during the first Covid-19 peak.

A case study to investigate the impact of overcrowding indices in emergency departments

BackgroundEmergency department (ED) overcrowding is widespread in hospitals in many countries, causing severe consequences to patient outcomes, staff work and the system, with an overall increase in costs. Therefore, health managers are constantly looking for new preventive and corrective measures to counter this phenomenon. To do this, however, it is necessary to be able to characterize the problem objectively. For this reason, various indices are used in the literature to assess ED crowding. In this work, we explore the use of two of the most widespread crowding indices in an ED of an Italian national hospital, investigate their relationships and discuss their effectiveness.MethodsIn this study, two of the most widely used indices in the literature, the National Emergency Department Overcrowding Scale (NEDOCS) and the Emergency Department Working Index (EDWIN), were analysed to characterize overcrowding in the ED of A.O.R.N. “A. Cardarelli” of Naples, which included 1678 clinical cases. The measurement was taken every 15 minutes for a period of 7 days.ResultsThe results showed consistency in the use of EDWIN and NEDOCS indices as measures of overcrowding, especially in severe overcrowding conditions. Indeed, in the examined case study, both EDWIN and NEDOCS showed very low rates of occurrence of severe overcrowding (2–3%). In contrast, regarding differences in the estimation of busy to overcrowded ED rates, the EDWIN index proved to be less sensitive in distinguishing these variations in the occupancy of the ED. Furthermore, within the target week considered in the study, the results show that, according to both EDWIN and NEDOCS, higher overcrowding rates occurred during the middle week rather than during the weekend. Finally, a low degree of correlation between the two indices was found.ConclusionsThe effectiveness of both EDWIN and NEDOCS in measuring ED crowding and overcrowding was investigated, and the main differences and relationships in the use of the indices are highlighted. While both indices are useful ED performance metrics, they are not always interchangeable, and their combined use could provide more details in understanding ED dynamics and possibly predicting future critical conditions, thus enhancing ED management.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List.

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

The Efficacy of Lavender Aromatherapy in Reducing the Overcrowding-Related Anxiety in Health Care Workers.

In general, emergency departments (EDs) are stressful workplaces with excessive workloads and time pressures. Crowding, which is an important problem worldwide disrupting ED functions, leads further increases in the stressors which health care workers are exposed to. Long-term exposure to stressors can lead to anxiety in health care workers. The aim of this study was to determine the effect of aromatherapy on crowding-related anxiety in ED health care workers. Crowding was measured simultaneously with the National Emergency Department Overcrowding Scale objectively and the Health Care Workers' Crowding Perception Evaluation Form subjectively. The state-trait anxiety level was measured at each crowding level according to the health care workers' perception. When perceived crowding was at severely overcrowding level, lavender oil aromatherapy was applied. Anxiety level was measured before and after aromatherapy. Aromatherapy was repeated 3 times on different days. A significant positive correlation was found between state anxiety level and perceived crowding (r = 0.415, p < 0.001). Aromatherapy was found to have a significant correlation in reducing the overcrowding-related anxiety in health care workers (p < 0.05). This study showed that there is a significant correlation between anxiety level and perceived crowding, and aromatherapy is related to a decrease in overcrowding-related anxiety. In EDs, lavender oil aromatherapy can be used as a complementary method in reducing the overcrowding-related anxiety. But further researches are needed to verify that aromatherapy has a causative effect on reducing overcrowding-related anxiety.

Central Venous Catheter Adverse Events Are not Associated with Crowding Indicators.

ObjectiveCrowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).MethodsWe conducted a retrospective observational study from 2008–2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU.ResultsOf 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08).ConclusionIn a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

S0020 The Effect of ER Crowding on Time to Fluid Initiation in Acute Pancreatitis

INTRODUCTION: Studies suggest that early fluid resuscitation in acute pancreatitis may improve outcomes. Thus, the timely diagnosis and treatment in the emergency room is vital. One factor consistently implicated in delay of care is ER crowding, which has been associated with increased inpatient mortality, longer hospital length of stay and higher healthcare costs. The primary aim of our study is to evaluate the effects of ER crowding on time to fluid initiation in patients who present to the emergency room with acute pancreatitis. METHODS: An observational cohort of consecutive unique patients who presented to the LAC + USC emergency room for acute pancreatitis between June 2015 and April 2017 were included. The time that the patient’s first set of vitals was recorded upon presentation to the emergency room triage was labeled as “time zero,” and the time that fluids were started was labeled as “time to fluid initiation.” The crowding level of the LAC + USC emergency room was determined by the National Emergency Department Overcrowding Scale (NEDOCS) at the time of patient presentation and was recorded on a scale from 1 to 4 (1 = normal, 2 = busy, 3 = overcrowded, 4 = severe). The primary endpoint was time to fluid initiation. Detailed demographic information, pancreatitis etiology, and medical history was recorded. Linear regression analysis to analyze the relationship between the crowding level to the time to fluid initiation. RESULTS: Overall, 42 patients presented when the ER had normal (level 1) crowding, 111 patients while it was busy (level 2), 119 patients while it was overcrowded (level 3) and 58 patients while it was (level 4) severely crowded. The features of the 330 patients stratified by crowding level was similar. Most of the patients in our study were of Hispanic ethnicity, 44% female, and 39% had comorbidities. Gallstone pancreatitis was the most common etiology. The time to fluid initiation was strongly correlated with ER crowding level and was significantly increased for each step increase in crowding (p < 0.001). It increased from 1.83 (±1.25 hours) in normal conditions to 2.78 (±2.5) hours when the ER was busy to 5.41 (±5) when overcrowded, and 7.1 (+6.8) when the condition was severe. CONCLUSION: ER overcrowding is strongly correlated with a delay in time to fluid initiation in patients with acute pancreatitis. Pathways to rapidly identify and trigger treatment are needed.Figure 1

Editorial: Delivering effective healthcare at lower cost: Introduction to the special issue

Editorial: Delivering effective healthcare at lower cost: Introduction to the special issue

Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department.

Practice variation exists in pain management of children with long bone fractures (LBFs). The objectives of this study were to describe current pain management in children with LBFs and the factors associated with the undertreatment of pain. We retrospectively studied children (aged 0-18years) with a diagnosis of LBF in a pediatric emergency department (PED) from November 2015 through August 2016. Demographic characteristics and quality measures were noted. We determined the impact of PED crowding using the National Emergency Department Overcrowding Scale. A total of 905 patients (63% male, 48% African American) were enrolled. Median age was 6years (interquartile range [IQR] 7years), 72% had upper extremity injuries, falls were the most common mechanism (74%), and the majority were discharged (77%). Median time to pain score was 6min (IQR 14min). Seventy-two percent received analgesia with a median time to order of 63min and medication receipt of 87min. Ibuprofen was the analgesia prescribed most commonly. There were no identified factors associated with oligoanalgesia. Nonuse of narcotics was associated with African-American race, public insurance, single fractures, and arrival via private vehicle. Ambulance arrivals, lower extremity fractures, and disaster mode were associated with receiving analgesia within 60min. In our study, 28% of children with LBFs did not receive pain medications, especially during normal PED volumes. Additional studies are required to explore triage as a venue for analgesia delivery for LBFs.

130 The National Emergency Department Overcrowding Scale and Perceived Staff Workload: Evidence for Construct Validity in a Pediatric Setting

Our objective was to determine if there is a correlation between perceived staff workload and the National Emergency Department Overcrowding Scale (NEDOCS) in a pediatric ED (PED). Our primary outcome was the R squared, on univariate linear regression, between perceived workload measured by the raw sum of NASA Task Load Index (TLX) subscales and most recent hourly NEDOCS. Secondary outcomes included correlation between each TLX subscale and NEDOCS, correlation among specific staff roles, correlation between mean TLX responses for all staff in a given hour and most recent hourly NEDOCS, and the ROC AUC for the raw sum TLX categorical prediction of NEDOCS as “severely overcrowded” or not.

The influence of Beijing medical care reform on crowded Emergency Department in the tertiary hospital

Objective To explore the influence of medical care reform on crowded emergency department in the tertiary hospital. Methods The 8 April 2017 was considered as turning point when Beijing began to implement medical care reform. The research subgroups consisted of pre-medical reform group, intra-medical reform group and post-medical reform group, according to the date 20 days before the medical reform, 20 days after the medical reform and 21-40 days after the medical reform. During this period, The NEDOCS scores(The National Emergency Department Overcrowding Scale) were calculated at 10:00, 14:00, 18:00 in the Emergency Department of Peking University Third Hospital every day, the mean of which assessed the degree of crowding. The key indicators in the NEDOCS scoring formula were compared to find the reasons for the change of emergency crowding. All statistical analyses were performed using SPSS version 25.0. Continuous data presented as means ± standard deviation (normal distribution), analyzed by t-tests or median ± quartile(abnormal distribution), analyzed by Mann-Whitney U test. Results The NEDOCS scores in the intra-medical reform group were statistically higher than that in the pre-medical reform group (401.69 vs 339.68, P 0.05). The number of ventilated patients (Rn) significantly increased after the reform (P<0.05). Conclusions The degree of emergency department crowding in the tertiary hospital has increased after the Beijing medical care reform in 2017. The increase in the number of critically ill patients may be the reason for the increased overcrowding in the emergency department. Key words: Crowding; Medical care reform; Emergency department; Overcrowding scale; Critical care medicine

Quantifying emergency department crowding: comparison between two scores

Introduction: Emergency department (ED) crowding is a major international concern with a negative impact on both patient care and providers. Currently, there is no consensus regarding measure of crowding. Therefore, emergency physicians have to choose between numerous scoring systems, from simple to more complex. The aim of the present study was to compare the complex National Emergency Department Overcrowding Scale (NEDOCS) with the simple ED Occupancy rate (OR) determination. We further evaluated the correlation between these scores and a qualitative assessment of crowding.Method: This study was conducted in two academic and one regional hospital in Liege Province, in Belgium; each accounting for an ED census of over 40,000 patient visits per year. Crowding measures were sampled four times a day, over a two-week period, in January 2016.Results: ED staff considered overcrowding as a major concern in the three ED. Median OR ranged from 68 to 100, while NEDOCS ranged from 64.5 to 76.3. A significant correlation was found in each ED between the OR and the NEDOCS (Pearson r = 0.973, 0.974 and 0.972), as well as between the OR, the NEDOCS and the subjective evaluation by the ED staff (p = 0.001).Conclusion: Crowding evaluation in ED requires validated scores. Our study in three different hospitals demonstrates that simple OR appeared as accurate as more sophisticated NEDOCS. Furthermore, this measure is perfectly correlated with the feeling of ED staff.

40 ED crowding: the acceptability of dysfunction

BackgroundCrowding in the Emergency Department is internationally recognised as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of crowding, including increased length of stay,...

The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department.

To evaluate the associations between real-time overall patient satisfaction and Emergency Department (ED) crowding as determined by patient percepton and crowding estimation tool score in a high-volume ED. A prospective observational study. A tertiary acute hospital ED and a Level 1 trauma center. ED patients. Crowding status was measured by two crowding tools [National Emergency Department Overcrowding Scale (NEDOCS) and Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool (SONET)] and patient perception of crowding surveys administered at discharge. ED crowding and patient real-time satisfaction. From 29 November 2015 through 11 January 2016, we enrolled 1345 participants. We observed considerable agreement between the NEDOCS and SONET assessment of ED crowding (bias = 0.22; 95% limits of agreement (LOAs): -1.67, 2.12). However, agreement was more variable between patient perceptions of ED crowding with NEDOCS (bias = 0.62; 95% LOA: -5.85, 7.09) and SONET (bias = 0.40; 95% LOA: -5.81, 6.61). Compared to not overcrowded, there were overall inverse associations between ED overcrowding and patient satisfaction (Patient perception OR = 0.49, 95% confidence limit (CL): 0.38, 0.63; NEDOCS OR = 0.78, 95% CL: 0.65, 0.95; SONET OR = 0.82, 95% CL: 0.69, 0.98). While heterogeneity exists in the degree of agreement between objective and patient perceived assessments of ED crowding, in our study we observed that higher degrees of ED crowding at admission might be associated with lower real-time patient satisfaction.

Optimal Measurement Interval for Emergency Department Crowding Estimation Tools

Emergency department (ED) crowding is a barrier to timely care. Several crowding estimation tools have been developed to facilitate early identification of and intervention for crowding. Nevertheless, the ideal frequency is unclear for measuring ED crowding by using these tools. Short intervals may be resource intensive, whereas long ones may not be suitable for early identification. Therefore, we aim to assess whether outcomes vary by measurement interval for 4 crowding estimation tools. Our eligible population included all patients between July 1, 2015, and June 30, 2016, who were admitted to the JPS Health Network ED, which serves an urban population. We generated 1-, 2-, 3-, and 4-hour ED crowding scores for each patient, using 4 crowding estimation tools (National Emergency Department Overcrowding Scale [NEDOCS], Severely Overcrowded, Overcrowded, and Not Overcrowded Estimation Tool [SONET], Emergency Department Work Index [EDWIN], and ED Occupancy Rate). Our outcomes of interest included ED length of stay (minutes) and left without being seen or eloped within 4 hours. We used accelerated failure time models to estimate interval-specific time ratios and corresponding 95% confidence limits for length of stay, in which the 1-hour interval was the reference. In addition, we used binomial regression with a log link to estimate risk ratios (RRs) and corresponding confidence limit for left without being seen. Our study population comprised 117,442 patients. The time ratios for length of stay were similar across intervals for each crowding estimation tool (time ratio=1.37 to 1.30 for NEDOCS, 1.44 to 1.37 for SONET, 1.32 to 1.27 for EDWIN, and 1.28 to 1.23 for ED Occupancy Rate). The RRs of left without being seen differences were also similar across intervals for each tool (RR=2.92 to 2.56 for NEDOCS, 3.61 to 3.36 for SONET, 2.65 to 2.40 for EDWIN, and 2.44 to 2.14 for ED Occupancy Rate). Our findings suggest limited variation in length of stay or left without being seen between intervals (1 to 4 hours) regardless of which of the 4 crowding estimation tools were used. Consequently, 4 hours may be a reasonable interval for assessing crowding with these tools, which could substantially reduce the burden on ED personnel by requiring less frequent assessment of crowding.

Abstract TP231: Every IV Thrombolysis Case Should be Less Than 45 Minutes: Not So Easy All the Time

Background: Target Stroke establishes the goal to administer IV Alteplase within 60 minutes of ED arrival. High-performing centers frequently treat within 45 minutes. Median door-to-needle (DTN) times at our tertiary care academic hospital are consistently &lt; 30 minutes. Monthly case reviews investigate factors associated with DTN times greater than 45 minutes. Methods: Utilizing our stroke registry, patients treated with Alteplase from 2013-2015 were identified. Baseline demographics, medical comorbidities, weekend or after hours (7PM-7AM) presentation, initial NIHSS, initial BP greater than 185/110 and management, posterior circulation symptoms and ED crowding using the National Emergency Department Overcrowding Scale (NEDOCS) were extracted. Arrival date and time of arrival were cross-referenced with NEDOCS. Patients were divided into cohorts of treatment less than 45 minutes vs. greater than 45 minutes. Continuous variables were tested for normal distribution using Shapiro-Wilk, then either an unpaired t test or Wilcoxon’s test was applied to test for significance. Dichotomous variables were tested for significance with Chi-square analysis. Results: A total of 239 patients were included in the analysis. Data is presented in Table 1. After adjusting for multiple comparisons, there was a statistically significant difference in the distribution of baseline NIHSS scores (p=0.0006), diabetes (p=0.0023), and minor strokes (NIHSS less than 3, p=0.0003). Conclusion: Diabetics and patients with minor symptoms are more likely to have longer DTN times. Elevated BP, ED crowding, weekend and after hour arrivals do not significantly delay evaluation and treatment. While not significant after adjusting for multiple tests, both posterior stoke recognition and method of treating BP should be scrutinized as they are modifiable risk factors. Future awareness of discrete patient characteristics may help identify patients at risk for prolonged DTN.DTN.

The utility of multidimensional ED overcrowding scale and modified national emergency department overcrowding scale to assess ED crowding: a prospective pilot study

Objective To establish a practicable and balanced emergency department overcrowding (EDO) assessment system suitable for domestic application in Chinese ED setting. Methods The factors that might affect EDO were evaluated by multiple linear regression analysis. The National Emergency Department Overcrowding Scale(NEDOCS) was modified(NEDOCSBJ). The database of factors which might affect EDO was founded and the Multidimensional ED Overcrowding Scale (MEDOS) items, including 9 objective and 3 subjective were screened. Simultaneously, the EDO assessment data pairs were collected three times a day (1: 00, 9: 00, 17: 00) for a period of 6 months. Consistency among the Visual Analogue Scale (VAS), NEDOCSBJ and MEDOS were checked by Bland-Altmann plot. Results The multiple linear regression was made with VAS (average value of VAS-physician and VAS-nurse) as outcome variable, Pbed/Bt, Xn, Wtime and ABI as independent variable. The modified NEDOCS (NEDOCSBJ) model was established: NEDOCSBJ=83.563×(Pbed/Bt)+ 7.201×(Xn)+ 0.116×Wtime+ 0.302×ABI+ 2.835. It was shown that the average value of MEDOS was 25.4 ± 5.8(n=552, 5-39). The correlation analysis showed that MEDOS correlates with VAS (r=0.664, P<0.01) and NEDOCSBJ (r=0.939, P<0.01) significantly. Intra-class correlation coefficients (ICC) between NEDOCSBJ and MEDOS, as well as Bland-Altman plot (95% limits of agreement: -6.74, 30.66), was fairly acceptable, which meant the consistency between the two methods. Conclusions It seems that modified NEDOCS (NEDOCSBJ) model has potential value for EDO evaluation, yet it is less practical in emergency environment since it is difficulties to oBtain the primary data, which need advanced patient information track system. MEDOS seems to a promising EDO evaluation method not only because it is intuitive, ready to evaluate, but also because of the availability and good proportionality and balance of the data. Key words: Emergency Department; Crowding; The National Emergency Department Overcrowding Scale; Visual Analogue Scale; Multidimensional ED Overcrowding Scale; Methodology; Bland-Altman plot