Prolonged Emergency Department Research Articles

A Granular Approach to Optimal and Fair Patient Placement in Hospital Emergency Departments

Prolonged emergency department (ED) length of stay (LOS) is associated with detrimental effects on patient care quality and outcomes. There is evidence that certain groups of patients experience longer LOS based on their gender or race, especially with regard to the part of LOS that is attributable to waiting to be seen by a clinician. This work tackles the patient prioritization and placement aspects of ED operations with the goal of improving throughput and wait time in a fair, equitable way. We present a novel Mixed Integer Linear Programming (MILP) predictive-prescriptive formulation that incorporates a breakdown of predicted patient ED LOS into actionable pieces. We incorporate considerations for fairness and reformulate the MILP formulation into a compact and computationally tractable formulation that can be solved efficiently in real time. To deal with uncertainty, we propose a sampling-based solution, and provide provable guarantees regarding its convergence, stability and sample complexity. The proposed solution increases the throughput of the ED by [Formula: see text] and decreases the average wait time by [Formula: see text] compared to current hospital practice. In addition, the method is near-optimal in terms of throughput, and produces high-quality solutions in terms of average wait time compared to a clairvoyant oracle. Our proposed approach demonstrates desirable properties when it comes to fairness in patient prioritization, illustrating a path for addressing hidden biases in patient ED wait times and hospital operations as a whole. This work was conducted in collaboration with a large US academic medical center. Data from more than 40,000 patient visits were used to shape and evaluate the predictive-prescriptive models. An important practical contribution is translating a complex algorithm’s output into recommendations that can be operationalized in the context of existing processes in the ED. Specifically, we develop an interpretable metamodel that is trained to mimic the predictive-prescriptive algorithm’s decisions and provides a transparent set of rules for patient placement. The method will be used by the hospital to improve patient flow and quality of care as well as to support more fair and consistent bed allocation decisions.

The One Pill Can Kill Myth.

"One Pill Can Kill" is a meme originating in the 1990s. This construct lists pharmaceuticals that have the alleged potential for fatality after the ingestion of a single pill by a toddler. However, its foundation is fundamentally flawed because it contravenes a basic principle of pediatric pharmacology, allometric scaling. Other than opioids, there are no literature examples of one pill killing a toddler. The negative outcome of the one pill can kill construct is inappropriate management manifested by over-referral of young children by poison centers to emergency departments for care, overly prolonged emergency department observation and needless hospital admissions. A more accurate construct is that one pill of anything other than opioids will not kill anybody with the caveat being that we are referring to regulated pharmaceuticals.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study.

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Boarding in the emergency department: challenges and mitigation strategies.

Herein, we conducted a review of the literature to better understand the issue of prolonged emergency department (ED) boarding by providing an overview of the current evidence on the available causes, consequences, and mitigation strategies. Severely ill patients awaiting transfer to intensive care units (ICU) imposes additional burdens on the emergency care team from both a clinical and management perspective. The reasons for prolonged ED boarding are multifactorial. ED boarding compromises patients' safety and outcomes, and is associated with increased team burnout and dissatisfaction. Mitigation strategies include the optimization of patients' flow, the establishment of resuscitative care units, deployment of mobile critical care teams, and improvements in training. Staffing adjustments, changes in hospital operations, and quality improvement initiatives are required to improve this situation, while active bed management and implementation of capacity command centers may also help. Considering the characteristics of healthcare systems, such as funding mechanisms, organizational structures, delivery models, access and quality of care, the challenge of ED boarding of critically ill patients requires a nuanced and adaptable approach. Solutions are complex but must involve the entirety of the hospital system, emergency department, staff adjustment, and education.

Assessing pattern of the Pediatric Multisystem Inflammatory Syndrome (PMIS) in children during the COVID-19 pandemic: experience from the emergency department of tertiary care center of a low-middle-income country

BackgroundPediatric Multisystem Inflammatory Syndrome (PMIS) is a hyperinflammatory condition affecting multiple organs in children, often resembling incomplete Kawasaki Disease during later phases of COVID-19 infection. Data on PMIS in low-middle-income countries, particularly in emergency department settings, is limited.ObjectivesThis prospective observational study at Aga Khan University Hospital, Karachi, aimed to determine the frequency, clinical presentation patterns, and laboratory parameters of children with PMIS visiting the emergency department during the COVID-19 pandemic. Secondary objectives included assessing factors associated with in-hospital mortality.MethodsFrom March 2020 to September 2021, patients meeting World Health Organization PMIS criteria were enrolled. COVID-19 testing included PCR and antibody testing. Data was collected through a questionnaire and analyzed statistically.ResultsAmong 56 PMIS patients (85.7% male, mean age 7.67 ± 4.8 years), respiratory symptoms (70%), neurological symptoms (57%), and gastrointestinal symptoms (54%) were common presentations. Signs included delayed capillary refill time (93%), low-volume pulses (89%), and hypotension (68%). COVID-19 antibodies were positive in the majority (78.6%) while PCR was positive in 18%. Risk factors for mortality included prolonged emergency department stay, and high Ferritin and Lactate Dehydrogenase levels.ConclusionPMIS affects children of all ages. Respiratory and gastrointestinal symptoms are the most frequent presentations. Elevated inflammatory markers, including LDH, Ferritin, D-dimer, and Pro-BNP, correlate with higher mortality risk.

Computer Simulation to Assess Emergency Department Length of Stay in Pediatric Traumatic Brain Injury.

Our study aimed to identify how emergency department (ED) arrival rate, process of care, and physical layout can impact ED length of stay (LOS) in pediatric traumatic brain injury care. Process flows and value stream maps were developed for 3 level I pediatric trauma centers. Computer simulation models were also used to examine "what if" scenarios based on ED arrival rates. Differences were observed in prearrival preparation time, ED physical layouts, and time spent on processes. Shorter prearrival preparation time, trauma bed location far from diagnostic or treatment areas, and ED arrival rates that exceed 20 patients/day prolonged ED LOS. This was particularly apparent in 1 center where computer simulation showed that relocation of trauma beds can reduce ED LOS regardless of the number of patients that arrive per day. Exceeding certain threshold ED arrival rates of children with traumatic brain injury can substantially increase pediatric trauma center ED LOS but modifications to ED processes and bed location may mitigate this increase.

Factors associated with prolonged emergency department length of stay in a resource-constrained setting

Prolonged length of stay (LOS) in the emergency department (ED) is a key factor in measuring ED crowding worldwide. This study aimed to identify factors associated with prolonged LOS in the ED to better understand these factors at our institution. This was a retrospective record review examining factors associated with prolonged emergency department length of stay (&gt;6-hours). Data were collected from electronic medical records, including patient demographics, chief complaints, triage acuity level, medication administration, diagnostic testing, consultations and patient disposition. In 2019, we recorded a total of 36,068 patient visits at our ED. Of these, 6439 (17.9%) patients met our definition of prolonged ED LOS (more than 6-hours) and were included in our analysis. Using multivariate analysis, we found that consulting services carried the highest predictor for prolonged ED LOS, with an adjusted odds ratio (aOR) of 23.0 and 95% confidence interval (CI) of 20.4–25.8. Followed by medication administration (aOR 2.0, CI 1.8–2.3), laboratory investigations (aOR 1.7, CI 1.5–2.0), radiological studies (aOR 1.8, CI 1.6–2.0), and non-Saudi nationality (aOR 1.3, CI 1.2–1.4), all p &lt; 0.01. ED LOS may be reduced by optimizing the process of laboratory/radiology testing and medication administration. More importantly however, implementing a timeframe monitoring system for consultations while emphasizing accelerated decision-making and disposition for patients can reduce ED LOS.

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data.

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program. Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression. The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive. Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge

Pediatric readiness is essential for all emergency departments (EDs). Children's experience of care may differ according to operational challenges in children's hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges. To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022. This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children's hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs. Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022. Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours). A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children's hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites. In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.

Improving Pediatric Ovarian Torsion Evaluation in the Pediatric Emergency Department: A Quality Improvement Initiative

Background: Transabdominal pelvic ultrasound (TPUS) is the diagnostic test of choice for the evaluation of ovarian torsion, a time-sensitive surgical emergency. A full bladder is required to visualize the ovaries. Bladder filling is a time-consuming process leading to delays to TPUS, poor visualization of ovaries requiring repeat studies, and prolonged emergency department length of stay (ED LOS). The primary objective was to decrease the time to TPUS by standardizing the bladder filling process. Methods: This quality improvement initiative occurred at a single, academic, quaternary-care children’s hospital ED and utilized the Institute for Healthcare Improvement Model for Improvement with sequential plan-do-study-act cycles. The first set of interventions implemented in August 2021 included a new electronic order set and bladder scan by ED nurses. Subsequent plan-do-study-act cycles aimed to decrease the time to intravenous fluid, decrease fluid requirement, and decrease the need for intravenous fluid. The primary outcome measure was the monthly mean time to TPUS. Secondary outcome measures included monthly mean ED LOS and percentage of repeat TPUS. We performed data analysis with statistical process control charts to assess for system change over time. Results: The preintervention baseline included 292 ED encounters more than 10 months, and postintervention analysis included 526 ED encounters more than 16 months. Time to TPUS decreased (138–120 min), ED LOS decreased (372–335 min), and repeat TPUS decreased (18% to 4%). All changes met the rules for special cause variation. Conclusions: Standardizing the bladder filling process was associated with decreased time to TPUS, ED LOS, and repeat TPUS.

Outcomes of critically ill COVID-19 patients boarding in the emergency department of a tertiary care center in a developing country: a retrospective cohort study

BackgroundBoarding of critically ill patients in the emergency department (ED) has long been known to compromise patient care and affect outcomes. During the COVID-19 pandemic, multiple hospitals worldwide experienced overcrowded emergency rooms. Large influx of patients outnumbered hospital beds and required prolonged length of stay (LOS) in the ED. Our aim was to assess the ED LOS effect on mortality and morbidity, in addition to the predictors of in-hospital mortality, intubation, and complications of critically ill COVID-19 ED boarder patients.MethodsThis was a retrospective cohort study, investigating 145 COVID-19-positive adult patients who were critically ill, required intensive care unit (ICU), and boarded in the ED of a tertiary care center in Lebanon. Data on patients who boarded in the emergency from January 1, 2020, till January 31, 2021, was gathered and studied.ResultsOverall, 66% of patients died, 60% required intubation, and 88% developed complications. Multiple risk factors were associated with mortality naming age above 65 years, vasopressor use, severe COVID pneumonia findings on CT chest, chemotherapy treatment in the previous year, cardiovascular diseases, chronic kidney diseases, prolonged ED LOS, and low SaO2 < 95% on triage. In addition, our study showed that staying long hours in the ED increased the risk of developing complications.ConclusionTo conclude, all efforts need to be drawn to re-establish mitigation strategies and models of critical care delivery in the ED to alleviate the burden of critical boarders during pandemics, thus decreasing morbidity and mortality rates. Lessons from this pandemic should raise concern for complications seen in ED ICU boarders and allow the promotion of health measures optimizing resource allocation in future pandemic crises.

174 A silver lining: the identification of silver trauma at triage for older persons (&amp;gt;65) presenting to the emergency department

Abstract Background Trauma in patients over 65 (silver trauma), can result in serious injury from lower impact mechanisms. The NOCA Major Trauma report highlights that 58% of major trauma is a result of a fall from 2 metres or less and mortality increases with age and comorbidities. Failure to identify, rapidly assess and treat older persons who have suffered silver trauma results in prolonged emergency department stays with an increase in morbidity and mortality. We therefore, performed a completed audit cycle to assess the identification of Silver Trauma in our emergency department. Methods A focus group involving key stakeholders was established, including Emergency Physicians, nurses and members of the Gerontological Emergency Department Intervention team. An audit assessed patients triaged as ‘major trauma’ from October to December 2022. We established silver trauma guidelines for triage. Teaching sessions on the recognition of silver trauma were provided, daily briefings were given, and information leaflets were placed in all triage areas. A triage discriminator of ‘Silver Trauma’ was introduced to prompt recognition and review by clinicians. A full audit cycle was completed. Results Our initial audit (October to December 2022) revealed 25 patients triaged as ‘Major Trauma’ who were aged over 65. After the completion of the initial audit and implementation of measures, 122 patients were triaged as ‘Silver Trauma’ between January 20th and March 31st. We identified that 59% (N = 72) were due to falls from 2 meters or less. Other mechanisms of injury included unwitnessed fall (21% N = 25), syncope (7% N = 8), fall from height (11% N = 13) and Major Trauma (3% N = 4). Seventy-one (58.19%) were admitted and 51 (41.80%) were discharged home. Conclusion This audit demonstrates that departmental education and implementation of a triage discriminator has significantly improved the recognition of silver trauma within the ED setting.

Association Between the Emergency Department Length of Stay and in-Hospital Mortality: A Retrospective Cohort Study.

The number of emergency department (ED) visits and prolonged ED length of stay (LOS) are increasing worldwide. Prolonged ED LOS may be associated with a higher risk of in-hospital mortality. Here, we analysed the association between of ED LOS and the risk of in-hospital mortality in a hospital in Jakarta, Indonesia. This was a single-centre retrospective cohort study performed in a referral academic hospital in Jakarta, Indonesia. Data on ED visits in 2019 were obtained from the electronic medical records. ED patient was used as the unit of the analysis. The dependent variable was all-cause in-hospital mortality during one's visit. The main independent variable was ED LOS with respect to approval (<8 h) and prolonged (≥8 h). Potential confounders were sex, age, triage categories, trauma-related case, malignancy-related case, labour-related case, and referral patients from other healthcare facilities. Multivariate logistic regression analysis was performed to evaluate the association of ED LOS and in-hospital mortality after adjusting for other confounders. There were 18,553 participants included in the analysis. The in-hospital mortality was 13.5% among all participants, and 63.5% participants had an ED LOS ≥8 h. Multivariate analysis showed that a prolonged ED LOS was associated with an increased risk of in-hospital mortality (adjusted relative risk, 2.69; 95% confidence interval, 2.40-3.03; P<0.001). Prolonged ED LOS was associated with risk an increased of in-hospital mortality after adjusting for several confounders. In future, hospital service plans should aim to reduce ED LOS and increase patient flow from the ED to in-patient wards.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Changes in Acute ED Visits by Race/Ethnicity During the Early COVID-19 Pandemic

Emergency department (ED) visits for conditions unrelated to the Coronavirus Disease 2019 (COVID-19) pandemic decreased during the early pandemic, raising concerns about critically ill patients forgoing care and increasing their risk of adverse outcomes. It is unclear if Hispanic and Black adults, who have a high prevalence of chronic conditions, sought medical assistance for acute emergencies during this time. This study used 2018–2020 ED visit data from the largest safety net hospital in Los Angeles County to estimate ED visit differences for cardiac emergencies, diabetic complications, and strokes, during the first societal lockdown among Black and Hispanic patients using time series analyses. Emergency department visits were lower than the expected levels during the first societal lockdown. However, after the lockdown ended, Black patients experienced a rebound in ED visits while visits for Hispanics remained depressed. Future research could identify barriers Hispanics experienced that contributed to prolonged ED avoidance.

Impact of Access Block Is Increasing Mortality in Emergency Departments in Nepal

Introduction:Emergency patients have to stay in the Emergency Department (ED) for hours to days to get ward admission for definite care in Nepal. Access block is a major issue in the ED of University Level Teaching Hospitals (ULTH) in Nepal. This study aimed to analyze the impact of access blocks in the EDs of Nepal.Method:Meta-analysis of different publications on ‘duration of ED Boarding’ and ‘mortality outcome of ED’ of ULTHs of Nepal till November 15, 2022Results:9.7% of ED patients were admitted to the ward. The time period from ED arrival to respective ward team consultation is 5.7 hours, consultation to ward admission is 5.6 hours, and admission to ward transfer is 8 hours. The average ED boarding time is 18.1 hours. 38% of patients arrived in ED via Ambulances. The time period from ED arrival to ward team consultation for those who need transfer to another center are 6.9 hours, consultation to admission is 5.7 hours, and admission to transfer is 8.7 hours (ED Boarding time 21.3 hours). Meta-analysis of three major ULTH’s showed mortality with respect to ED boarding time to be 17% in &lt; 1 hour, 40.4% in 1 - 6 hours, 27.4% in 6-12 hours, 9.1% in 12-24 hours, 4% in 24-28 hours and 2.1% in &gt;48 hours. Among them, higher age, greater mortality rate. The immediate causes of mortality comparing 2018 vs 2010 are Sepsis &amp; Septic shock 32.2% vs 18%, Cardiac Causes 21.8% vs 14.8%, Aspiration Pneumonia 19.5% vs 14.8%, Severe Lung Diseases 12.7% vs 16.4%, Hypovolumic &amp; Haemorrhagic Shock 9.2% vs 34.4% and Poisoning 4.6% vs 1.6%.Conclusion:Prolonged ED boarding due to Access Block is triggering increased mortality in the ED.

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators.

Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360min) is associated with poor outcomes in this cohort of ED referrals. This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64min (IQR 35-105min). Age ≥ 65years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034). Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.

Prolonged length of stay and its associated factors at adult emergency department in amhara region comprehensive specialized hospitals, northwest Ethiopia

BackgroundProlonged length of stay at the emergency department interferes with the main goal of emergency care and results in adverse patient outcomes like nosocomial infection, dissatisfaction, morbidity, and mortality. Despite this, little is known about the length of stay and the factors that influence it in Ethiopia’s emergency department.MethodsAn institution-based cross-sectional study was conducted on 495 patients admitted at Amhara region comprehensive specialized hospitals emergency department from May 14 to June 15/2022. A systematic random sampling was employed to select study participants. A pretested structured interview-based questionnaire was used to collect data by using Kobo toolbox software. SPSS version 25 was used for data analysis. Bi-variable logistic regression analysis was carried out to select variables with P-value < 0.25. The significance of association was interpreted using an Adjusted Odds Ratio with a 95% confidence interval. Variables with P-value < 0.05 in the multivariable logistic regression analysis were inferred to be significantly associated with length of stay.ResultOut of 512 enrolled participants, 495 were participated with a response rate of 96.7%. The prevalence of prolonged length of stay in the adult emergency department was 46.5% (95%CI: 42.1, 51.1). Lack of insurance (AOR: 2.11; 95% CI: 1.22, 3.65), non-communicative presentation (AOR: 1.98; 95% CI: 1.07, 3.68), delayed consultation (AOR: 9.5; 95% CI: 5.00, 18.03), overcrowding (AOR: 4.98; 95% CI: 2.13, 11.68), and shift change experience (AOR: 3.67; 95% CI: 1.30, 10.37) were significantly associated with prolonged length of stay.ConclusionThe result of this study is found to be high based on Ethiopian target emergency department patient length of stay. Lack of insurance, presentation without communication, delayed consultation, overcrowding, and shift change experience were significant factors for prolonged emergency department length of stay. Therefore, interventions like expansion of organizational setup are needed to decrease the length of stay to an acceptable level.

24 hours - Life in the E.R.: A state-wide data linkage analysis of in-patients with prolonged emergency department length of stay in New South Wales, Australia.

Describe the characteristics and predictors of mortality for patients who spend more than 24 h in the ED waiting for an in-patient bed and compare baseline clinical and demographic characteristics between tertiary and non-tertiary hospitals. This was a state-wide analysis data linkage analysis of adult (age >16 years) ED presentations across New South Wales from 2019 to 2020. Cases were included if their mode of separation from ED indicated admission to an in-patient unit including critical care ward and their ED length of stay was greater than or equal to 24 h. Cases were categorised by service-related groups based on principle diagnosis. A total of 26 854 eligible cases were identified. The most common diagnosis groups were psychiatry, cardiology and respiratory. The odds ratio (OR) for 30-day all-cause mortality in admitted patients with an ED length of stay greater than 24 h were highest in those aged >75 years (OR 15.18, 95% confidence interval [CI] 9.99-23.07, P < 0.001), oncology (OR 10.45, 95% CI 7.93-13.77, P < 0.001) and haematology patients (OR 2.95, 95% CI 2.01-4.33, P < 0.001). Interventions and models of care to address ED access block need to focus on mental health patients, older patients particularly those with cardiorespiratory illness and oncology and haematology patients for whom risk of mortality is disproportionately higher.