Reduction In Emergency Department Length Of Stay Research Articles

POCUS-first for nephrolithiasis: A Monte Carlo simulation illustrating cost savings, LOS reduction, and preventable radiation

ObjectivesNon-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure. MethodsWe created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure. ResultsUsing this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually. ConclusionIf adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.

376 Point-of-Care Ultrasound-First for the Evaluation of Urolithiasis in Patients Who Fit Choosing Wisely Criteria: National Cost Savings and Length of Stay Reduction

Study ObjectivesChoosing Wisely guidelines recommend against ordering non-contrast computed tomography (NCCT) for patients with suspected urolithiasis who are under the age of 50 and have a history of recurrent kidney stones. Our primary objective was to estimate the annual national cost savings and reduction in emergency department (ED) length of stay (LOS) from using a point-of-care ultrasound (POCUS)-first approach for patients with urolithiasis meeting Choosing Wisely criteria.MethodsWe created and ran 1,000 trials of a Monte Carlo simulation. The study population included all patients who presented to the ED and were diagnosed with urolithiasis. Using this simulation, we modeled national cost savings in averted advanced imaging from a POCUS-first approach for urolithiasis. The model assumes that patients with indeterminate or negative POCUS studies underwent NCCT for further evaluation. We applied the same Monte Carlo model to estimate the reduction in ED LOS.ResultsUsing this model, a POCUS-first approach in our select patient population for diagnosing urolithiasis was estimated to save a mean (±SD) of $25.5 million (±$2.7 million) by avoiding 203,000 (±21,000) NCCT scans. This resulted in a national cumulative decrease of 205,000 (±874,000) ED bed-hours.ConclusionsIf adopted widely, a POCUS-first approach for suspected urolithiasis in patients who meet Choosing Wisely criteria could yield significant cost savings and reduction in ED LOS. Further research is needed to explore drivers of the lack of widespread adoption of this clinical workflow.No, authors do not have interests to disclose Study ObjectivesChoosing Wisely guidelines recommend against ordering non-contrast computed tomography (NCCT) for patients with suspected urolithiasis who are under the age of 50 and have a history of recurrent kidney stones. Our primary objective was to estimate the annual national cost savings and reduction in emergency department (ED) length of stay (LOS) from using a point-of-care ultrasound (POCUS)-first approach for patients with urolithiasis meeting Choosing Wisely criteria. Choosing Wisely guidelines recommend against ordering non-contrast computed tomography (NCCT) for patients with suspected urolithiasis who are under the age of 50 and have a history of recurrent kidney stones. Our primary objective was to estimate the annual national cost savings and reduction in emergency department (ED) length of stay (LOS) from using a point-of-care ultrasound (POCUS)-first approach for patients with urolithiasis meeting Choosing Wisely criteria. MethodsWe created and ran 1,000 trials of a Monte Carlo simulation. The study population included all patients who presented to the ED and were diagnosed with urolithiasis. Using this simulation, we modeled national cost savings in averted advanced imaging from a POCUS-first approach for urolithiasis. The model assumes that patients with indeterminate or negative POCUS studies underwent NCCT for further evaluation. We applied the same Monte Carlo model to estimate the reduction in ED LOS. We created and ran 1,000 trials of a Monte Carlo simulation. The study population included all patients who presented to the ED and were diagnosed with urolithiasis. Using this simulation, we modeled national cost savings in averted advanced imaging from a POCUS-first approach for urolithiasis. The model assumes that patients with indeterminate or negative POCUS studies underwent NCCT for further evaluation. We applied the same Monte Carlo model to estimate the reduction in ED LOS. ResultsUsing this model, a POCUS-first approach in our select patient population for diagnosing urolithiasis was estimated to save a mean (±SD) of $25.5 million (±$2.7 million) by avoiding 203,000 (±21,000) NCCT scans. This resulted in a national cumulative decrease of 205,000 (±874,000) ED bed-hours. Using this model, a POCUS-first approach in our select patient population for diagnosing urolithiasis was estimated to save a mean (±SD) of $25.5 million (±$2.7 million) by avoiding 203,000 (±21,000) NCCT scans. This resulted in a national cumulative decrease of 205,000 (±874,000) ED bed-hours. ConclusionsIf adopted widely, a POCUS-first approach for suspected urolithiasis in patients who meet Choosing Wisely criteria could yield significant cost savings and reduction in ED LOS. Further research is needed to explore drivers of the lack of widespread adoption of this clinical workflow.No, authors do not have interests to disclose If adopted widely, a POCUS-first approach for suspected urolithiasis in patients who meet Choosing Wisely criteria could yield significant cost savings and reduction in ED LOS. Further research is needed to explore drivers of the lack of widespread adoption of this clinical workflow.

Cost effectiveness of a 1-hour high-sensitivity troponin-T protocol: An analysis of the RAPID-TnT trial.

To understand the economic impact of an accelerated 0/1-hour high-sensitivity troponin-T (hs-cTnT) protocol. To conduct a patient-level economic analysis of the RAPID-TnT randomised trial in patients presenting with suspected acute coronary syndrome (ACS). An economic evaluation was conducted with 3265 patients randomised to either the 0/1-hour hs-cTnT protocol (n=1634) or the conventional 0/3-hour standard-of-care protocol (n=1631) with costs reported in Australian dollars. The primary clinical outcome was all-cause mortality or new/recurrent myocardial infarction. Over 12-months, mean per patient costs were numerically higher in the 0/1-hour arm compared to the conventional 0/3-hour arm (by $472.49/patient, 95% confidence interval [95%CI]: $-1,380.15 to $2,325.13, P=0.617) with no statistically significant difference in primary outcome (0/1-hour: 62/1634 [3.8%], 0/3-hour: 82/1631 [5.0%], HR: 1.32 [95%CI: 0.95-1.83], P=0.100). The mean emergency department (ED) length of stay (LOS) was significantly lower in the 0/1-hour arm (by 0.62h/patient, 95%CI: 0.85 to 0.39, P<0.001), but the subsequent 12-month unplanned inpatient costs was numerically higher (by $891.22/patient, 95%CI: $-96.07 to 1,878.50, P=0.077). Restricting the analysis to patients with hs-cTnT concentrations≤29ng/L, mean per patient cost remained numerically higher in the 0/1-hour arm (by $152.44/patient, 95%CI:$-1,793.11 to $2,097.99, P=0.988), whilst the reduction in ED LOS was more pronounced (by 0.70h/patient, 95%CI: 0.45-0.95, P<0.001). There were no differences in resource utilization between the 0/1-hour hs-cTnT protocol versus the conventional 0/3-hour protocol for the assessment of suspected ACS, despite improved initial ED efficiency. Further refinements in strategies to improve clinical outcomes and subsequent management efficiency are needed.

Abstract 6984: Cost Effectiveness of a 1-Hour High-Sensitivity Troponin-t Protocol in Suspected Acute Coronary Syndrome: A Trial-Based Analysis of the Rapid-tnt Randomised Trial

Introduction: To better understand the economic impact of an accelerated 0/1-hour high-sensitivity troponin-T (hs-cTnT) protocol compared to conventional 0/3-hour protocol, we conducted a patient-level economic analysis of the RAPID-TnT randomised trial with a 12-month follow-up in patients presenting to emergency department (ED) with suspected acute coronary syndrome (ACS). Methods: An economic evaluation was conducted with 3265 patients randomised to either the 0/1-hour hs-cTnT protocol (n=1634) or the conventional 0/3-hour protocol (n=1631). The primary outcome measure was a composite of all-cause mortality and new/recurrent myocardial infarction (MI). Results: Mean per patients costs were numerically higher in the 0/1-hour arm compared to the conventional 0/3-hour arm (by $1830.56/patient, 95% confidence interval [95%CI]: $-1610.83 - 5271.96, P=0.30) with no statistically significant difference in primary outcome (0/1-hour: 62/1634 [3.8%], 0/3-hour: 82/1631 [5.0%], HR: 1.32 [95%CI: 095-1.83], P=0.1). The mean ED length of stay (LOS) was significantly lower in the 0/1-hour arm (by 0.63 hours/patient, 95%CI: 0.34-0.92, P&lt;0.001), but the cost saving was offset but the higher cumulative emergency-related inpatient costs (by $2247.31/patient, 95%CI: -656.55 - 5151.18, P=0.12). Restricting the analysis to patients with hs-cTnT≤29ng/L, the mean per patients cost remained numerically higher in the 0/1-hour arm (by $1480.24/patient, 95%CI:$-1097.62 - 2058.10, P=0.26), but the reduction in ED LOS was more pronounced (by 0.75 hours/patient, 95%CI: 0.46-1.05, P&lt;0.001). Conclusions: This economic evaluation suggest that there were no differences in costs and outcomes between the 0/1-hour hs-cTnT protocol and the conventional 0/3-hour protocol for the assessment of suspected ACS in ED after 1 year of follow-up from the Australian healthcare system perspective. Our observations suggest that the 0/1-hour hs-cTnT protocol improves initial ED efficiency with more rapid exclusion of ACS and discharge. However, the associated cost savings were offset by the subsequent emergency inpatient costs. Further refinements in cost-effective strategies to improve clinical outcomes whilst efficiently utilising healthcare resources is needed.

Increasing consultant-level staffing as a proportion of overall physician coverage improves emergency department length of stay targets

ObjectivesOne goal of Emergency Department (ED) operations is achieving an overall length of stay (LOS) that is less than four hours. The goal of the current study was to assess for association between increasing number of on-duty EM Consultants and LOS, while adjusting for overall (all-grade) on-duty emergency doctors’ numbers and other operational factors.MethodsThis was a retrospective analysis of three years (2016–2019) of data, employing a unit of analysis of 3276 eight-hour ED shifts. The study was conducted using a prospectively populated ED database in a busy (annual census 420,000) Middle Eastern ED with staffing by Consultants and multiple non-Consultant grades (Specialists, fellows, and residents). Using logistic regression, the main predictor variable of “on-duty Consultant n” was assessed for association with the study’s primary (dichotomous) endpoint: whether a shift’s median LOS met the target of < 240 min. Linear regression was used to assess for association between on-duty Consultant n and the study’s secondary (continuous) endpoint: median LOS for the ED shift.ResultsMultivariate logistic regression adjusting for a number of operations factors (including total EP on-duty complement) identified an association between increasing n of on-duty Consultants and the likelihood of a shift’s meeting the 4-h ED LOS target (OR 1.27, 95% CI 1.20 to 1.34, p < .0001). Multiple linear regression, which also adjusted for total on-duty EP n and other operational factors, also indicated LOS benefit from more on-duty Consultants: each additional on-duty Consultant was associated with a shift’s median LOS improving by 5.4 min (95% CI 4.3 to 6.5, p < .0001).ConclusionsAt the study site, in models that adjusted for overall on-duty EP numbers as well as myriad other operational factors, increasing numbers of on-duty Consultants was associated with a statistically and operationally significant reduction in ED LOS.

LO28: Innovating for overcrowding: analyzing the impact of a novel emergency physician role on patient flow

Introduction: Overcrowding in the Emergency Department (ED) results in delays in care, and increased patient morbidity and mortality. Innovative departmental approaches have the potential to make patient flow through the ED more efficient and reduce overcrowding by improving patient throughput. The Calgary zone ED recently piloted a new physician role, the Emergency Physician Lead (EPL), a senior physician working closely with the charge nurse and consulting services to provide physician leadership, and to troubleshoot flow issues and safety breeches such as EMS offload delays and long emergency inpatient (EIP) stays. The objective of this study was to evaluate the efficacy of the EPL by determining its effect on key metrics of patient flow, and by identifying which specific EPL interventions were most effective at improving patient throughput. Methods: A retrospective cohort design was used to compare Foothills Medical Centre (FMC) ED patients seen by the EPL from March-June 2019 (n = 1343 patients) with a control group from the same period in 2018 (n = 5530). An EMR search was used to collect patient data and generate descriptive statistics, which were compared between groups by Mann-Whitney U-test. Patient handover notes left by the EPL were also collected and analyzed by two independent assessors to develop a list of actions taken by the EPL. Each patient was then coded based on the actions in the handover note, and means for each coded group were compared to control to find correlations between action and changes in key flow metrics. Results: Patients whose care involved the EPL had a 40% shorter average ED length of stay (ELOS) compared to control (515 vs 865 min, p &lt; 0.001). The EPL was especially effective for patients with ELOS above the 90th percentile, with a 58% relative reduction. EPL patients also had lower average times from first contact with the department to first order being placed (79 vs 143 min, p &lt; 0.001), and spent less time as EIPs after being admitted (390 vs 515 mins, p &lt; 0.001). EPL actions aimed at early ordering of investigations or early management showed the largest relative reductions in ELOS, followed by actions related to resolving issues with consulting services (56% and 48% respectively, p &lt; 0.001). Conclusion: The EPL role appears to be associated with improvements in several key metrics of patient flow. Specific EPL actions were correlated with marked decreases in length of stay. The EPL may be an effective strategy to improve patient throughput and combat ED overcrowding.

Service Evaluation of Methoxyflurane Versus Standard Care for Overall Management of Patients with Pain Due to Injury.

IntroductionInhaled methoxyflurane is an analgesic used for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain that is increasingly being used in hospital emergency departments to provide rapid analgesia. It is widely accepted that effective pain relief can facilitate patient care and flow through the emergency department (ED). The main aim of this evaluation was to assess the impact of inhaled methoxyflurane on patient length of stay (LOS) in the ED compared with standard care.MethodsAdult patients with moderate to severe trauma pain and Glasgow coma score of 15 were included in the evaluation. Evaluation forms were completed for 79 patients who received methoxyflurane and were matched with 80 patients who received standard care.ResultsOverall the mean time spent in the ED was reduced by 71 min in those patients who were administered methoxyflurane compared with patients who received standard care. Furthermore, analysis of LOS by injury type demonstrated a reduction in ED LOS by 183 min for patients with shoulder dislocation who were treated with methoxyflurane compared with patients who received standard care. There was no reduction in ED LOS for patients with lower limb, hip or pelvic injuries between the two treatment groups.ConclusionUse of methoxyflurane in adult patients with trauma pain significantly reduced the ED LOS and may potentially improve patient flow through the ED.

Triage to Observation: A Quality Improvement Initiative for Chest Pain Patients Presenting to the Emergency Department.

The objective of this study was to evaluate the impact of a rapid admission protocol for chest pain patients presenting to the emergency department (ED) on ED length-of-stay (LOS). In this study, ED LOS was defined as the time from triage check-in until the time the patient physically leaves the ED. The purpose of this quality improvement study was to decrease ED crowding. This is a single-center prospective cohort study performed as a quality improvement initiative. This study implemented a rapid admission protocol for patients who were at moderate risk for a major adverse cardiac event based on the HEART score. When a patient presented to the ED through triage with a chief complaint of chest pain, this protocol allowed the provider-in-triage (PIT) to identify eligible patients for potential rapid admission to the hospital's clinical decision unit (CDU). The PIT would complete a rapid medical screening examination, initiate the patient's workup, and call the CDU providers to further evaluate the patient. By identifying these patients early, the lengthy ED chest pain workup contributing to longer ED LOS could then be completed in the CDU. The total number of patients seen in the ED over the study period was 34,251. The total number of patients admitted to the CDU during the study period was 1,442. The PIT identified 13 patients for rapid admission to the CDU during the study period. These patients had a statistically significant reduction in ED LOS (P < 0.001). ED LOS was also adjusted to identify delays in patient movement resulting in a statistically significant difference (P < 0.001). Implementation of a rapid admission protocol for chest pain patients at moderate risk for a major adverse cardiac event resulted in a reduction in ED LOS. Adjusted ED LOS was also significant, highlighting a delay in patient movement from the ED to the CDU indicating continued barriers affecting ED holding times.

Abstract TP464: System Changes Decrease Emergency Department Length of Stay for Hemorrhagic Stroke Patients

Background/Purpose: American Stroke Association guidelines recommend that a length of stay (LOS) in the Emergency Department (ED) of less than 6 hours improve outcomes in patients with hemorrhagic stroke. In the second quarter of 2017, patients at our academic medical facility averaged an ED LOS of 6.3 hours. Issues identified that extended LOS were: 1) a lack of process to alert required providers and stroke RN, 2) unfamiliarity of ED nurses with complex hemorrhagic stroke protocols, and 3) need for hemorrhagic stroke clinical care pathways with standardized order sets. Methods: Collaboration was formed between the emergency department, neurosurgery, neuro ICU, stroke program manager, and neuro ICU trained stroke nurses. The following improvements were implemented: 1) a subarachnoid hemorrhage and intra-cerebral hemorrhage (SAH/ICH) activation was developed to formalize a process to alert and mobilize specialty services upon patient arrival in the ED, 2) formation of a collaboration between an ED RN and expertly trained stroke nurses to provide care for the complex hemorrhagic stroke patient, and 3) implementation of standardized order sets for the electronic medical record. Results: Eleven months after the implementation of process improvements, there was a statistically significant reduction in ED LOS for hemorrhagic stroke patients. LOS decreased from an average of 6.3 hours to 3.1 hours. Conclusion: An activation system expediting specialty services and expert nursing care with the use of hemorrhagic stroke clinical care pathways and order sets reduces LOS in the ED and may improve patient outcomes. Future Recommendations: Monitor LOS statistics on a quarterly basis. Periodically re-evaluate the timeliness of SAH/ICH activation and compliance with clinical care pathways and standardized order sets to ensure sustainability.

Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay.

The objective was to evaluate the effect of an emergency clinician-initiated "ED admission holding order set" on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients. We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a "non-value-added" activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior. The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention. We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change.

Does Reducing Inpatient Length of Stay Have Upstream Effects on the Emergency Room: Exploring the Impact of the General Internal Medicine Care Transformation Initiative.

The General Internal Medicine (GIM) Care Transformation Initiative implemented at one of four teaching hospitals in the same city resulted in improved efficiency of in-hospital care. Whether it had beneficial effects upstream in the emergency department (ED) is unclear. Controlled before-after study of ED length of stay (LOS) and crowding metrics for the intervention site (n = 108,951 visits) compared to the three other teaching hospitals (controls, n = 300,930 visits). Our primary outcome was ED LOS for GIM patients but secondary outcomes included ED LOS for all adults and ED crowding metrics. The GIM Care Transformation was associated with an additional 2.8-hour reduction in median ED LOS (from 25.6 hours to 13.5 hours) over and above the 9.3-hour decline (from 30.6 hours to 21.3 hours) seen in the three control EDs for GIM patients who were hospitalized (p < 0.001). As less than one in 30 ED visits resulted in a GIM ward admission, the median ED LOS for all patients declined by 15 minutes (from 4.6 hours to 4.3 hours, p < 0.001) in the control hospitals and by 30 minutes (from 5.7 hours to 5.1 hours, p < 0.001) at the intervention hospital pre versus post (p = 0.04 for the 15-minute additional reduction, p < 0.001 for level change on interrupted time series). Other metrics of ED crowding improved by similar amounts at the intervention and control hospitals with no statistically significant differences. Although the GIM Care Transformation Initiative was associated with substantial reductions in ED LOS for patients admitted to GIM wards at the intervention hospital, it resulted in only minor changes in overall ED LOS and no appreciable changes in ED crowding metrics.

Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis

BackgroundWe sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario...

Maintaining an open trauma intensive care unit bed for rapid admission can be cost-effective.

In 2012, we implemented a ready open trauma intensive care unit (TICU) bed process. Our hypothesis was that this process would decrease emergency department (ED) length of stay (LOS) in a cost-effective manner without worsening clinical outcomes. We developed a charge nurse without a patient assignment to facilitate this open bed. We also provided team training for early ICU resuscitation. All Level 1 activations admitted directly to the TICU before and after the implementation were examined. Patients taken directly to the operating room from the ED, deaths within 24 hours of admission, and patients with nonsurvivable head injuries were excluded. Cost-effectiveness of the position was examined. Age (mean [SD], 45.78 [18.71] years), sex (74.7% male), and Injury Severity Score (ISS) (mean [SD], 17.27 [9.26]) were not significantly different. Median ED LOS for the postimplementation group decreased from 230 minutes to 66 minutes (p < 0.001). Median ICU LOS (from 3.29 to 2.98 days, p = 0.13) and total median hospital LOS (from 10.71 to 7.98 days, p = 0.06) decreased but were not statistically significant. Controlling for age, ISS, sex, and mechanism of injury the postimplementation group had a 29% reduction in ICU LOS (2.12 days), a 28% reduction in hospital LOS (4.34), and a 54% reduction in ED LOS (154 minutes). The LOS decreased despite a small increase in ISS (from 15.89 to 18.37). Observed/expected mortality did not differ between the groups, preimplementation/postimplementation of 0.87 and 0.92. Nursing productivity increased one nurse after implementation at a cost of $624 per day. The ICU LOS decrease of 1.6 days at a rate of $1,144 average ICU daily cost of room and board totaled $1,830 per patient. The decreased ICU LOS dollars minus the increase nurse pay resulted in an overall savings of $1,206 per patient. Rapid access to the TICU made possible by the charge nurse without a direct assignment and team training has a potential cost savings without adversely affecting patient outcomes. Cost analysis, level III.

The effect of laboratory testing on emergency department length of stay: a multihospital longitudinal study applying a cross-classified random-effect modeling approach.

ObjectivesThe objective was to examine the relationship between laboratory testing (including test volume and turnaround time [TAT]) and emergency department (ED) length of stay (LOS), using linked patient‐level data from four hospitals across 4 years.MethodsThis was a retrospective, multisite cohort study of patients presenting to any one of four EDs in New South Wales, Australia, during a 2‐month period (August and September) in 2008, 2009, 2010, and 2011. Data from ED information systems were linked to laboratory test data. A cross‐classified random‐effect modeling approach was applied to identify factors affecting ED LOS, taking into account the correlation between patients' presentations at the same hospital and/or in the same calendar year. Number of test order episodes (tests ordered at one point in time during the ED stay) and TAT (time from laboratory order receipt to result available) were examined.ResultsAs the number of test order episodes increased, so did the duration of patient ED LOS (p < 0.0001). For every five additional tests ordered per test order episode, the median ED LOS increased by 10 minutes (2.9%, p < 0.0001); each 30‐minute increase in TAT was, on average, associated with a 5.1% (17 minutes; p < 0.0001) increase in ED LOS, after adjustment for other factors. Patients presenting to the ED at night (7 p.m. to 7 a.m.) had longer stays than those presenting during the daytime, although the median TATs at nights were shorter than those during the daytime.ConclusionsLaboratory testing has a direct effect on patients' LOS in ED. Laboratory TAT, number of testing episodes, and test volume influence ED LOS. Targeted increases of ED resources and staffing after‐hours may also contribute to reductions in ED LOS.

The Long-Term Effect of an Independent Capacity Protocol on Emergency Department Length of Stay: A before and after Study.

PurposeIn this study, we determined the long-term effects of the Independent Capacity Protocol (ICP), in which the emergency department (ED) is temporarily used to stabilize patients, followed by transfer of patients to other facilities when necessary, on crowding metrics.Materials and MethodsA before and after study design was used to determine the effects of the ICP on patient outcomes in an academic, urban, tertiary care hospital. The ICP was introduced on July 1, 2007 and the before period included patients presenting to the ED from January 1, 2005 to June 31, 2007. The after period began three months after implementing the ICP from October 1, 2007 to December 31, 2010. The main outcomes were the ED length of stay (LOS) and the total hospital LOS of admitted patients. The mean number of monthly ED visits and the rate of inter-facility transfers between emergency departments were also determined. A piecewise regression analysis, according to observation time intervals, was used to determine the effect of the ICP on the outcomes.ResultsDuring the study period the number of ED visits significantly increased. The intercept for overall ED LOS after intervention from the before-period decreased from 8.51 to 7.98 hours [difference 0.52, 95% confidence interval (CI): 0.04 to 1.01] (p=0.03), and the slope decreased from -0.0110 to -0.0179 hour/week (difference 0.0069, 95% CI: 0.0012 to 0.0125) (p=0.02).ConclusionImplementation of the ICP was associated with a sustainable reduction in ED LOS and time to admission over a six-year period.

11 Performance-Based Compensation for Emergency Physicians Improves Adherence to Interventions Focused on Reducing Emergency Department Length of Stay

Study Objective: Process flow mapping identified the interval from completion of the emergency physician evaluation to the time a patient leaves the emergency department (ED) as a significant contributor to ED length of stay (LOS) and boarding at our institution. In an attempt to shorten this period and decrease overall LOS, we evaluated the effect of an intervention whereby emergency physicians entered holding orders for stable adult inpatient medicine patients following discussion with the appropriate admitting service. While use of the holding orders resulted in a 60-minute reduction in ED LOS, emergency physician utilization of the holding orders was only 9.4% during the first 11 months of availability. We hypothesized that implementation of a performance-based compensation measure evaluating holding order utilization would motivate physician behavior change in this area. The aim of this study was to assess the effect of the implementation of a performance-based compensation measure on the rate of physician adherence to holding order utilization. Methods: For this prospective, observational study, the rate of holding order set usage was evaluated pre-and post implementation of the performance-based compensation measure. Emergency physicians at an academic tertiary care referral center ED were educated regarding the new compensation measure via electronic mail and at a scheduled faculty meeting. Written performance feedback for individual physicians was also provided. Utilization rates were compared using the chi-squared test and pre-and post implementation median times for patients who did and did not receive ED-based holding orders were compared using Mood's median test. Results: During the 12-month study period, 10,462 adult admitted patients were eligible for emergency physician-initiated holding orders, 9498 prior to and 964 following implementation of the compensation measure. ED-based holding orders were used in 895/9498 (9.4%) cases in the pre-implementation phase and in 152/964 (15.8%) cases during the post-implementation period, χ2=38.42, df=1, p<0.001. The median time from completion of the emergency physician evaluation to placement of an admitting bed order was 37 minutes (IQR 18, 72) for those patients receiving ED-based holding orders and 87 minutes (IQR 49, 135) for those without holding orders, p<0.001. In addition, the median ED LOS for holding orders patients (459 minutes; IQR 330, 538) was significantly shorter than the median LOS for patients without holding orders (500 minutes; IQR 340, 570), p<0.001. Conclusion: In this population, adherence to emergency department-based quality improvement interventions was more effective following the implementation of individual performance-based compensation metrics. We observed increased utilization of relevant ED-based holding orders, a reduction in the median time to bed order placement, and a reduction in overall length of stay following implementation of this performance-based compensation measure. We conclude that performance-based compensation can effectively augment ED-based quality improvement strategies focused on improving patient throughput.

Evaluating the Effect of Clinical Decision Units on Patient Flow in Seven Canadian Emergency Departments

To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC). A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates. At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates. With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate.

Improving Patient Flow in Acute Coronary Syndromes in the Face of Hospital Crowding

BackgroundThe current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease. ObjectiveTo measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS. MethodsPrimary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post- availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death. ResultsIn the post-implementation period there was a 30% (95% confidence interval [CI] 36–44%) reduction in admissions to telemetry with a 33% (95% CI 26–39%) reduction in ED LOS and a 20% (95% CI 7–34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p=0.001). ConclusionThe focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.

Changes in Patient Flow Among Five Hospitals Participating in a Learning Collaborative

This was an evaluation of the efforts of five hospitals that participated in a collaborative aimed at improving patient flow and reducing emergency department (ED) crowding. Interviews with hospital implementation team members were conducted at two separate times, and multivariate linear regression models and bivariate logistic models were constructed to assess changes in ED length of stay (LOS) and left without being seen (LWBS). By the end of the collaborative, four of the five hospitals had at least one fully implemented improvement strategy. Those hospitals experienced modest improvements in patient flow: a hospital that implemented front-end improvements and devoted additional resources to fast track had a 51-min reduction in ED LOS, another that implemented only front-end improvements had a 9-min reduction in LOS, a third hospital that improved communication between the ED and inpatient units to facilitate admissions decreased LWBS from 0.6% to 0.4%, and a fourth hospital reduced LOS by 59 min for mid-acuity patients by establishing a new care process for them. Results suggest that relatively small changes may lead to improvements in measures of patient flow that are modest, at best.