Total Emergency Department Length Of Stay Research Articles

Effectiveness of accelerated diagnostic protocols for reducing emergency department length of stay in patients presenting with chest pain: A systematic review and meta-analysis.

In recent years, there has been an increase in the use of accelerated diagnostic protocols (ADPs) and high-sensitivity troponin assays (hsTn) for the assessment of chest pain in emergency departments (EDs). This study aimed to quantitatively summarize the operational and clinical outcomes of ADPs implemented for patients with suspected cardiac chest pain. To be considered eligible for inclusion, studies must have implemented some form of ADP within the ED for evaluating adult (age ≥18 years) patients presenting with chest pain using Tn assays. The primary outcome was ED length of stay (LOS). Secondary outcomes included the proportion of patients admitted and the proportion with 30-day major adverse cardiac events (MACE). Thirty-seven articles involving 404,566 patients met the inclusion criteria, including five randomized controlled trials (RCTs) and 32 observational studies. A significant reduction in total ED LOS was reported in 22 observational studies and four RCTs. Emergency departments with longer baseline ED LOS showed significantly larger reductions in LOS after ADP implementation. This observed association persisted after adjusting for both the change in serial Tn measurement interval and transition from conventional Tn assay to an hsTn assay (β = -0.26; 95% CI, -0.43 to -0.10). Three studies reported an increase in the proportion of patients admitted after introducing an ADP, one of which was significant while 15 studies reported a significant decrease in admission proportion. There was moderate heterogeneity among the 13 studies that reported MACE proportions, with a non-significant pooled risk ratio of 0.95 (95% CI, 0.86-1.04). Implementation of ADPs for chest pain presentations decreases ED LOS, most noticeably within sites with a high baseline LOS; this decreased LOS is seen even in the absence of any change in troponin assay type. The decrease in LOS occurred alongside reductions in hospital admissions, while not increasing MACE. The observed benefits translated across multiple countries and health regions.

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

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

A Method for Projections of the Emergency Department Behaviour by Non-Communicable Diseases From 2019 to 2039.

In this paper, a new method for prediction of future performance and demand on emergency department (ED) in Spain is presented. Increased life expediency and population aging in Spain, along with their corresponding health conditions such as non-communicable diseases (NCDs), have been suggested to contribute to higher demands on ED. These lead to inferior performance of the department and cause longer ED length of stay (LoS). Prediction and quantification of behavior of ED is, however, challenging as ED is one of the most complex parts of hospitals. Using detailed computational approaches integrated with clinical data behavior of Spain's ED in future years was predicted. First, statistical models were developed to predict how the population and age distribution of patients with non-communicable diseases change in Spain in future years. Then, an agent-based modeling approach was used for simulation of the emergency department to predict impacts of the changes in population and age distribution of patients with NCDs on the performance of ED, reflected in ED LoS, between years 2019 and 2039. Results from different projection scenarios indicated that Spain would experience a continuous increase in total ED LoS from 5.7 million hours in 2019 to 6.2 million hours in 2039 if same human and physical resources, as well as same ED configuration, are used. The results from this study can provide health care provider with quantitative information on required staff and physical resources in the future and allow health care policymakers to improve modifiable factors contributing to the demand and performance of ED.

Fits, faints, falls and funny turns: cost and capacity savings in Queensland from the accelerated transient attack pathway initiative (ATAP).

falls, seizures, syncope and transient ischaemic attacks (TIA) are common presentations to emergency departments sharing overlapping clinical features and diagnostic uncertainties. These transient attacks can be markers of serious adverse outcomes and are associated with high admission rates. We evaluated the effects of an integrated suite of pathways for transient attacks designed to improve adherence to best practices and reduce costs through fewer admissions. a suite of clinician-designed pathways based on initial presenting diagnosis was developed to support ambulant care in a large hospital in Queensland, Australia. We performed a set of regression analyses to identify the differences in total cost and length of stay (LOS) before and after implementation. We conducted a Monte Carlo simulation to estimate the cost savings of the freed capacity in the patient cohort. pathway implementation was associated with reduced admitted LOS and costs. Falls patients admitted LOS declined by 32.5%, and admission costs by 19.5%. Syncope, seizure, and TIA patients admitted LOS declined by 22% with no change in admitted costs. Despite a small increase in 90-day representations, total emergency department LOS was unchanged. Emergency department costs were similar between falls and non-falls patients. The Monte Carlo analysis showed that the most likely outcome was a cost savings in freed capacity of $71 per patient episode. the ATAP suite of pathways was associated with reduction in LOS, release of capacity and reduction in costs. Further study is needed to evaluate mechanisms and clinical outcomes in this vulnerable population.

P130: Timely initial assessment by a physician (IAP) improves community emergency department wait times

Introduction: Prior Canadian Emergency Department (ED) studies have demonstrated variable benefits of initial assessment physician (IAP) to rapidly assess and initiate care of ED patients after triage. These studies have been conducted primarily in academic teaching and large urban hospitals. It is not clear if such an IAP role could be beneficial in an small community hospital. Our pilot study hypothesized that instituting a supported IAP role can reduce physician intial assessment (PIA) time, total ED length of stay (LOS), and left-without-being-seen (LWBS) rates. Methods: This was a pre and post interrupted time series observational study at a community ED in Niagara Health Systems (Welland Ontario, 4 MD shifts, 36hrs total coverage, 30000 annual visits). In July 2017, an IAP ED shift (with separate assessment/treatment area) was re-purposed, with nursing support, to reduce initial time to MD assessment after triage. For lower acuity cases, the IAP MD generally completed full case management & disposition. Higher acuity complex cases were initiated by IAP, and transferred into the main ED care areas for “inside” MD management. Administrative data was accessed for 6 months prior to intervention, and 4 months available post-intervention. Descriptive statistics were calculated for collected data. Results: A modest improvement in different administrative ED performance metrics was observed. The following changes were noted pre and post IAP intervention: PIA time reduced from 3.6hrs to 3.2hrs, total ED LOS reduced from 19.2hrs to 13.8hrs, and daily LWBS rate reduced from 4.2% to 3.7%. This pilot study demonstrated improvement trends in ED performance metrics, although there is insufficient data to show statistical significance. Aggregate data was not subgrouped based on CTAS categories. This pilot was not intended to collect patient or staff satisfaction data, adverse events, nor designed to demonstrate cost-effectiveness Conclusion: Introducing an IAP shift in a small community ED has shown improvement trends for various ED throughput measures pertaining to outcomes such as PIA time, total LOS and LWBS rates. Further research is required to determine statistical significance of time reductions, satisfaction (patients, staff), resource utilization impact and CTAS subgroup performance. This improvement demonstrates potential impact system-wide across Niagara region.

P130: Cumulative daily boarding time: a new way to measure emergency department congestion and hospital-wide flow

Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is one of the major contributors to ED overcrowding, and an indicator of hospital-wide deficiencies in capacity and flow. Most indicators of ED overcrowding have measured either counts or percentages of patient subgroups (e.g. number/percentage of patients waiting in triage or number/percentage of admitted patients as compared to full ED census), or specific process time intervals related to patient movement through the hospital (e.g. Physician to Initial Assessment (PIA) time or total ED Length of Stay (EDLOS)). We sought to 1) devise an alternative measure of ED overcrowding that captured the dynamic and disproportionate resource utilization of admitted versus non-admitted patients in the ED, and to 2) determine the association of this measure with selected ED quality metrics for non-admitted patients. Methods: We conducted a retrospective multi-centre observational study at three very high-volume community hospitals in the Greater Toronto Area. Data on all patients visiting the ED during the period between January 1, 2015 and December 31, 2016 were included in the study. We calculated the total daily cumulative boarding time - or time to bed (TTB) - for each day of the study duration. The daily cumulative TTB was calculated as the time from decision to admit to transfer from the ED for all admitted patients within a 24-hour period. We conducted linear regression analysis to determine the association between our measured daily cumulative TTB and daily median and 90th percentile PIA and EDLOS times for non-admitted patients. Results: Preliminary results for 2015 indicate a total cumulative TTB time ranging from 50,973 hours to 191,093 patient-hours for the year, with daily mean cumulative TTB ranging from 140 524 patient-hours/day among the three hospitals. In all three hospitals, there was a statistically significant (p<0.01) positive association between daily cumulative TTB and both median and 90th percentile PIA times for all patients, and median EDLOS times for non-admitted CTAS 1 -3 patients. There was a statistically significant (p<0.05) positive association between daily cumulative TTB and 90th percentile EDLOS for non-admitted CTAS 1-3 patients in two of the three hospitals, with the third hospital showing a positive but non-significant association. Conclusion: Bed boarding constitutes a significant resource cost for EDs, and has a negative impact on timeliness of ED care for the general ED population, particularly more complex (CTAS 1-3) non-admitted patients.

P128: Time of transfer of admitted patients from the ED: a potential area for improvement of patient flow in very high-volume emergency departments

Introduction: Bed boarding of admitted patients in the Emergency Department (ED) is widely recognized as a major contributor to overcrowding, particularly in very high-volume hospitals. The issue of bed boarding is directly tied to hospital-wide capacity, flow and operations. Early morning discharge from inpatient units has been identified as a low-cost intervention to decrease bed boarding, as it allows earlier transfer of admitted patients from the ED. Several hospitals have instituted discharge before noon, or discharge before 10AM policies, practices and targets. Our objectives were 1) to assess the current status of flow within 3 high-volume community hospitals with respect to time of day of discharges from the in-patient units and time of day of transfers from the ED to in-patient units, and 2) to assess the association between time of transfer from the ED and total ED Length of Stay (EDLOS) of admitted patients. Methods: We conducted a retrospective multi-centre observational study during the period of January 1, 2015 to December 31, 2015 at three high-volume community hospitals within Ontario, Canada. All patients admitted to the Medicine service were identified. Time of discharge from the in-patient units and time of transfer from the ED were collected for all patients. EDLOS was calculated for all patients as a function of time of transfer from the ED. Results: Preliminary findings show that, for the three community hospitals, only 11.7% - 19.6% of admitted patients were discharged from the in-patient units during the period between 6AM and 12PM, with a peak discharge time of 2PM in all three hospitals. A concurrent lag was observed in the time of transfer of patients from the ED, with peak transfer times occurring the late afternoon between 3PM and 9PM, and coinciding with a peak in patient volume in the ED. Patients transferred out of the ED earlier in the day (between 12AM 11:59AM) had between 1.4 hours to 8.0 hours lower mean EDLOS when compared to those patients transferred later in the day (between 12PM 11:59PM). Conclusion: Hospital-wide flow and operational issues have a significant impact on ED bed boarding, and potential efficiencies seem at the current time to be underutilized. Interventions aimed at optimizing flow must be implemented alongside those aimed at increasing capacity in order to improve bed boarding. ** These findings are best communicated in graphic form to better represent the dynamics of the flow in and out of the ED over a 24-hour period, and will be presented in graphic format if selected for the conference.

Code Help: Can This Unique State Regulatory Intervention Improve Emergency Department Crowding?

IntroductionEmergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed “Code Help.” Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed.MethodsThis was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations.ResultsOf 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations.ConclusionIn this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.

Emergency Department Telemedicine Shortens Rural Time-To-Provider and Emergency Department Transfer Times.

Emergency department (ED)-based telemedicine has been implemented in many rural hospitals to provide specialty care and expertise to patients with critical time-sensitive conditions. The purpose of this study was to measure the impact of ED-based telemedicine on timeliness of care in participating rural hospitals. Matched cohort study of patients seen in 1 of 14 rural hospitals in a large Midwestern telemedicine network. Telemedicine cases were matched 2:1 with controls based on age, diagnosis, and hospital. The primary outcome was door-to-provider time, and secondary outcomes included ED length-of-stay (LOS) and time-to-transfer in those transferred to other hospitals. Of 127,928 qualifying ED encounters, 2,857 consulted telemedicine and were matched with nontelemedicine controls. Door-to-provider time was shorter in telemedicine patients by 6.0 min (95% confidence interval [CI] 4.3-7.8 min). The first provider seeing the patient was a telemedicine provider in 41.7% of telemedicine encounters, and in these cases, telemedicine was 14.7 min earlier than local providers. ED LOS was 22.1 min shorter (95% CI 3.1-41.2) among transferred patients, but total ED LOS was longer (40.2 min, 95% CI 30.8-49.6 min) for all telemedicine patients. Telemedicine decreases ED door-to-provider time, most commonly because the telemedicine provider was the first provider seeing a patient. Among transferred patients, ED LOS at the first hospital was shorter in patients who had telemedicine consulted. Future work will focus on the clinical impact of more timely rural ED care.

Early burn team consultation in the emergency department improves efficiency and patient throughput

Objective: The objective of the study is to assess the relationship between expedited burn surgery evaluation and total length of stay (LOS) in the emergency department (ED) in a high-volume tertiary burn care institution and extrapolate these results to the efficiency and cost-effectiveness of patient care. Methods: A retrospective review was performed of all patients evaluated by the burn surgery team and discharged from the University of Rochester Medical Center ED between November 2012 and June 2013. One hundred and three primary patients were identified and their time from arrival to discharge and the timing of burn surgery consultation were analyzed. Patients were stratified into two groups, early and late, based on how soon after arrival they were seen by the burn surgery service. Tests of statistical significance were performed, comparing total time in the ED, time to evaluation by ED provider, and time to evaluation by the burn surgery service. Results: Burn surgery was consulted and evaluated the early group significantly sooner than the late group (early mean: 63 min, late mean: 191 min; P Conclusions: Early burn surgery consultation is associated with a significantly reduced total ED LOS, arguing for immediate burn surgery consultation irrespective of ED provider contact so that patient throughput can be increased. Furthermore, the reduced LOS may translate into higher patient satisfaction, improved patient care, and lower opportunity cost of ED space.

New Zealand\u2019s emergency department target \u2013 did it reduce ED length of stay, and if so, how and when?

BackgroundIn 2009, the New Zealand government introduced a hospital emergency department (ED) target – 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when.MethodsWe adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing.ResultsReported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing.ConclusionsWhile the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in ‘standing for’ improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients.

Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes. This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota. Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality. Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9). ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.

Comparison of a rapid albuterol pathway with a standard pathway for the treatment of children with a moderate to severe asthma exacerbation in the emergency department

ABSTRACTObjective: The objective of this study was to determine if a rapid albuterol delivery pathway with a breath-enhanced nebulizer can reduce emergency department (ED) length of stay (LOS), while maintaining admission rates and side effects, when compared to a traditional asthma pathway with a standard jet nebulizer. Methods: Children aged 3–18 presenting to a large urban pediatric ED for asthma were enrolled if they were determined by pediatric asthma score to have a moderate to severe exacerbation. Subjects were randomized to either a standard treatment arm where they received up to 2 continuous albuterol nebulizations, or a rapid albuterol arm where they received up to 4 rapid albuterol treatments with a breath-enhanced nebulizer, depending on severity scoring. The primary endpoint was ED LOS from enrollment until disposition decision. Asthma scores, albuterol dose, side effects, and return visits were also recorded. Results: A total of 50 subjects were enrolled (25 in each arm). The study LOS was shorter in the rapid albuterol group (118 vs. 163 minutes, p = 0.0002). When total ED LOS was analyzed, the difference was no longer statistically significant (192 vs. 203 minutes, p = 0.65). There were no statistically significant differences with respect to admission rates, asthma score changes, side effects, or return visits. Conclusion: A rapid albuterol treatment pathway that utilizes a breath-enhanced nebulizer is an effective alternative to traditional pathways that utilize continuous nebulizations for children with moderate to severe asthma exacerbations in the ED.

LO54: A descriptive analysis of ED length of stay of admitted patients ‘boarded’ in the emergency department

Introduction: Previous studies have shown a link between Emergency Department (ED) overcrowding and worse clinical outcomes, increased risk of in-hospital mortality, higher costs, and longer times to treatment. Prolonged ED Length of Stay (LoS) of admitted patients awaiting a bed on in-patient units has been identified as a major driver of ED overcrowding. The purpose of this study is to provide a descriptive analysis of ED LoS among admitted patients, and determine the impact of prolonged ED LoS on total hospital in-patient length of stay (IP LoS). Methods: We conducted a single-site retrospective study for the period between January 1-December 31, 2015 at a very high volume community hospital. All patients aged ≥18 years admitted from the ED to acute in-patient Medicine units were identified. We carried out overall descriptive analysis (including analysis of day-of-the-week variability) on ED LoS. The mean total IP LoS for those patients with ED LoS<12 hours, 12-24 hours, and ≥24 hours were calculated and analyzed using ANOVA and Tukey HSD tests. Results: A total of 6,961 individuals were admitted to the medical units over the 12-month period. The median and mean ED LoS for admitted patients were 22.9 hrs (IQR: 13.9 hrs- 33.1 hrs) and 25.6 hrs respectively. Using ANOVA, there was a statistically significant difference in means of ED LoS as a function of the day of the week (p<0.0001), with Mondays having the highest mean ED LoS (27.6 hrs), and Fridays having the lowest (23.1 hrs). The mean IP LoS for those with ED LoS<12 hours, 12-24 hours, and ≥24 hours, were 6.8 days, 6.9 days, and 8.5 days respectively, with a statistically significant difference between group means (p<0.0001). Multiple pairwise comparisons of group means showed a statistically significant (p<0.05) difference between mean IP LOS of those with an EDLOS≥24 hours and those with an EDLOS<24 hours. Conclusion: Preliminary results indicate that ED LoS≥24 hours among admitted patients was associated with an increase in total IP LoS.*In the next 1-2 months, we intend to explore the role of other independent variables (age, sex, comorbidity, isolation status, and telemetry) on total ED LoS, and its association with IP LoS.

Do delays in radiology lead to breaches in the 4-hour rule?

To assess trends in medical imaging requests before and after the 4-hour rule commenced and to assess the imaging time component of emergency department (ED) length of stay (LOS). Retrospective analysis of ED patients and imaging requests 1 year prior to and 3 years after implementation of the 4-hour rule (April to December for 2011-2014) was performed at a single adult tertiary referral Level 1 trauma hospital with Level 6 ED. Logistic regression was used to evaluate trends in the number of ED patient presentations, patient triage categories, and imaging requests for these patients. The imaging component of the total ED LOS was compared for patients who met the 4-hour target and patients who did not. Compared to 2011 (before the 4-hour rule), ED presentations increased 4.74% in 2012, 12.7% in 2013, 21.28% in 2014 (p<0.01). Total imaging requests increased 23.05% in 2012, 48.04% in 2013, 60.77% in 2014 (p<0.01). For patients breaching the 4-hour rule, the mean time before radiology request was 2.4-2.8 hours; mean time from imaging request to completion was 1.2-1.3 hours; mean time from imaging completion to discharge from ED was the longest component of ED LOS (4.9-5.9 hours). There has been a significant increase in imaging requests, with a trend towards more CT and less radiography requests. Imaging requests for patients who breached the 4-hour target were made on average 2.4-2.8 hours after triage and average time after imaging in itself, exceeded 4 hours. Imaging is not likely a causative factor for patients breaching the 4-hour target.

Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency.

Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay. We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks. The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82-239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485-1,274 minutes). The median CRT was 55 minutes (IQR 21-115 minutes), and the median DMI was 58 minutes (IQR 25-126 minutes). The CII measured 26% (95% CI 23-28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations. The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.

Nurse initiated reinsertion of nasogastric tubes in the Emergency Department: A randomised controlled trial

Patients sometimes present to the Emergency Department (ED) for reinsertion of nasogastric tubes (NGT) because of tube dislodgement. They usually need to wait for a long time to see a doctor before the NGT can be reinserted. This study aimed at investigating the feasibility of nurse initiated NGT insertion for these patients in order to improve patient outcome. This is a prospective randomised controlled trial. Patients requiring NGT reinsertion were randomised to receive treatment by either nurse initiated reinsertion of NGT (NIRNGT) or the standard NGT insertion protocol. Questionnaires were given to both groups of patients, relatives and ED nurses afterwards. Outcome measures included door-to-treatment time, total length of stay (LoS) in the ED and the satisfaction of patients, relatives and nurses. Twenty-two patients were recruited to the study and randomised: 12 in the standard NGT insertion protocol and 10 in the NIRNGT protocol. The door-to-treatment time of the NIRNGT group (mean=45.6 min) was significantly shorter than the standard NGT insertion group (mean=123.08 min; p=0.003). No statistically significant difference was detected between the total ED LoS (p=0.575). Patients, relatives and nurses were generally satisfied with the new treatment protocol. Patients can undergo NGT reinsertion significantly faster by adopting a nurse initiated reinsertion of NGT (NIRNGT) protocol.

Overuse of Computed Tomography Pulmonary Angiography in the Evaluation of Patients with Suspected Pulmonary Embolism in the Emergency Department

Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism (PE) to the emergency department (ED). The objective was to assess the percentage of computed tomographic pulmonary angiography (CT-PA) procedures that could have been avoided by use of the Wells score coupled with D-dimer testing (Wells/D-dimer) or pulmonary embolism rule-out criteria (PERC) in ED patients with suspected PE. The authors conducted a prospective cohort study of adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were calculated. A research blood sample was obtained for D-dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED length of stay (LOS) and CT-PA time as defined by time from order to initial radiologist interpretation. Of 152 suspected PE subjects available for analysis (mean ± SD age = 46.3 ± 15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72 subjects with low-risk Wells scores who did not have D-dimers performed in the ED, archived research samples were negative in 16 (22%). All 21 subjects with low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time (median = 160 minutes) accounted for more than half of total ED LOS (median = 295 minutes). In total, 9.2 and 13.8% of CT-PA procedures could have been avoided by use of PERC and Wells/D-dimer, respectively.

Effect of rotational patient assignment on emergency department length of stay

The study evaluated the impact of rotational assignment of emergency department (ED) patients to residents on patient's length of stay (LOS) and resident satisfaction. The study was conducted in a university, inner-city, adult ED. Prior to the intervention, residents saw patients at their own rate as patient charts were placed into a common rack waiting to be seen. The intervention involved directly assigning patients with medical emergencies in sequential rotation to residents. Patients with surgical conditions were seen under the old self-paced system for comparison. A retrospective chart review of LOS of all ED visits for a period of 2 wks before, 6 wks after, and 1 yr after the intervention was conducted. ED administration and staffing during the study were unchanged. Comparisons excluded critical cases and nonurgent cases triaged away. A postintervention survey of physician satisfaction was conducted. During the study period, demographic characteristics of medical and surgical patients did not differ significantly between the time periods. The average total ED LOS for moderately ill medical patients decreased significantly from 7.11 to 5.86 h at 6 wks and remained significantly improved 1 yr later at 6.21 h. During the same periods, the average total LOS increased significantly for the surgical patients. Residents reported that the new system was more fair and did not affect teaching quality. The rotational assignment of patients to resident physicians led to significantly less ED LOS while improving resident satisfaction without affecting education.