Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study.
ABSTRACT: OBJECTIVE:Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off-Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness. METHODS:This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance-ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness. RESULTS:A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post-hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130?721 could result in an annualised reduction of approximately 3912?h in waiting time to be seen by a doctor. CONCLUSION:With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost-effective strategy to consider.
Project description:Background:Left ventricular assist device (LVAD) patients are vulnerable to over-utilization of resources. Methods and results:We explored the pattern of emergency department (ED) presentations of LVAD patients and their costs compared with non-LVAD heart failure patients. ED visits between 7/2008 and 7/2017 were reviewed to identify 145 LVAD patients, and 435 patients with known heart failure were selected using propensity score matching for age and sex. ED evaluation metrics, hospitalization cost, and length of stay (LOS) were analyzed. Although the most common ED presentations and their frequency differed between groups, few were LVAD specific. LVAD patients were more likely to have taken personal vehicles or be flown to the ED. They had similar times to triage, rooming, and physician evaluation compared with non-LVAD patients. However, LVAD patients were noted to have a shorter time from physician assessment to disposition (109.8 min vs. 177.0 min, p < 0.001) and, overall, LVAD patients had shorter ED LOS (6.33 vs. 9.82 hrs, p = 0.0001). For patients admitted, no significant difference was found between groups in hospital LOS (6.67 vs 6.58 days, p = 0.928) or total cost ($28,766 vs $21,524, p = 0.087). Conclusion:Shorter disposition times without increases in LOS or costs may identify a created healthcare disparity among LVAD patients.
Project description:OBJECTIVE:The objective of this study is to assess the impact of a multimodal intervention on emergency department (ED) crowding and patient flow in a Dutch level 1 trauma center. METHODS:In this cross-sectional study, we compare ED crowding and patient flow between a 9-month pre-intervention period and a 9-month intervention period, during peak hours and overall (24/7). The multimodal intervention included (1) adding an emergency nurse practitioner (ENP) and (2) five medical specialists during peak hours to the 24/7 available emergency physicians (EPs), (3) a Lean programme to improve radiology turnaround times, and (4) extending the admission offices' openings hours. Crowding is measured with the modified National ED OverCrowding Score (mNEDOCS). Furthermore, radiology turnaround times, patients' length of stay (LOS), proportion of patients leaving without being seen (LWBS) by a medical provider, and unscheduled representations are assessed. RESULTS:The number of ED visits were grossly similar in the two periods during peak hours (15,558 ED visits in the pre-intervention period and 15,550 in the intervention period) and overall (31,891 ED visits in the pre-intervention period vs. 32,121 in the intervention period). During peak hours, ED crowding fell from 18.6% (pre-intervention period) to 3.5% (intervention period), radiology turnaround times decreased from an average of 91?min (interquartile range 45-256?min) to 50?min (IQR 30-106?min., p <?0.001) and LOS reduced with 13?min per patient from 167 to 154?min (p <?0.001). For surgery, neurology and cardiology patients, LOS reduced significantly (with 17?min, 25?min, and 8?min. respectively), while not changing for internal medicine patients. Overall, crowding, radiology turnaround times and LOS also decreased. Less patients LWBS in the intervention period (270 patients vs. 348 patients, p <?0.001) and less patients represented unscheduled within 1 week after the initial ED visit: 864 (2.7%) in the pre-intervention period vs. 645 (2.0%) patients in the intervention period, p <?0.001. CONCLUSIONS:In this hospital, a multimodal intervention successfully reduces crowding, radiology turnaround times, patients' LOS, number of patients LWBS and the number of unscheduled return visits, suggesting improved ED processes. Further research is required on total costs of care and long-term effects.
Project description:BACKGROUND:Measuring and understanding main determinants of length of stay (LOS) in emergency departments (EDs) is critical from an operations perspective, since LOS is one of the main performance indicators of ED operations. Therefore, this study analyzes both the main and interaction effects of four widely-used independent determinants of ED-LOS. METHODS:The analysis was conducted using secondary data from an ED of a large urban hospital in Izmir, Turkey. Between-subject factorial analysis of variance (ANOVA) was used to test the main and interaction effects of the corresponding factors. P values <.05 were considered statistically significant. RESULTS:While the main effect of gender was insignificant, age, mode of arrival, and clinical acuity had significant effects, whereby ED-LOS was significantly higher for the elderly, those arriving by ambulance, and clinically-categorized high-acuity patients. Additionally, there was an interaction between the age and clinical acuity in that, while ED-LOS increased with age for high acuity patients, the opposite trend occurred for low acuity patients. When ED-LOS was modeled using gender, age, and mode of arrival, there was a significant interaction between age and mode of arrival. However, this interaction was not significant when the model included age, mode of arrival, and clinical acuity. CONCLUSION:Significant interactions exist between commonly used ED-LOS determinants. Therefore, interaction effects should be considered in analyzing and modelling ED-LOS.
Project description:Background Syncope is a common presentation to the emergency department (ED), yet little is known regarding patient mode of arrival. Methods We identified patients ?20 years old who presented to the ED with a primary diagnosis of syncope in Alberta and Ontario, Canada, between 2010 and 2016. Outcomes included 30-day in-hospital mortality, ED revisits, and rehospitalizations according to mode of arrival and discharge status. The estimated cost for ambulance use was calculated based on the provincial rates (Alberta CAD$385 and Ontario $240). Results A total of 271,601 syncope presentations to the ED were identified and 60.7% arrived by ambulance. A total of 76.3% (n = 125,793) of ambulance users and 87.0% of self-presenters (n = 92,845) were discharged from the ED. Regardless of mode of arrival, discharged patients were younger with fewer comorbidities. Compared with ambulance users admitted, those discharged had lower in-hospital mortality (0.2% vs 3.5%, P < 0.001), ED revisits (4.4% vs 10.4%, P < 0.001), and rehospitalizations (3.6% vs 10.7%, P < 0.001). Discharged self-presenters also had significantly lower outcomes (P < 0.001, for each outcome) compared with admitted self-presenters. The estimated cost for ambulance use among patients discharged from the ED was $33,137,735. Conclusion A majority of syncope patients arrived to the ED by ambulance, and over 3 quarters were directly discharged home. Although discharged patients had a favourable short-term prognosis, they incurred high transportation costs. Strategies aimed at preventing unnecessary ambulance use are needed.
Project description:Emergency Departments (ED) are trying to alleviate crowding using various interventions. We assessed the effect of an alternative model of care, the Medical Team Evaluation (MTE) concept, encompassing team triage, quick registration, redesign of triage rooms and electronic medical records (EMR) on door-to-doctor (waiting) time and ED length of stay (LOS). We conducted an observational, before-and-after study at an urban academic tertiary care centre. On July 17th 2014, MTE was initiated from 9:00 a.m. to 10 p.m., 7 days a week. A registered triage nurse was teamed with an additional senior ED physician. Data of the 5-month pre-MTE and the 5-month MTE period were analysed. A matched comparison of waiting times and ED LOS of discharged and admitted patients pertaining to various Emergency Severity Index (ESI) triage categories was performed based on propensity scores. With MTE, the median waiting times improved from 41.2 (24.8-66.6) to 10.2 (5.7-18.1) minutes (min; P < 0.01). Though being beneficial for all strata, the improvement was somewhat greater for discharged, than for admitted patients. With a reduction from 54.3 (34.2-84.7) to 10.5 (5.9-18.4) min (P < 0.01), in terms of waiting times, MTE was most advantageous for ESI4 patients. The overall median ED LOS increased for about 15 min (P < 0.01), increasing from 3.4 (2.1-5.3) to 3.7 (2.3-5.6) hours. A significant increase was observed for all the strata, except for ESI5 patients. Their median ED LOS dropped by 73% from 1.2 (0.8-1.8) to 0.3 (0.2-0.5) hours (P < 0.01). In the same period the total orders for diagnostic radiology increased by 1,178 (11%) from 10,924 to 12,102 orders, with more imaging tests being ordered for ESI 2, 3 and 4 patients. Despite improved waiting times a decrease of ED LOS was only seen in ESI level 5 patients, whereas in all the other strata ED LOS increased. We speculate that this was brought about by the tendency of triage physicians to order more diagnostic radiology, anticipating that it may be better for the downstream physician to have more information rather than less.
Project description:OBJECTIVES:We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators. DESIGN:Adjusted before-after analysis. SETTING:A large hospital in the Champagne-Ardenne region, France. PARTICIPANTS:Patients admitted to the ED between 13 January 2015 and 13 January 2017. INTERVENTION:Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016). PRIMARY AND SECONDARY OUTCOME MEASURES:Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions. RESULTS:The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%. CONCLUSIONS:The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.
Project description:OBJECTIVE:Test if therapy dogs reduce anxiety in emergency department (ED) patients. METHODS:In this controlled clinical trial (NCT03471429), medically stable, adult patients were approached if the physician believed that the patient had "moderate or greater anxiety." Patients were allocated on a 1:1 ratio to either 15 min exposure to a certified therapy dog and handler (dog), or usual care (control). Patient reported anxiety, pain and depression were assessed using a 0-10 scale (10 = worst). Primary outcome was change in anxiety from baseline (T0) to 30 min and 90 min after exposure to dog or control (T1 and T2 respectively); secondary outcomes were pain, depression and frequency of pain medication. RESULTS:Among 93 patients willing to participate in research, 7 had aversions to dogs, leaving 86 (92%) were willing to see a dog six others met exclusion criteria, leaving 40 patients allocated to each group (dog or control). Median and mean baseline anxiety, pain and depression scores were similar between groups. With dog exposure, median anxiety decreased significantly from T0 to T1: 6 (IQR 4-9.75) to T1: 2 (0-6) compared with 6 (4-8) to 6 (2.5-8) in controls (P<0.001, for T1, Mann-Whitney U and unpaired t-test). Dog exposure was associated with significantly lower anxiety at T2 and a significant overall treatment effect on two-way repeated measures ANOVA for anxiety, pain and depression. After exposure, 1/40 in the dog group needed pain medication, versus 7/40 in controls (P = 0.056, Fisher's exact test). CONCLUSIONS:Exposure to therapy dogs plus handlers significantly reduced anxiety in ED patients.
Project description:We 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 Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions.Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators.Median ED LOS improved by up to 26% (63?min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91?min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26).These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.
Project description:<h4>Background</h4>RAAPID (Referral, Access, Advice, Placement, Information, and Destination) is a 24-h call center in Alberta, Canada, facilitating urgent telephone consultations between physicians and specialists. We evaluated the extent to which RAAPID calls to Otolaryngology-Head and Neck Surgery (OHNS) reduced visits to the emergency department and specialty clinics.<h4>Methods</h4>This was a cross-sectional study evaluating all telephone consultations to OHNS from physicians in northern Alberta between 2013 and 2014 (T1) (where consultations by residents occurred) and 2015 to 2017 (T2) (where consultations were done by consultants during office hours and residents during after hours). Outcomes of the calls included medical advice, specialty clinic referrals, and emergency department (ED) referrals. Differences in the reduction of ED visits and costs, overall as well as in T1 and T2, were assessed using multivariate logistic regression.<h4>Results</h4>Overall, 62.3% (1064/1709) of telephone consultations reduced ED visits consisting of advice being provided (n?=?884; 83.1%) and referral to specialty clinics (n?=?180; 16.9%). The adjusted odds ratio of calls reducing emergency visits in T2 as compared to T1 was 2.47 (95% CI 1.99 to 3.08). The adjusted odds ratio of reducing ED visits during office hours compared to after-hours 2.54 (95% CI 1.77-3.64). The estimated direct costs avoided from ED visits in T1 and T2 were $42,224.22 and $114,393.86, respectively.<h4>Conclusion</h4>RAAPID telephone consultations to OHNS were effective in reducing ED visits and healthcare costs. This model should be considered in other areas to improve efficiencies within the health system.
Project description:Background:Dialysis patients who require ambulance transport to the emergency department ("ambulance-ED") may subsequently require timely dialysis in a monitored setting ("urgent dialysis"). Objective:The purpose of this study was to develop and internally validate a risk prediction model for urgent dialysis based on patient characteristics at the time of paramedic assessment before ambulance-ED. Design:Cohort Study. Setting:Region of Nova Scotia, Canada, covered by a single emergency medical services provider. Patients:Thrice-weekly hemodialysis patients who initiated dialysis between 2009 and 2013 (follow-up to 2015) and experienced one or more ambulance-ED events. Measurements:The primary outcome ("urgent dialysis") was defined as dialysis within 24 hours of an ambulance-ED in a monitored setting or dialysis within 24 hours of an ambulance-ED with an initial ED potassium of >6.5 mmol/L. Predictors of urgent dialysis based on paramedic assessment before ambulance-ED included presenting complaint, vital signs and time from last dialysis to ambulance dispatch. Methods:Associations with urgent dialysis were analyzed using logistic regression from which a risk prediction model was created. The model was internally validated using bootstrapping and model performance was assessed by discrimination and calibration. Results:Among 197 patients, there were 624 ambulance-ED events and 87 episodes of urgent dialysis. Weakness as a presenting complaint (odds ratio [OR]: 4.62, 95% confidence interval [CI]: 1.23-17.29), >24 hours since last dialysis (OR: 2.09, 95% CI: 1.15-3.81), and vital signs, including heart rate <60 beats/minute (OR: 3.06, 95% CI: 1.09-8.61), oxygen saturation <90% (OR: 3.04, 95% CI: 1.55-5.94), elevated respiratory rate (?20 breaths/min), and systolic blood pressure>160 mmHg, were associated with urgent dialysis after ambulance-ED. A risk prediction model incorporating these variables had very good discrimination (C-statistic: 0.81, 95% CI: 0.76-0.86). The negative predictive value was 93.6% using the optimal cut point. Of patients who were predicted to need urgent dialysis but were transported to a facility incapable of providing it, 31% were re-transported for urgent dialysis. Limitations:Findings of our study may not be generalizable to other centers where the practice of ambulance transfer and availability of monitored dialysis may differ, and data were lacking for potential missed dialysis sessions or changes in routine dialysis scheduling. Conclusions:Patient characteristics at the time of paramedic assessment are associated with urgent dialysis after ambulance-ED. This risk prediction model has the potential to guide dialysis patient transport to dialysis-capable facilities when needed.