The objective of this study is to evaluate the impact of emergency department (ED) crowding levels on patient admission decisions and outcomes.
A retrospective study was performed based on 2-year ...electronic health record data from a tertiary care hospital ED in Alberta, Canada. Using modified Poisson regression models, we studied the association of patient admission decisions and 7-day revisit probability with ED crowding levels measured by: 1) the total number of patients waiting and in treatment (ED census), 2) the number of boarding patients (boarder census), and 3) the average physician workload, calculated by the total number of ED patients divided by the number of physicians on duty (physician workload census). The control variables included age, gender, treatment area, triage level, and chief complaint. A subgroup analysis was performed to evaluate the heterogeneous effects among patients of different acuity levels.
Our dataset included 141,035 patient visit records after cleaning from August 2013 to July 2015. The patient admission probability was positively correlated with ED census (relative risk RR = 1.006, 95% confidence interval CI = 1.005 to 1.007) and physician workload census (RR = 1.029, 95% CI = 1.027 to 1.032), but inversely correlated with boarder census (RR = 0.991, 95% CI = 0.989 to 0.993). We further found that the 7-day revisit probability of discharged patients was positively associated with boarder census (RR = 1.009, 95% CI = 1.004 to 1.014).
Patient admission probability was found to be directly associated with ED census and physician workload census, but inversely associated with the boarder census. The effects of boarder census and physician workload census were stronger for patients of triage levels 3–5. Our results suggested that (i) insufficient physician staffing may lead to unnecessary patient admissions; (ii) too many boarding patients in ED leads to an increase in unsafe discharges, and as a result, an increase in 7-day revisit probability.
•Patients are more likely to be admitted when ED is more crowded.•Insufficient physician staffing may lead to unnecessary patient admissions.•Too many boarders leads to more unsafe discharges and worse patient outcomes.
The coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) ...services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic.
We conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions.
While outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (−8.1%) than in 2019. The largest decrease occurred in April 2020 (−30.4%), followed by the May to August period (−12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020.
Overall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.
Background: Electrocardiograms (ECGs) are one of the most basic and fundamental screening tools used in the emergency department (ED). Previous studies have shown machine diagnosis of ECG to be ...unreliable, the ECG machine does provide a simpler classification of: 1- Normal, 2- Otherwise normal, 3- Borderline, and 4- Abnormal printed on the ECG. We aim to investigate if machine classification could be used reliably as a screening test for triage.
Methods: This cross-sectional study was conducted from 1 to 14 June 2019 of ED at King Abdullah Medical Complex using electronic medical records. The ECGs were put into sets of 25 traces/set and then presented to 21 board-certified emergency medicine attending physicians (EMPs) to assess and decide on one of the actions: Put in the waiting area, see in triage, or admit immediately. The responses were analyzed for inter-subject correlation coefficient kappa (k).
Results: Of the 3,149 patients, 452 had ECGs done from which 200 ECGs were chosen at random. The inter-subject correlation coefficient was found to be 0.315 ± 0.187 denoting a fair to moderate correlation. From the ECG traces classified as "Normal" by the ECG machine, only 46% ended up in the waiting room. While almost 15% were admitted immediately to an ED bed. In contrast, 27% of those labeled as "Abnormal" ended up in the waiting room, while 44% were admitted to an ED bed.
Conclusion: The machine classification of the ECG traces unfortunately failed remarkably to predict the EMP's decision. As such, the assessment of the attending EMP remains a necessary and essential part of the assessment.
Background
Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is ...evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.
Objectives
To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.
Search methods
We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).
Selection criteria
We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.
Data collection and analysis
Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed‐effect risk ratio. We used a random‐effects risk ratio for sensitivity analysis of heterogenous data.
Main results
A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.
Authors' conclusions
Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long‐term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.
Background
In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide ...primary care services alongside or within hospital EDs for patients with non‐urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost‐effective. This is the first update of the original Cochrane Review published in 2012.
Objectives
To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non‐urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs).
Search methods
We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews.
Selection criteria
Randomised trials, non‐randomised trials, controlled before‐after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non‐urgent conditions, as compared to the care provided by regularly scheduled EPs.
Data collection and analysis
We used standard methodological procedures expected by Cochrane.
Main results
We identified four trials (one randomised trial and three non‐randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non‐urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.
There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital‐based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low‐certainty for all outcomes.
No data were reported on adverse events (such as ED returns and mortality).
Authors' conclusions
We assessed the evidence from the four included studies as of very low‐certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non‐urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.
Substantial variability exists in the care of febrile, well-appearing infants. We aimed to assess the impact of a national quality initiative on appropriate hospitalization and length of stay (LOS) ...in this population.
The initiative, entitled Reducing Variability in the Infant Sepsis Evaluation (REVISE), was designed to standardize care for well-appearing infants ages 7 to 60 days evaluated for fever without an obvious source. Twelve months of baseline and 12 months of implementation data were collected from emergency departments and inpatient units. Ill-appearing infants and those with comorbid conditions were excluded. Participating sites received change tools, run charts, a mobile application, live webinars, coaching, and a LISTSERV. Analyses were performed via statistical process control charts and interrupted time series regression. The 2 outcome measures were the percentage of hospitalized infants who were evaluated and hospitalized appropriately and the percentage of hospitalized infants who were discharged with an appropriate LOS.
In total, 124 hospitals from 38 states provided data on 20 570 infants. The median site improvement in percentages of infants who were evaluated and hospitalized appropriately and in those with appropriate LOS was 5.3% (interquartile range = -2.5% to 13.7%) and 15.5% (interquartile range = 2.9 to 31.3), respectively. Special cause variation toward the target was identified for both measures. There was no change in delayed treatment or missed bacterial infections (slope difference 0.1; 95% confidence interval, -8.3 to 9.1).
Reducing Variability in the Infant Sepsis Evaluation noted improvement in key aspects of febrile infant management. Similar projects may be used to improve care in other clinical conditions.
Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with ...self-limiting conditions from those with serious illnesses that require acute treatment.
This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department.
Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions.
The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.
Introduction
The HINTS exam is a series of bedside ocular motor tests designed to distinguish between central and peripheral causes of dizziness in patients with continuous dizziness, nystagmus, and ...gait unsteadiness. Previous studies, where the HINTS exam was performed by trained specialists, have shown excellent diagnostic accuracy. Our objective was to assess the diagnostic accuracy of the HINTS exam as performed by emergency physicians on patients presenting to the emergency department (ED) with a primary complaint of vertigo or dizziness.
Methods
A retrospective cohort study was performed using data from patients who presented to a tertiary care ED between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient characteristics of those who received the HINTS exam were assessed along with sensitivity and specificity of the test to rule out a central cause of stroke.
Results
A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix‐Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam.
Conclusions
Our results suggest that despite widespread use of the HINTS exam in our ED, its diagnostic value in that setting was limited. The test was frequently used in patients who did not meet criteria to receive the HINTS exam (i.e., continuous vertigo, nystagmus, and unsteady gait). Additional training of emergency physicians may be required to improve test sensitivity and specificity.
Seasonal influenza causes significant morbidity and mortality and has a substantial economic impact on the healthcare system. The main objective of this study was to compare the cost per patient for ...a rapid commercial PCR assay (Xpert® Flu) with an in-house real-time PCR test for detecting influenza virus. Community patients with influenza like-illness attending the Emergency Department (ED) as well as hospitalized patients in the Hospital Clínic of Barcelona were included. Costs were evaluated from the perspective of the hospital considering the use of resources directly related to influenza testing and treatment. For the purpose of this study, 366 and 691 patients were tested in 2013 and 2014, respectively. The Xpert® Flu test reduced the mean waiting time for patients in the ED by 9.1 hours and decreased the mean isolation time of hospitalized patients by 23.7 hours. This was associated with a 103€ (or about $113) reduction in the cost per patient tested in the ED and 64€ ($70) per hospitalized patient. Sensitivity analyses showed that Xpert® Flu is likely to be cost-saving in hospitals with different contexts and prices.
We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours.
We ...conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours.
Overall, 24,905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions.
A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.
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