- Email: [email protected]
171 Rationing Critical Care Access From Emergency Department: Electronic Classification System for Critical Care Admission
Research Forum Abstracts
168
Patients With Access to Primary Care Call Their Doctors Before Coming to the Emergency Department With Lower Acuity Illness
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Study Objectives: Greater access to primary care is thought by some analysts to mean fewer emergency department (ED) visits. Patients with a primary care physician (PCP) are encouraged to call their physician prior to coming to our ED to prevent unnecessary visits. We wished to study the population of patients coming to the ED who have a PCP. Our objective was to determine if such patients who present with a non emergent complaint have called their PCP prior to coming to the ED. Further we wanted to describe any difference between the group that called their PCP and the group that did not. Methods: A survey was administered by a trained research associate using a closed ended item. This is a subset analysis of a larger study. In this analysis only patients with PCPs were used and divided into 2 groups, those who called and those who did not call their PCP. The study was approved by the institutional review board. Simple descriptive statistics were used with confidence interval 95%. Setting: The survey was administered in the waiting room of an urban tertiary care academic institution, 7 days a week between 12:00 and 24:00 from 4/15/10 to 8/2/10. Participants: A convenience sample of adult patients waiting for 15 minutes or more in the waiting area of an ED in a tertiary care academic institute were eligible to be interviewed. These patients were deemed “non-emergent” and comprised the study group. Results: A total of 399 patients were interviewed and had usable data. 315 (78.5%) had a primary care physician but 12 did not indicate whether they called their physician and were excluded. Of the 303 patients with PCPs, 54.7% called their physician before coming to the ED. The group that called their physician was similar to the group that did not call in age and sex. The group that called their physicians were proportionally more likely to be white [77.7% (71.4,84.0) vs 51.1% (42.7,59.5) p⬍0.001] and privately insured [65.1% (57.8,72.4) vs 43.8% (35.5,52.1), p⬍0.001]. Those who called their physician perceived that they could see their physician sooner than those who did not call their PCP [“could see in 1-3 days” 76.5% (69.7,83.3) vs 52.5% (43.6,61.4), p⬍0.001]. A chief complaint was given by 237 (78%), of which abdominal pain was the most common - 11%. A subgroup of patients with obvious non urgent chief complaints (toothache, cold/cough, sexually transmitted disease, menstrual cramps and rash) were seen in both populations in a similar frequency [6.1% (2.0,10.2) in the call group and 8.5% (3.2,13.8) in the not call group, p⫽.65]. Conclusion: In this study almost 80% of patients presenting to the ED with nonemergent complaints had a PCP. Contrary to public opinion, the majority of ED patients with non-emergent complaints who have primary care physicians call their physician before coming to the ED for care.
169
“Lead Triage Physician” Initiative: An Unsuccessful Hospitalist-Based Attempt to Address Emergency Department Crowding and Patient Flow
Haydar SA, Strout TD, Botler J/Maine Medical Center, Portland, ME
Study Objective: Detailed analysis of emergency department (ED) event data identified the time period from completion of emergency physician evaluation (doc done) to admitting physician bed order (bed order) as a significant contributor to ED boarding at our institution. To address this issue at the clinical microsystems level, an innovative Hospitalist Medicine position, the Lead Triage Physician (LTP), was created with the goal of facilitating inpatient medicine evaluations in the ED through the expeditious entry of admission orders and hospital bed placement. The objective of this study was to evaluate the effect of the LTP on markers of ED flow. Methods: We used a quasi-experimental, interrupted time-series analysis design with 2 comparison groups to evaluate the effect of the LTP on ED length of stay (length of stay ), door to physician time (DTP), door to completion of emergency physician evaluation (DTDD) time, and completion of emergency physician evaluation to inpatient bed order (DDBO) time. These time outcomes were compared for patients admitted by the LTP, patients admitted via adult inpatient medicine during the same time period (AIM-10), and patients admitted via adult inpatient medicine for the same 2 calendar month block, 1 year prior to the intervention (AIM-09). Data were obtained through query of an electronic ED
S234 Annals of Emergency Medicine
tracking system. Analyses included assessment of data normality, computation of appropriate summary statistics, and comparisons of group medians with the KruskalWallis test and post-hoc Mann-Whitney U tests adjusted for multiple comparisons. Results: Outcomes for 1884 patients were studied: 234 admitted via the LTP, 827 admitted via AIM-10, and 823 admitted via AIM-09 the previous calendar year. Median ED length of stay was similar across the 3 groups: LTP ⫽ 488, AIM-10 ⫽ 488, AIM-09 ⫽ 444 minutes, with the 2009 inpatient medicine group having a statistically significantly shorter length of stay, H ⫽ 31.499, df ⫽ 2, p ⬍ 0.001. Similarly, median DTP time was significantly shorter in the AIM-2009 group at 22 minutes compared to 28 (LTP) and 25 (AIM-10) minutes, H⫽12.093, df ⫽ 2, p ⬍ 0.002. DTDD time was also shorter in the AIM-09 group (197 min) when compared to the LTP (220 min) and AIM-10 (221 min) groups, H ⫽ 22.383, df ⫽ 2, p ⬍ 0.001. Median DDBO times, 78 min (LTP), 85 min (AIM-10), and 89 min (AIM09), did not vary significantly by group, H⫽0.653, df ⫽ 2, p ⫽ 0.721. Conclusions: In this cohort of adult ED patients admitted to inpatient medical units, the addition of a LTP did not decrease critical markers of ED flow. In fact, we observed a trend towards increased length of stay and DTP times with the addition of the LTP. While additional research is necessary to thoroughly understand the reasons for a general lack of positive effect with the LTP, we suspect that protocol violations, difficulties with protocol adherence, and limited support from some stakeholders may have played a role.
170
Deferred Emergency Department Care at a Community Hospital
Herman L, Melton N, Patacsil J, Chan SB/Resurrection Medical Center, Chicago, IL
Study Objectives: Crowding is a major concern in emergency departments (ED) across the US. Crowding negatively affects the ED experience by delaying medical care, decreasing patient satisfaction, and increasing staff frustration. Deferred care or diverting patients away from the ED has been proposed as a partial solution to easing crowding. This study evaluates the appropriateness, timeliness and the patients’ willingness to use the Health Access Program (HAP), a deferred care initiative. Methods: The HAP was active at an urban medical center from November 2007 to February 2009. Strict exclusion criteria were established. If no exclusion criteria were present, patients were referred by the triage nurse directly to the emergency physician for a medical screening exam (MSE). Following MSE, a suitable HAP candidate was registered and directed to the Health Access Specialist (HAS), a social worker with specialized training in referral of patients to health care resources. Data collected included vital signs, chief complaints, insurance status, detailed times for the HAP process, and outcome. An emergency physician reviewed every chart of HAP patients and abstracted the data. Difference between groups was tested using Student’s t-test. Results: During the study period, 153 patients were entered into HAP. Thirty-5 were excluded because of inappropriate referral. Eleven patients had no outcomes recorded. Of the remaining 107 patients, 44.1% were male, mean age: 31.6 years. Thirty-six percent were self-pay and 64% had some form of third party payer. The average length of stay in the ED to completion of HAP referral was 111 minutes. After screening, 17 patients chose to be treated by the emergency physician anyway. These 17 patients had already spent an average of 229 minutes to completion of the HAS process. However, 90 (84.1%) patients left to pursue care at the referral site. These 90 patients only spent an average time of 63 minutes to completion of the HAS process. The difference of 166 minutes was statistically significant (P⫽.006). Conclusion: Eighty-four percent of patients were willing to participate in the referral program. Patients who elected to remain in the ED had already spent a significantly longer period of time than those who elected to seek care at a referral site. Of the patients entered into HAP, 64% had a third-party payer.
171
Rationing Critical Care Access From Emergency Department: Electronic Classification System for Critical Care Admission
Neves FF, Pazin-Filho A/Medical School of São Carlos - Federal University of São Carlos, Sao Carlos, Brazil; Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil
Study Objectives: Crowded emergency departments (ED) are common and a considerable percentage of patients require intensive care. Intensive care units (ICU) are becoming a rare resource and rationing is required, even though ethical concerns are raised. This situation is of further consequences in developing countries, where
Volume , . : October
Research Forum Abstracts intensive care resources are even scarcer. We sought to evaluate the impact of prioritization information system over in-hospital and ICU stay and mortality. Methods: We retrospectively selected all patients admitted to a seventeen-bed adult non-coronary ICU which receives patients from a tertiary emergency department 1 year prior the introduction of the new system (Group I; 542; 47.3⫾21.6 years; 64.2% male) and compared them with those patients admitted after (Group II; 479; 48.2⫾20.2 years; 65.5% male). Group II was selected using a system based on semi-quantitative clinical prioritization and administrative sorting for equal clinical priorities. We adjusted for age, sex, ICU admission delay, Charlson comorbidity index and surgical intervention. For in-hospital and ICU stay we also adjusted for the respectively mortality. Results: Odds ratio for in-hospital mortality was 0.67(0.51;0.88) and logtransformed in-hospital stay was -0.14(-0.21;-0.006) lower for Group II. No difference was observed for ICU mortality or stay. Conclusion: Implementing a prioritization information system for ICU admission based on patients’ needs and using administrative requirements for sorting patients with equivalent priorities when rationing is needed had impact over inhospital death and stay, but not over ICU stay.
172
Why Do Patients With Minor Complaints Prefer Emergency Departments Over Primary Care Physicians?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Emergency departments (EDs) are increasingly seeing patients with minor medical complaints. Study Objective: Analyze why patients prefer to come to ED with minor complaints over a visit to their primary care physician (PCP). Method: This is a survey of 400 adult patients waiting at least 15 minutes to be seen by a physician or physician extender. The patients were surveyed in the waiting area of an academic tertiary care ED from April to August 2010. The study was approved by the Institutional Review Board. Information was collected on a closed ended item questionnaire and analyzed using JMP 8.0 for Mac. Results: Of the 400 patients studied, 20.6% did not have access to a PCP. Of the remaining patients, 56.6% had considered going to primary care for their presenting complaints, and 47.5% had called a doctor prior to ED arrival. Reasons for choosing ED over PCP: 36% patients presented to the ED due to the concern that their problem was urgent and required immediate attention. One third of the patients (33.4%) were referred to the ED by their PCPs. 12.5% of patients reported that they could not get a timely appointment with their PCP and therefore, came to the ED. 11% patients preferred the ED because it offered more services than their PCP’s office. We also looked at the distribution of insurance and employment status of our survey population and found that, while 54% of patients were unemployed, only 16.8% reported having no insurance of any kind. Nearly half the patients (48.5%) had Medicaid or Medicare with or without additional private medical insurance. 30.2% of the patients had private medical insurance. Only 3 patients (0.75%) felt that it was more expensive to go to the PCP than come to the ED, and 6 patients (1.5%) reported a lack of transportation to the PCP as 1 of the factors in their decision to come to the ED. Conclusion: Our survey reveals that many patients who present to the ED with minor complaints do so because they either perceive their complaints to be urgent, or because their PCP refers them to the ED. Most of these patients have some type of insurance coverage, and financial constraints are often not a deciding factor in this preference of the ED over the PCP. This result may reflect a trend seen in health care where overburdened PCP practices refer patients to the ED.
173
How Comfortable Are Patients With Different Triage Personnel, and What Do They Expect While Waiting to See a Physician?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Multidisciplinary triage is increasingly employed by emergency departments (EDs) to decrease waiting times. Study Objective: Study the level of comfort for patients with different triage personnel and their perceived needs while waiting to see a physician in the emergency department.
Volume , . : October
Methods: This was an Institutional Review Board approved survey of 400 adult patients waiting for more than 15 minutes in the ED waiting room of a university tertiary care hospital from April to August 2010. The Likert scale (0-5; 0 being very uncomfortable, 5 being very comfortable) was used to assess the comfort level of patients with different triage personnel (triage nurse, emergency medicine resident, emergency medicine attending). We hypothesized that there were no differences between comfort levels of patients with the above personnel. Patients also listed 3 items from a pre-formatted list of 12 items that they would like the hospital to improve in the current ED waiting room. JMP 8.0 and STATA 10.0 were used for data analysis. Results: The study population had a mean age of 38.9 years (SD 14.8 years). There were 52.5% women. African Americans constituted 26.3%, Caucasians 63.4% and the remaining 10.3% belonged to other races. Analysis of the Likert score for triage personnel revealed: emergency physician (mean 3.85, SD 1.17), triage nurse (mean 3.69, SD 1.25) and emergency medicine resident (mean 3.59, SD 1.19). On paired t tests, we rejected our null hypotheses of no difference between Likert scores for emergency physician and emergency medicine residents (p⫽0.000) and emergency physicians and triage nurse (p⫽0.006). We could not reject the null hypothesis of no difference between preference for triage nurse and emergency medicine residents (p⫽0.078). On analyzing the 3 recommendations for waiting room improvements given by patients, 70% patients said to be given a better estimate of their waiting time, and 43.5% wanted to know why they were waiting. Of the sample, 30% recommended having a coffee/sandwich shop in the waiting area, 16.5% wanted more privacy, 14.8% wanted a quiet area and 14% wanted cleanliness to be improved. Conclusion: Survey subjects were more comfortable with physician triage rather than nurse or resident triage. Most patients expressed the desire to improve communication to give them a better estimate of waiting time and explain why they are waiting. What matters to most patients is the overall experience in the ED and not just their interaction with the treating physician and steps like opening a coffee/ sandwich shop within ED waiting room, improving privacy, cleanliness and a quiet in the area may improve satisfaction of patients.
174
Do Hospital Occupancy Levels Affect Initial Inpatient Level of Care for Emergency Department Admissions?
Delgado M, Liu V, Kipnis P, Gardner MN, Escobar GJ/Stanford University School of Medicine, Palo Alto, CA; Kaiser Permanente Division of Research, Systems Research Initiative, Oakland, CA
Study Objectives: A previous multicenter study of emergency department (ED) admissions subsequently transferred from general medical-surgical wards to the intensive care unit (ICU) within 24 hours suggested factors other than severity of illness affect inpatient level of care triage decisions. We sought to determine whether hospital bed occupancy levels affect the initial inpatient level of care disposition for ED after controlling for pre-admission severity of illness. Methods: This was a retrospective cohort study of inpatient admissions through the ED in 10 U.S. hospitals in a large integrated health care delivery system from July 1, 2007 to June 30, 2009. We used multinomial logistic regression to test the association between hospital occupancy (⬍80%, 80-89%, 90-100%) and inpatient disposition (ward, transitional care unit, intensive care unit) adjusting for age, sex, admitting diagnosis category, Laboratory-based Acute Physiology Score (LAPS), Commorbidity Points Score (COPS), admission day of the week, night vs. daytime admission. All data were abstracted from the electronic medical record. The analyses were performed on the entire cohort sample and then by deciles of predicted mortality at the time of admission. Results: There were 133,307 ED patient admissions available for analysis. Overall, 69% were admitted to the ward, 22% to the transitional care unit (TCU), and 9% to the ICU. The mean daily hospital occupancy rate was 79% (SD 9%) with 36% of patients admitted when occupancy was 80-89% and 8% admitted when occupancy was 90-100%. In the full cohort analysis, compared with hospitals operating at ⬍80% capacity, hospitals operating at 80-89% capacity were more likely to admit patients to the ICU (RR 1.16, 95% CI 1.11-1.21) rather than the ward but no more likely to admit patients to the TCU (RR 1.00, 95% CU 0.98-1.03). When hospital occupancy was at 90-100% capacity, patients were even more likely to be admitted to ICU rather than the ward (RR 1.23, 95% CI 1.14-1.32) but less likely to be admitted to the TCU (RR 0.86, 95% CI 0.81-0.91). In subgroup analysis by decile of predicted mortality at admission, the increased likelihood of admission to the ICU rather than the ward when the hospital was full remained consistent. The
Annals of Emergency Medicine S235
168
Patients With Access to Primary Care Call Their Doctors Before Coming to the Emergency Department With Lower Acuity Illness
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Study Objectives: Greater access to primary care is thought by some analysts to mean fewer emergency department (ED) visits. Patients with a primary care physician (PCP) are encouraged to call their physician prior to coming to our ED to prevent unnecessary visits. We wished to study the population of patients coming to the ED who have a PCP. Our objective was to determine if such patients who present with a non emergent complaint have called their PCP prior to coming to the ED. Further we wanted to describe any difference between the group that called their PCP and the group that did not. Methods: A survey was administered by a trained research associate using a closed ended item. This is a subset analysis of a larger study. In this analysis only patients with PCPs were used and divided into 2 groups, those who called and those who did not call their PCP. The study was approved by the institutional review board. Simple descriptive statistics were used with confidence interval 95%. Setting: The survey was administered in the waiting room of an urban tertiary care academic institution, 7 days a week between 12:00 and 24:00 from 4/15/10 to 8/2/10. Participants: A convenience sample of adult patients waiting for 15 minutes or more in the waiting area of an ED in a tertiary care academic institute were eligible to be interviewed. These patients were deemed “non-emergent” and comprised the study group. Results: A total of 399 patients were interviewed and had usable data. 315 (78.5%) had a primary care physician but 12 did not indicate whether they called their physician and were excluded. Of the 303 patients with PCPs, 54.7% called their physician before coming to the ED. The group that called their physician was similar to the group that did not call in age and sex. The group that called their physicians were proportionally more likely to be white [77.7% (71.4,84.0) vs 51.1% (42.7,59.5) p⬍0.001] and privately insured [65.1% (57.8,72.4) vs 43.8% (35.5,52.1), p⬍0.001]. Those who called their physician perceived that they could see their physician sooner than those who did not call their PCP [“could see in 1-3 days” 76.5% (69.7,83.3) vs 52.5% (43.6,61.4), p⬍0.001]. A chief complaint was given by 237 (78%), of which abdominal pain was the most common - 11%. A subgroup of patients with obvious non urgent chief complaints (toothache, cold/cough, sexually transmitted disease, menstrual cramps and rash) were seen in both populations in a similar frequency [6.1% (2.0,10.2) in the call group and 8.5% (3.2,13.8) in the not call group, p⫽.65]. Conclusion: In this study almost 80% of patients presenting to the ED with nonemergent complaints had a PCP. Contrary to public opinion, the majority of ED patients with non-emergent complaints who have primary care physicians call their physician before coming to the ED for care.
169
“Lead Triage Physician” Initiative: An Unsuccessful Hospitalist-Based Attempt to Address Emergency Department Crowding and Patient Flow
Haydar SA, Strout TD, Botler J/Maine Medical Center, Portland, ME
Study Objective: Detailed analysis of emergency department (ED) event data identified the time period from completion of emergency physician evaluation (doc done) to admitting physician bed order (bed order) as a significant contributor to ED boarding at our institution. To address this issue at the clinical microsystems level, an innovative Hospitalist Medicine position, the Lead Triage Physician (LTP), was created with the goal of facilitating inpatient medicine evaluations in the ED through the expeditious entry of admission orders and hospital bed placement. The objective of this study was to evaluate the effect of the LTP on markers of ED flow. Methods: We used a quasi-experimental, interrupted time-series analysis design with 2 comparison groups to evaluate the effect of the LTP on ED length of stay (length of stay ), door to physician time (DTP), door to completion of emergency physician evaluation (DTDD) time, and completion of emergency physician evaluation to inpatient bed order (DDBO) time. These time outcomes were compared for patients admitted by the LTP, patients admitted via adult inpatient medicine during the same time period (AIM-10), and patients admitted via adult inpatient medicine for the same 2 calendar month block, 1 year prior to the intervention (AIM-09). Data were obtained through query of an electronic ED
S234 Annals of Emergency Medicine
tracking system. Analyses included assessment of data normality, computation of appropriate summary statistics, and comparisons of group medians with the KruskalWallis test and post-hoc Mann-Whitney U tests adjusted for multiple comparisons. Results: Outcomes for 1884 patients were studied: 234 admitted via the LTP, 827 admitted via AIM-10, and 823 admitted via AIM-09 the previous calendar year. Median ED length of stay was similar across the 3 groups: LTP ⫽ 488, AIM-10 ⫽ 488, AIM-09 ⫽ 444 minutes, with the 2009 inpatient medicine group having a statistically significantly shorter length of stay, H ⫽ 31.499, df ⫽ 2, p ⬍ 0.001. Similarly, median DTP time was significantly shorter in the AIM-2009 group at 22 minutes compared to 28 (LTP) and 25 (AIM-10) minutes, H⫽12.093, df ⫽ 2, p ⬍ 0.002. DTDD time was also shorter in the AIM-09 group (197 min) when compared to the LTP (220 min) and AIM-10 (221 min) groups, H ⫽ 22.383, df ⫽ 2, p ⬍ 0.001. Median DDBO times, 78 min (LTP), 85 min (AIM-10), and 89 min (AIM09), did not vary significantly by group, H⫽0.653, df ⫽ 2, p ⫽ 0.721. Conclusions: In this cohort of adult ED patients admitted to inpatient medical units, the addition of a LTP did not decrease critical markers of ED flow. In fact, we observed a trend towards increased length of stay and DTP times with the addition of the LTP. While additional research is necessary to thoroughly understand the reasons for a general lack of positive effect with the LTP, we suspect that protocol violations, difficulties with protocol adherence, and limited support from some stakeholders may have played a role.
170
Deferred Emergency Department Care at a Community Hospital
Herman L, Melton N, Patacsil J, Chan SB/Resurrection Medical Center, Chicago, IL
Study Objectives: Crowding is a major concern in emergency departments (ED) across the US. Crowding negatively affects the ED experience by delaying medical care, decreasing patient satisfaction, and increasing staff frustration. Deferred care or diverting patients away from the ED has been proposed as a partial solution to easing crowding. This study evaluates the appropriateness, timeliness and the patients’ willingness to use the Health Access Program (HAP), a deferred care initiative. Methods: The HAP was active at an urban medical center from November 2007 to February 2009. Strict exclusion criteria were established. If no exclusion criteria were present, patients were referred by the triage nurse directly to the emergency physician for a medical screening exam (MSE). Following MSE, a suitable HAP candidate was registered and directed to the Health Access Specialist (HAS), a social worker with specialized training in referral of patients to health care resources. Data collected included vital signs, chief complaints, insurance status, detailed times for the HAP process, and outcome. An emergency physician reviewed every chart of HAP patients and abstracted the data. Difference between groups was tested using Student’s t-test. Results: During the study period, 153 patients were entered into HAP. Thirty-5 were excluded because of inappropriate referral. Eleven patients had no outcomes recorded. Of the remaining 107 patients, 44.1% were male, mean age: 31.6 years. Thirty-six percent were self-pay and 64% had some form of third party payer. The average length of stay in the ED to completion of HAP referral was 111 minutes. After screening, 17 patients chose to be treated by the emergency physician anyway. These 17 patients had already spent an average of 229 minutes to completion of the HAS process. However, 90 (84.1%) patients left to pursue care at the referral site. These 90 patients only spent an average time of 63 minutes to completion of the HAS process. The difference of 166 minutes was statistically significant (P⫽.006). Conclusion: Eighty-four percent of patients were willing to participate in the referral program. Patients who elected to remain in the ED had already spent a significantly longer period of time than those who elected to seek care at a referral site. Of the patients entered into HAP, 64% had a third-party payer.
171
Rationing Critical Care Access From Emergency Department: Electronic Classification System for Critical Care Admission
Neves FF, Pazin-Filho A/Medical School of São Carlos - Federal University of São Carlos, Sao Carlos, Brazil; Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil
Study Objectives: Crowded emergency departments (ED) are common and a considerable percentage of patients require intensive care. Intensive care units (ICU) are becoming a rare resource and rationing is required, even though ethical concerns are raised. This situation is of further consequences in developing countries, where
Volume , . : October
Research Forum Abstracts intensive care resources are even scarcer. We sought to evaluate the impact of prioritization information system over in-hospital and ICU stay and mortality. Methods: We retrospectively selected all patients admitted to a seventeen-bed adult non-coronary ICU which receives patients from a tertiary emergency department 1 year prior the introduction of the new system (Group I; 542; 47.3⫾21.6 years; 64.2% male) and compared them with those patients admitted after (Group II; 479; 48.2⫾20.2 years; 65.5% male). Group II was selected using a system based on semi-quantitative clinical prioritization and administrative sorting for equal clinical priorities. We adjusted for age, sex, ICU admission delay, Charlson comorbidity index and surgical intervention. For in-hospital and ICU stay we also adjusted for the respectively mortality. Results: Odds ratio for in-hospital mortality was 0.67(0.51;0.88) and logtransformed in-hospital stay was -0.14(-0.21;-0.006) lower for Group II. No difference was observed for ICU mortality or stay. Conclusion: Implementing a prioritization information system for ICU admission based on patients’ needs and using administrative requirements for sorting patients with equivalent priorities when rationing is needed had impact over inhospital death and stay, but not over ICU stay.
172
Why Do Patients With Minor Complaints Prefer Emergency Departments Over Primary Care Physicians?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Emergency departments (EDs) are increasingly seeing patients with minor medical complaints. Study Objective: Analyze why patients prefer to come to ED with minor complaints over a visit to their primary care physician (PCP). Method: This is a survey of 400 adult patients waiting at least 15 minutes to be seen by a physician or physician extender. The patients were surveyed in the waiting area of an academic tertiary care ED from April to August 2010. The study was approved by the Institutional Review Board. Information was collected on a closed ended item questionnaire and analyzed using JMP 8.0 for Mac. Results: Of the 400 patients studied, 20.6% did not have access to a PCP. Of the remaining patients, 56.6% had considered going to primary care for their presenting complaints, and 47.5% had called a doctor prior to ED arrival. Reasons for choosing ED over PCP: 36% patients presented to the ED due to the concern that their problem was urgent and required immediate attention. One third of the patients (33.4%) were referred to the ED by their PCPs. 12.5% of patients reported that they could not get a timely appointment with their PCP and therefore, came to the ED. 11% patients preferred the ED because it offered more services than their PCP’s office. We also looked at the distribution of insurance and employment status of our survey population and found that, while 54% of patients were unemployed, only 16.8% reported having no insurance of any kind. Nearly half the patients (48.5%) had Medicaid or Medicare with or without additional private medical insurance. 30.2% of the patients had private medical insurance. Only 3 patients (0.75%) felt that it was more expensive to go to the PCP than come to the ED, and 6 patients (1.5%) reported a lack of transportation to the PCP as 1 of the factors in their decision to come to the ED. Conclusion: Our survey reveals that many patients who present to the ED with minor complaints do so because they either perceive their complaints to be urgent, or because their PCP refers them to the ED. Most of these patients have some type of insurance coverage, and financial constraints are often not a deciding factor in this preference of the ED over the PCP. This result may reflect a trend seen in health care where overburdened PCP practices refer patients to the ED.
173
How Comfortable Are Patients With Different Triage Personnel, and What Do They Expect While Waiting to See a Physician?
Kamali MF, Jain A, Jain M, Schneider SM/University of Rochester, Rochester, NY
Background: Multidisciplinary triage is increasingly employed by emergency departments (EDs) to decrease waiting times. Study Objective: Study the level of comfort for patients with different triage personnel and their perceived needs while waiting to see a physician in the emergency department.
Volume , . : October
Methods: This was an Institutional Review Board approved survey of 400 adult patients waiting for more than 15 minutes in the ED waiting room of a university tertiary care hospital from April to August 2010. The Likert scale (0-5; 0 being very uncomfortable, 5 being very comfortable) was used to assess the comfort level of patients with different triage personnel (triage nurse, emergency medicine resident, emergency medicine attending). We hypothesized that there were no differences between comfort levels of patients with the above personnel. Patients also listed 3 items from a pre-formatted list of 12 items that they would like the hospital to improve in the current ED waiting room. JMP 8.0 and STATA 10.0 were used for data analysis. Results: The study population had a mean age of 38.9 years (SD 14.8 years). There were 52.5% women. African Americans constituted 26.3%, Caucasians 63.4% and the remaining 10.3% belonged to other races. Analysis of the Likert score for triage personnel revealed: emergency physician (mean 3.85, SD 1.17), triage nurse (mean 3.69, SD 1.25) and emergency medicine resident (mean 3.59, SD 1.19). On paired t tests, we rejected our null hypotheses of no difference between Likert scores for emergency physician and emergency medicine residents (p⫽0.000) and emergency physicians and triage nurse (p⫽0.006). We could not reject the null hypothesis of no difference between preference for triage nurse and emergency medicine residents (p⫽0.078). On analyzing the 3 recommendations for waiting room improvements given by patients, 70% patients said to be given a better estimate of their waiting time, and 43.5% wanted to know why they were waiting. Of the sample, 30% recommended having a coffee/sandwich shop in the waiting area, 16.5% wanted more privacy, 14.8% wanted a quiet area and 14% wanted cleanliness to be improved. Conclusion: Survey subjects were more comfortable with physician triage rather than nurse or resident triage. Most patients expressed the desire to improve communication to give them a better estimate of waiting time and explain why they are waiting. What matters to most patients is the overall experience in the ED and not just their interaction with the treating physician and steps like opening a coffee/ sandwich shop within ED waiting room, improving privacy, cleanliness and a quiet in the area may improve satisfaction of patients.
174
Do Hospital Occupancy Levels Affect Initial Inpatient Level of Care for Emergency Department Admissions?
Delgado M, Liu V, Kipnis P, Gardner MN, Escobar GJ/Stanford University School of Medicine, Palo Alto, CA; Kaiser Permanente Division of Research, Systems Research Initiative, Oakland, CA
Study Objectives: A previous multicenter study of emergency department (ED) admissions subsequently transferred from general medical-surgical wards to the intensive care unit (ICU) within 24 hours suggested factors other than severity of illness affect inpatient level of care triage decisions. We sought to determine whether hospital bed occupancy levels affect the initial inpatient level of care disposition for ED after controlling for pre-admission severity of illness. Methods: This was a retrospective cohort study of inpatient admissions through the ED in 10 U.S. hospitals in a large integrated health care delivery system from July 1, 2007 to June 30, 2009. We used multinomial logistic regression to test the association between hospital occupancy (⬍80%, 80-89%, 90-100%) and inpatient disposition (ward, transitional care unit, intensive care unit) adjusting for age, sex, admitting diagnosis category, Laboratory-based Acute Physiology Score (LAPS), Commorbidity Points Score (COPS), admission day of the week, night vs. daytime admission. All data were abstracted from the electronic medical record. The analyses were performed on the entire cohort sample and then by deciles of predicted mortality at the time of admission. Results: There were 133,307 ED patient admissions available for analysis. Overall, 69% were admitted to the ward, 22% to the transitional care unit (TCU), and 9% to the ICU. The mean daily hospital occupancy rate was 79% (SD 9%) with 36% of patients admitted when occupancy was 80-89% and 8% admitted when occupancy was 90-100%. In the full cohort analysis, compared with hospitals operating at ⬍80% capacity, hospitals operating at 80-89% capacity were more likely to admit patients to the ICU (RR 1.16, 95% CI 1.11-1.21) rather than the ward but no more likely to admit patients to the TCU (RR 1.00, 95% CU 0.98-1.03). When hospital occupancy was at 90-100% capacity, patients were even more likely to be admitted to ICU rather than the ward (RR 1.23, 95% CI 1.14-1.32) but less likely to be admitted to the TCU (RR 0.86, 95% CI 0.81-0.91). In subgroup analysis by decile of predicted mortality at admission, the increased likelihood of admission to the ICU rather than the ward when the hospital was full remained consistent. The
Annals of Emergency Medicine S235