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179: Vertical Patient Flow, an Innovative Approach to Crowding In US Academic Emergency Departments
Research Forum Abstracts on diversion at least once during a 24-hour period. A two-way ANOVA with Bonferroni adjustment for multiple comparisons was applied to determine the differences in workload rate among sites and on days with and without periods of ED diversion. Results: The annual ED census among the nine participating EDs ranged from 43K-101K patients. The number of ED beds ranged from 27 to 95. The percentage of days that an ED diverted at least once varied from 4.9 to 86.6%. On days with ambulance diversion, the mean daily workload rate significantly varied from 17.1 to 62.1 patient LOS hours per ED bed (p ⬍ 0.001). Differences in daily workload rate between diversion and non-diversion days varied significantly among sites (p ⬍ 0.001), ranging from 0.9 to 7.2 patient LOS hours per ED bed with the days on diversion having on average a higher workload rate. With the exception of one site, the difference between diversion and non-diversion was statistically significant for all sites (p⬍0.05). Conclusion: In comparing a diverse sample of EDs across the US, days with diversion episodes had a higher workload rate. However, there was also a significant amount of variation with daily workload rates and whether or not ambulance diversion occurred during a 24-hour period using a daily workload rate as a marker of ED crowding. Decisionmaking criteria about going on diversion likely varied among different EDs and was not based only on quantitative, objective measures, but may have included a subjective, situational component not well understood (see table).
179
Vertical Patient Flow, an Innovative Approach to Crowding In US Academic Emergency Departments
Hamedani AG, Liu SW, Brown DF, Asplin BR, Camargo Jr CA/University of Wisconsin School of Medicine & Public Health, Madison, WI; Massachusetts General Hospital, Boston, MA; Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: We sought to determine the extent to which a variety of emergency department (ED) crowding solutions have been implemented in US academic EDs. We were particularly interested in learning about “vertical patient flow,” ie, front-end evaluation and management of patients where the patient does not actually occupy a traditional ED room. Methods: An electronic survey was sent to the physician leadership of every US academic ED, as defined as the primary site of an allopathic emergency medicine residency program (n⫽152). Initial non-responders received two subsequent emails about the survey. The survey asked about the extent to which various hospital-based or ED-based operational solutions to ED crowding have been initiated and/or implemented, including vertical patient flow. Results: To date, 119/152 (78%) of academic EDs have responded. The mean ED volume across all sites was 76,356 visits (median: 74,600), with a mean ED length of stay (LOS) for all patients of 4.9 hours (mean admitted LOS, 7.6 hours; admitted LOS, 3.8 hours). On average, 25% of ED patients were admitted, comprising over half (56%) of admissions to these academic hospitals. The two most prevalent hospital-based initiatives (either implemented or in the process of being implemented) were inpatient discharge coordination (86% of responding hospitals) and surgical schedule smoothing (43%), while the least prevalent was canceling elective surgeries (30%). The two most prevalent ED-based initiatives were bedside registration (92%) and fast track (88%), while the least prevalent was physician triage (39%). Almost two-thirds (62%) of US academic EDs reported using an observation unit. Vertical patient flow was relatively common, with 30% of respondents reporting that their ED had initiated vertical patient flow, while implementation was partial/in progress for another 39%. Nearly 70% of the EDs using vertical patient flow stated that they had formally incorporated it into their operational work flow; of those, this occurred on a daily basis for 65% of sites. Of those using vertical patient flow, 60% use it to manage emergency severity index (ESI) of 3, 4, and 5 patients, while 40% reserve it for ESI 4 and 5 patients only. Over half (52%) of the respondents reported that vertical flow patients are taken to an area designated for them, while 44% of
S60 Annals of Emergency Medicine
respondents return patients to the waiting room. Of those who report not having initiated vertical patient flow, 32% reported “definite plans” do so and an additional 44% said they were considering implementation in the future. Conclusion: A variety of hospital-based and ED-based crowding solutions have been implemented in academic EDs. Many sites have formally incorporated a vertical patient flow model into their front-end evaluation of urgent and non-urgent patients on a daily basis. This indicates that vertical patient flow is an emerging paradigm for alleviating ED crowding and deserves inclusion in any compendium of ED crowding solutions. Future studies should test how this new approach affects outcomes, including patient safety, ED length-of-stay, and patient satisfaction.
180
Implementation of a Multifaceted Electrocardiogram Screening Policy In the Emergency Department and Its Impact on ST–Elevation Myocardial Infarction Percutaneous Coronary Intervention Times
Cassidy, MD, FACEP DD, Papa, MD, MSc L, Reimer, MD F, Ritter, RN CL, Williams, RN DA, Townsend, RN CS/Orlando Regional Medical Center, Orlando, FL
Study Objectives: The Joint Commission (TJC) recommends that the core performance measure of “door to percutaneous coronary intervention (PCI) time” be less than 90 minutes from hospital arrival. This study evaluated the impact of an emergency department (ED) multifaceted electrocardiogram (ECG) screening intervention on “time to PCI” for patients with suspected acute myocardial infarction and assessed the correlation between ECG screening time and time to PCI. Methods: This cross-sectional pre and post intervention study was conducted at an academic urban hospital with an emergency medicine training program using a hospital core measures database from July 2004 to September 2009. In an attempt to improve quality of care and to meet the TJC recommended standard of “door to PCI” within 90 minutes, a policy was implemented in the ED in January 2006 (intervention #1) requiring all patients with any symptom of acute coronary syndrome receive an electrocardiogram (ECG) within 10 minutes of arrival and that it be screened, signed, and timed by the attending ED physician. In January 2008 second intervention (intervention #2) geared at improving compliance with this policy was implemented which included “ECG rounds” twice daily during which the policy was reviewed with ED nursing and support staff and ECG equipment was checked and calibrated, biweekly chart reviews with feedback for non-compliant cases and posting of weekly ECG time statistics. The main outcomes were “time to PCI” and the percentage of PCI’s performed within 90 minutes of arrival in each of the periods 1) pre-intervention, 2) post intervention #1, and 3) post-intervention #2. Additionally, an assessment of time to screening ECG and percentage of patients having an ECG performed within 10 minutes of arrival after intervention #2 was conducted. Data was analyzed using descriptive statistics with 95%CI, the Mann Whitney U Test and Pearson correlation. Results: There were 447 cases included in the analysis. “Door to PCI” time in minutes decreased from 171 min (95%CI⫽143-200) to 87 min (95%CI⫽79-94) following intervention #1 and further to 70 min (95%CI⫽63-77) following intervention #2 (P⬍0.001). The percentage of PCI’s being performed within 90 minutes in the pre-intervention period was 41% (95%CI⫽32-50), after intervention #1 it was 71% (95%CI⫽61-80), and after intervention #2 it was 89% (95%CI⫽8394) (P⬍0.001). The effect of intervention #2 on ECG performance was such that time to screening ECG decreased from 9.7 min (95%CI⫽4.7-14.7) to 5.7 min (95%CI⫽4.7-6.7). Additionally, following intervention #2 the percentage of patients having an ECG performed within 10 minutes of arrival increased from 74% (95%CI⫽66-82) to 92% (95%CI⫽86-98) (P⫽0.001). The correlation between time to ECG and time to PCI was 0.64 (P⫽0.01). Conclusions: Strategies to improve the ability to meet core performance measures are needed particularly in light of health care reform. Implementation of a multifaceted ED ECG screening policy improved the ability of this urban ED to meet TJC core performance measures and improved care of patients with acute coronary syndrome. The application of such protocols to other hospitals and emergency departments would need further study.
Volume , . : September
179
Vertical Patient Flow, an Innovative Approach to Crowding In US Academic Emergency Departments
Hamedani AG, Liu SW, Brown DF, Asplin BR, Camargo Jr CA/University of Wisconsin School of Medicine & Public Health, Madison, WI; Massachusetts General Hospital, Boston, MA; Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: We sought to determine the extent to which a variety of emergency department (ED) crowding solutions have been implemented in US academic EDs. We were particularly interested in learning about “vertical patient flow,” ie, front-end evaluation and management of patients where the patient does not actually occupy a traditional ED room. Methods: An electronic survey was sent to the physician leadership of every US academic ED, as defined as the primary site of an allopathic emergency medicine residency program (n⫽152). Initial non-responders received two subsequent emails about the survey. The survey asked about the extent to which various hospital-based or ED-based operational solutions to ED crowding have been initiated and/or implemented, including vertical patient flow. Results: To date, 119/152 (78%) of academic EDs have responded. The mean ED volume across all sites was 76,356 visits (median: 74,600), with a mean ED length of stay (LOS) for all patients of 4.9 hours (mean admitted LOS, 7.6 hours; admitted LOS, 3.8 hours). On average, 25% of ED patients were admitted, comprising over half (56%) of admissions to these academic hospitals. The two most prevalent hospital-based initiatives (either implemented or in the process of being implemented) were inpatient discharge coordination (86% of responding hospitals) and surgical schedule smoothing (43%), while the least prevalent was canceling elective surgeries (30%). The two most prevalent ED-based initiatives were bedside registration (92%) and fast track (88%), while the least prevalent was physician triage (39%). Almost two-thirds (62%) of US academic EDs reported using an observation unit. Vertical patient flow was relatively common, with 30% of respondents reporting that their ED had initiated vertical patient flow, while implementation was partial/in progress for another 39%. Nearly 70% of the EDs using vertical patient flow stated that they had formally incorporated it into their operational work flow; of those, this occurred on a daily basis for 65% of sites. Of those using vertical patient flow, 60% use it to manage emergency severity index (ESI) of 3, 4, and 5 patients, while 40% reserve it for ESI 4 and 5 patients only. Over half (52%) of the respondents reported that vertical flow patients are taken to an area designated for them, while 44% of
S60 Annals of Emergency Medicine
respondents return patients to the waiting room. Of those who report not having initiated vertical patient flow, 32% reported “definite plans” do so and an additional 44% said they were considering implementation in the future. Conclusion: A variety of hospital-based and ED-based crowding solutions have been implemented in academic EDs. Many sites have formally incorporated a vertical patient flow model into their front-end evaluation of urgent and non-urgent patients on a daily basis. This indicates that vertical patient flow is an emerging paradigm for alleviating ED crowding and deserves inclusion in any compendium of ED crowding solutions. Future studies should test how this new approach affects outcomes, including patient safety, ED length-of-stay, and patient satisfaction.
180
Implementation of a Multifaceted Electrocardiogram Screening Policy In the Emergency Department and Its Impact on ST–Elevation Myocardial Infarction Percutaneous Coronary Intervention Times
Cassidy, MD, FACEP DD, Papa, MD, MSc L, Reimer, MD F, Ritter, RN CL, Williams, RN DA, Townsend, RN CS/Orlando Regional Medical Center, Orlando, FL
Study Objectives: The Joint Commission (TJC) recommends that the core performance measure of “door to percutaneous coronary intervention (PCI) time” be less than 90 minutes from hospital arrival. This study evaluated the impact of an emergency department (ED) multifaceted electrocardiogram (ECG) screening intervention on “time to PCI” for patients with suspected acute myocardial infarction and assessed the correlation between ECG screening time and time to PCI. Methods: This cross-sectional pre and post intervention study was conducted at an academic urban hospital with an emergency medicine training program using a hospital core measures database from July 2004 to September 2009. In an attempt to improve quality of care and to meet the TJC recommended standard of “door to PCI” within 90 minutes, a policy was implemented in the ED in January 2006 (intervention #1) requiring all patients with any symptom of acute coronary syndrome receive an electrocardiogram (ECG) within 10 minutes of arrival and that it be screened, signed, and timed by the attending ED physician. In January 2008 second intervention (intervention #2) geared at improving compliance with this policy was implemented which included “ECG rounds” twice daily during which the policy was reviewed with ED nursing and support staff and ECG equipment was checked and calibrated, biweekly chart reviews with feedback for non-compliant cases and posting of weekly ECG time statistics. The main outcomes were “time to PCI” and the percentage of PCI’s performed within 90 minutes of arrival in each of the periods 1) pre-intervention, 2) post intervention #1, and 3) post-intervention #2. Additionally, an assessment of time to screening ECG and percentage of patients having an ECG performed within 10 minutes of arrival after intervention #2 was conducted. Data was analyzed using descriptive statistics with 95%CI, the Mann Whitney U Test and Pearson correlation. Results: There were 447 cases included in the analysis. “Door to PCI” time in minutes decreased from 171 min (95%CI⫽143-200) to 87 min (95%CI⫽79-94) following intervention #1 and further to 70 min (95%CI⫽63-77) following intervention #2 (P⬍0.001). The percentage of PCI’s being performed within 90 minutes in the pre-intervention period was 41% (95%CI⫽32-50), after intervention #1 it was 71% (95%CI⫽61-80), and after intervention #2 it was 89% (95%CI⫽8394) (P⬍0.001). The effect of intervention #2 on ECG performance was such that time to screening ECG decreased from 9.7 min (95%CI⫽4.7-14.7) to 5.7 min (95%CI⫽4.7-6.7). Additionally, following intervention #2 the percentage of patients having an ECG performed within 10 minutes of arrival increased from 74% (95%CI⫽66-82) to 92% (95%CI⫽86-98) (P⫽0.001). The correlation between time to ECG and time to PCI was 0.64 (P⫽0.01). Conclusions: Strategies to improve the ability to meet core performance measures are needed particularly in light of health care reform. Implementation of a multifaceted ED ECG screening policy improved the ability of this urban ED to meet TJC core performance measures and improved care of patients with acute coronary syndrome. The application of such protocols to other hospitals and emergency departments would need further study.
Volume , . : September