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205 Does an Emergency Department Asthma Pathway and Clinical Asthma Score Significantly Increase the Emergency Department Length of Stay?
Research Forum Abstracts Conclusion: Community members in Zambia and Kenya experience a wide range of medical emergencies. They rely on family members and neighbors for assistance during emergencies, most commonly with transportation to medical facilities. Identifying novel transportation solutions and creating community education initiatives are a few answers that may address community-identified barriers to emergency care.
204
Inpatient Admission Rates for Syncope Vary Among and Within Countries: A Metaanalysis
Eskin B, Allegra JR/Morristown Medical Center, Morristown, NJ
Study Objectives: Inpatient admission of emergency department (ED) patients with syncope has low diagnostic and therapeutic yield. Admission rates may vary from place to place and this may provide clues as to which factors influence the emergency physician’s decision to admit these patients. We sought to examine the variability of the rates of admission for syncope in different countries and among sites within countries. Methods: Design: Using PubMed and the Boolian operators and OR, we searched for papers using the following terms: (hospitalization or admit) and (emergency service, hospital, or emergency medical services or emergency medicine) and (syncope). We also searched the reference lists in the included papers for additional studies. Types of papers: From the abstracts we picked out papers for full review. Included papers had to (1) have data that allowed calculation of the admission rate and (2) include adult patients. We excluded papers for any of the following reasons: (1) studies done at sites with observation units, (2) adults of all ages not included (eg, age > 65), (3) duplicate publications on the same population,(4) data on syncope and near syncope could not be separated, (5) study done over > 5 years, and (6) admission rates not available. Results: The search yielded 80 papers. We found three others from the reference lists of the these papers. We eliminated six papers because they were duplicate studies on the same population, two because adults of all ages were not included, one each because the site had an observation unit, data on syncope and near syncope could not be separated and the study was done over > 5 years and forty-two because admission rates were not available. This left 30 papers included in the study. The mean admission rates in each country varied considerably. The highest mean admission rate by country, 63% in France, was 5.3-fold the lowest, 12% in Canada (Table). The United States (US) was at the higher end of this range. The individual rates in the US were, by state: California 34%, 51%, 55%, 59%; Utah 47%; Massachusetts 69%; and New York 83%, so the highest rate in the US was 2.4 times the lowest rate. For individual studies in Italy, the ratio of the highest (69%) to lowest rate (39%) was 1.7, whereas in the United Kingdom, this ratio was 1.4 (50% versus 36%). Conclusion: There is great variability of the rates of admission for syncope in different countries and among sites within countries. These variations could be due to factors that influence the emergency physician’s decision to admit these patients, such as the type and availability of health insurance, enforcement of guidelines, financial incentives and concern about malpractice.
205
Does an Emergency Department Asthma Pathway and Clinical Asthma Score Significantly Increase the Emergency Department Length of Stay?
Marshall KA, Morgan DL, Lucia DJ/Baylor Scott & White Healthcare, McLane Children’s Hospital, Temple, TX; A&M Health Science Center, Temple, TX
Study Objectives: Asthma is the most common chronic disease of childhood, affecting more than 7 million children in the United States (US). Many hospitals have developed emergency department (ED) clinical pathways for the assessment and treatment of asthma to improve the quality of care for these patients. These ED asthma pathways (EDAP) typically use standardized clinical asthma scoring systems (CAS) which physicians and nurses use to guide consistent ED treatment and to help determine further observation or need for hospital admission. Previous studies have evaluated these EDAP for rate of hospitalization as well as the effect on return visits. There are concerns that the additional evaluation required by the CAS could lead to extended ED length of stay (EDLOS) which leads to ED crowding. A few studies in other countries have analyzed the effect of such pathways on the EDLOS, but there is limited similar data for the US. The goal of this study was to determine if the EDAP and CAS would significantly increase the EDLOS for asthma patients while also evaluating the effect on hospitalization rate and return visits at a children’s hospital in the US. Methods: This was a retrospective before-and-after study performed at an academic children’s hospital ED during two five-month periods, a year before and immediately after the initiation of an EDAP. All patients seen at the children’s emergency department from September 2012 through January 2013 were compared to those from September 2013 through January 2014. Using the hospital’s electronic medical record, EDLOS, disposition, and return visits within 72 hours were evaluated for each period. Results: The total number of ED visits during the study periods increased from 9,724 prior to the pathway to 10,398 after the pathway (6.5% increase). The number of visits for asthma related issues increased from 327 to 382 during the two study periods (16.8% increase, P¼.23). The average age and fraction of males were similar for both groups (6.7 years, 59% male). Prior to use of the EDAP, 70 asthma patients (21.4%) were admitted to the hospital. Following initiation of the EDAP, 111 (29.1%) patients were admitted (7.7% increase, P¼.02). The EDLOS for all asthma patients increased from 147 minutes to 160 minutes (8.8% increase, P¼.02). Although the pathway detected more patients that required admission, the EDLOS of discharged asthma patients increased only 6 minutes from 129 minutes to 135 minutes (4.7% increase, P¼.17). The fraction of discharged patients that returned within 72 hours remained similar for both groups (4.0% and 2.6%, P¼.31). Conclusions: This is a novel study on the effect of an EDAP on a children’s hospital EDLOS in the US. The EDAP detected more asthma patients that required admission, which increased the total EDLOS for these patients. However, the EDAP did not significantly affect the EDLOS for discharged patients. This suggests that acquiring a CAS and using an EDAP will provide more consistent care and decisionmaking amongst a variety of providers while having little effect the EDLOS for the majority of asthma patients. This study is limited by the single site and short study periods. Additional studies are needed to evaluate if further use and familiarity with the EDAP and CAS will lead to decreased EDLOS for all patients in multiple emergency departments and a more consistent approach to a common childhood disease.
Table.
COUNTRY Canada South Korea Spain Belgium Not the US Australia Italy United Kingdom US Ireland France
MEAN ADMISSION RATE, % (–SD)
NUMBER OF STUDIES IN EACH COUNTRY
12 0.1 22 25 28 40 14 41 9 44 11 45 5 50 21 51 63
2 1 1 1 23 2 10 5 7 1 1
No. of Gen. Surgery Consultations and % of Admitted in Calgary EDs by Site and Month.
S74 Annals of Emergency Medicine
206
Adoption of Interventions to Reduce Emergency Department Crowding from 2007 to 2010
Honigman LS, Schuur JD, Chambers JG, Pines JM/George Washington University, Washington, DC; Brigham and Women’s Hospital, Boston, MA; Albany Medical College, Albany, NY; George Washington University Hospital, Washington, DC
Study Objectives: Recently, there has been increasing emergency department (ED) crowding, which can adversely affect patient care. Various interventions have been implemented by hospitals to reduce crowding; however, few studies have examined how many or which facilities have adopted these strategies. We evaluated the trend in implementation of crowding interventions from 2007 to 2010 across the U.S. We also explored the relationship between crowding levels, measured as average ED length of stay (LOS), and implementation of interventions. Methods: We used data from the 2007-2010 National Hospital Ambulatory Medical Care Survey to analyze 17 unique ED crowding interventions. We calculated the mean number of interventions adopted across the 4-year period and evaluated the trend using linear regression analysis. Median ED LOS by hospital was a proxy measurement for ED crowding, which was used to divide hospitals into quartiles of ED
Volume 64, no. 4s : October 2014
204
Inpatient Admission Rates for Syncope Vary Among and Within Countries: A Metaanalysis
Eskin B, Allegra JR/Morristown Medical Center, Morristown, NJ
Study Objectives: Inpatient admission of emergency department (ED) patients with syncope has low diagnostic and therapeutic yield. Admission rates may vary from place to place and this may provide clues as to which factors influence the emergency physician’s decision to admit these patients. We sought to examine the variability of the rates of admission for syncope in different countries and among sites within countries. Methods: Design: Using PubMed and the Boolian operators and OR, we searched for papers using the following terms: (hospitalization or admit) and (emergency service, hospital, or emergency medical services or emergency medicine) and (syncope). We also searched the reference lists in the included papers for additional studies. Types of papers: From the abstracts we picked out papers for full review. Included papers had to (1) have data that allowed calculation of the admission rate and (2) include adult patients. We excluded papers for any of the following reasons: (1) studies done at sites with observation units, (2) adults of all ages not included (eg, age > 65), (3) duplicate publications on the same population,(4) data on syncope and near syncope could not be separated, (5) study done over > 5 years, and (6) admission rates not available. Results: The search yielded 80 papers. We found three others from the reference lists of the these papers. We eliminated six papers because they were duplicate studies on the same population, two because adults of all ages were not included, one each because the site had an observation unit, data on syncope and near syncope could not be separated and the study was done over > 5 years and forty-two because admission rates were not available. This left 30 papers included in the study. The mean admission rates in each country varied considerably. The highest mean admission rate by country, 63% in France, was 5.3-fold the lowest, 12% in Canada (Table). The United States (US) was at the higher end of this range. The individual rates in the US were, by state: California 34%, 51%, 55%, 59%; Utah 47%; Massachusetts 69%; and New York 83%, so the highest rate in the US was 2.4 times the lowest rate. For individual studies in Italy, the ratio of the highest (69%) to lowest rate (39%) was 1.7, whereas in the United Kingdom, this ratio was 1.4 (50% versus 36%). Conclusion: There is great variability of the rates of admission for syncope in different countries and among sites within countries. These variations could be due to factors that influence the emergency physician’s decision to admit these patients, such as the type and availability of health insurance, enforcement of guidelines, financial incentives and concern about malpractice.
205
Does an Emergency Department Asthma Pathway and Clinical Asthma Score Significantly Increase the Emergency Department Length of Stay?
Marshall KA, Morgan DL, Lucia DJ/Baylor Scott & White Healthcare, McLane Children’s Hospital, Temple, TX; A&M Health Science Center, Temple, TX
Study Objectives: Asthma is the most common chronic disease of childhood, affecting more than 7 million children in the United States (US). Many hospitals have developed emergency department (ED) clinical pathways for the assessment and treatment of asthma to improve the quality of care for these patients. These ED asthma pathways (EDAP) typically use standardized clinical asthma scoring systems (CAS) which physicians and nurses use to guide consistent ED treatment and to help determine further observation or need for hospital admission. Previous studies have evaluated these EDAP for rate of hospitalization as well as the effect on return visits. There are concerns that the additional evaluation required by the CAS could lead to extended ED length of stay (EDLOS) which leads to ED crowding. A few studies in other countries have analyzed the effect of such pathways on the EDLOS, but there is limited similar data for the US. The goal of this study was to determine if the EDAP and CAS would significantly increase the EDLOS for asthma patients while also evaluating the effect on hospitalization rate and return visits at a children’s hospital in the US. Methods: This was a retrospective before-and-after study performed at an academic children’s hospital ED during two five-month periods, a year before and immediately after the initiation of an EDAP. All patients seen at the children’s emergency department from September 2012 through January 2013 were compared to those from September 2013 through January 2014. Using the hospital’s electronic medical record, EDLOS, disposition, and return visits within 72 hours were evaluated for each period. Results: The total number of ED visits during the study periods increased from 9,724 prior to the pathway to 10,398 after the pathway (6.5% increase). The number of visits for asthma related issues increased from 327 to 382 during the two study periods (16.8% increase, P¼.23). The average age and fraction of males were similar for both groups (6.7 years, 59% male). Prior to use of the EDAP, 70 asthma patients (21.4%) were admitted to the hospital. Following initiation of the EDAP, 111 (29.1%) patients were admitted (7.7% increase, P¼.02). The EDLOS for all asthma patients increased from 147 minutes to 160 minutes (8.8% increase, P¼.02). Although the pathway detected more patients that required admission, the EDLOS of discharged asthma patients increased only 6 minutes from 129 minutes to 135 minutes (4.7% increase, P¼.17). The fraction of discharged patients that returned within 72 hours remained similar for both groups (4.0% and 2.6%, P¼.31). Conclusions: This is a novel study on the effect of an EDAP on a children’s hospital EDLOS in the US. The EDAP detected more asthma patients that required admission, which increased the total EDLOS for these patients. However, the EDAP did not significantly affect the EDLOS for discharged patients. This suggests that acquiring a CAS and using an EDAP will provide more consistent care and decisionmaking amongst a variety of providers while having little effect the EDLOS for the majority of asthma patients. This study is limited by the single site and short study periods. Additional studies are needed to evaluate if further use and familiarity with the EDAP and CAS will lead to decreased EDLOS for all patients in multiple emergency departments and a more consistent approach to a common childhood disease.
Table.
COUNTRY Canada South Korea Spain Belgium Not the US Australia Italy United Kingdom US Ireland France
MEAN ADMISSION RATE, % (–SD)
NUMBER OF STUDIES IN EACH COUNTRY
12 0.1 22 25 28 40 14 41 9 44 11 45 5 50 21 51 63
2 1 1 1 23 2 10 5 7 1 1
No. of Gen. Surgery Consultations and % of Admitted in Calgary EDs by Site and Month.
S74 Annals of Emergency Medicine
206
Adoption of Interventions to Reduce Emergency Department Crowding from 2007 to 2010
Honigman LS, Schuur JD, Chambers JG, Pines JM/George Washington University, Washington, DC; Brigham and Women’s Hospital, Boston, MA; Albany Medical College, Albany, NY; George Washington University Hospital, Washington, DC
Study Objectives: Recently, there has been increasing emergency department (ED) crowding, which can adversely affect patient care. Various interventions have been implemented by hospitals to reduce crowding; however, few studies have examined how many or which facilities have adopted these strategies. We evaluated the trend in implementation of crowding interventions from 2007 to 2010 across the U.S. We also explored the relationship between crowding levels, measured as average ED length of stay (LOS), and implementation of interventions. Methods: We used data from the 2007-2010 National Hospital Ambulatory Medical Care Survey to analyze 17 unique ED crowding interventions. We calculated the mean number of interventions adopted across the 4-year period and evaluated the trend using linear regression analysis. Median ED LOS by hospital was a proxy measurement for ED crowding, which was used to divide hospitals into quartiles of ED
Volume 64, no. 4s : October 2014