Research Forum Abstracts compared to 193 minutes (P<.001). Changes in overall LOS, TTN, and TTB were not statistically significant. Conclusion: Unexpectedly, a new rotational patient assignment model did not improve ED timing metrics when compared to a geographical-based assignment model in our hospital.
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Troponin Testing Contributes More to Emergency Department Length of Stay than Age or ESI Level
Milano P, Eiting E, Kim H, Gruber P, Desai S, Vasquez V, Dasu S/Keck School of Medicine of USC, Los Angeles, CA; University of Southern California, Marshall School of Business, Los Angeles, CA
Study Objectives: The emergency department (ED) at Los Angeles County-USC Medical Center (LAC+USC) is one of the busiest in the country, seeing approximately 180,000 patients per year. Due to high volumes and limited inpatient bed availability, ED throughput remains a major focus of quality improvement in this institution. Prediction modeling can help identify potential bottlenecks and thereby foster initiatives to improved ED operations. In an effort to improve our overall ED length of stay (LOS), the chief complaint of “chest pain” was studied. Nationally, chest pain accounts for approximately 6 million ED visits per year. These patients present with a variety of risk factors, symptoms, and signs reflecting many possible etiologies. Diagnostic approaches for this complaint are often time consuming, requiring serial troponin assays. A prediction model could potentially help develop a protocol that could reduce ED boarding for these patients. Methods: A retrospective cohort study was performed using a data set of 3408 patients who presented to the ED at LAC+USC with a chief complaint of “chest pain” between January 1, 2010 and June 30, 2010. The LOS was defined as the period from when the patient was placed in a bed to when they left the department, either to an inpatient bed or discharged home. Time spent in the ED waiting room was not included. Laboratory tests including troponin were not sent until after initial physician evaluation. Pearson correlation coefficients were determined comparing independent variables of age, Emergency Service Index (ESI) level, and whether a troponin was sent with the dependent variable of ED LOS. Results: The correlation coefficient was found to be +0.573 for troponin usage, -0.070 for ESI level, and +0.285 for age when compared to ED LOS. All three of these correlation coefficients were significant at the 0.01 level. These findings indicate that sending a troponin for a chest pain workup contributed more to ED LOS than either ESI level or age. Conclusion: These findings demonstrate that troponin testing in ED patients who present with a chief complaint of chest pain greatly impact ED LOS. To improve ED operations, a focus on troponin testing could lead to significant improvements. Early ordering of troponin assays from triage or point-of-care troponin may lead to reduced ED boarding times. Additionally, developing a protocol for the standardization of serial troponin utilization in an effort to reduce variability among emergency physicians may also contribute to improved ED LOS.
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Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department
Weston V, Aldeen A, Gravenor S, Jain S, Schmidt M, Malik S/Northwestern, Chicago, IL
Study Objectives: Emergency department (ED) crowding is associated with detrimental effects on patient satisfaction, door-to-physician time (DTP), and ED length of stay (LOS). Triage liaison providers (TLP) have been successful in reducing DTP and left without being seen (LWBS) visits. Prior studies have evaluated attending physicians and mid-level providers as TLP, but no published studies have evaluated resident physicians as TLP. This study compares operational performance, patient satisfaction, and cost-effectiveness outcomes between resident and attending physicians as TLP. Methods: This retrospective, observational cohort study compared aggregate operational performance at an urban, academic ED with 88,000 annual visits, 50 residents, and 28 attendings. A TLP was present 1130-1930 on weekdays from 10/ 2013-1/2014, staffed by PGY-3/4 residents or attending physicians. Outcomes for all ED patients on the TLP days were compared to baseline (defined as historical, pre-TLP data from 10/2011-1/2012). Primary outcomes were defined as differences in: median ED LOS, median DTP, proportion of LWBS, proportion of “very good” overall patient satisfaction scores, and cost effectiveness. Proportions are described with 95% confidence intervals, medians with interquartile ranges,
Volume 64, no. 4s : October 2014
and differences with the t-test and Mann-Whitney U test. Cost effectiveness was calculated with annual revenue generated through LWBS capture offset by TLP cost. Results: Over the 4-month study period, residents worked 29 days as TLP and attendings worked 48 days as TLP, compared to 92 days baseline; 6,683 visits were analyzed in the resident group, 10,814 in the attending group, and 19,298 in the baseline group. Overall median LOS was not significantly different with a TLP compared to baseline. Attending TLP were associated with a lower median LOS for admitted patients compared to resident (6.63 hours versus 6.97 hours, P¼.004) or baseline (6.63 hours versus 7.03 hours, P<.0001). Conversely, attending TLP were associated with a higher median LOS for discharged patients compared to resident (4.28 hours versus 4.18 hours, P¼.01) or baseline (4.28 hours versus 4.17 hours, P¼.0002). Proportion of LWBS was 3.12% (95% CI 2.73 to 3.55) for resident TLP and 3.08% (95% CI 2.77 to 3.41) for attending, both significantly better than baseline (4.71%, 95% CI 4.43 to 5.01). Median DTP was 35 min (IQR 17-81) for resident TLP, significantly lower (P<.0001) than attending (39 min, IQR 19-87) or baseline (51 min, IQR 21-117). Proportion of very good patient satisfaction scores was 55% (95% CI 53 to 56) for resident TLP and 56% (95% CI 55 to 57) for attending, compared to baseline (53%, 95% CI 52 to 54). Annual profit generated for physicianbased collections through LWBS capture (after deducting respective salary costs) equated to a gain of $77,997 (ROI: 54%) for resident TLP and a loss of $104,752 (ROI: -31%) for attending TLP. Accounting for hospital-based collections made both profitable, generating $684,504 in profit (ROI: 317%) for resident TLP and $519,467 in profit (ROI: 86%) for attending TLP. Conclusions: At an academic ED, resident TLP improved door-to-physician times and LWBS more than attendings or historical control. Attending TLP improved patient satisfaction and the median LOS of admitted patients more than residents did. Both resident and attending TLP are cost effective, but residents have the more favorable cost-benefit profile.
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GEDI WISE: Geriatric Emergency Department Patients’ Priorities for Health-Related Quality of Life - A Qualitative Study
Dresden SM, McCarthy Danielle M, Engel Kirsten G, Aldeen A, Courtney DM/ Northwestern University Feinberg School of Medicine, Chicago, IL
Study Objectives: Health-related quality of life (HRQoL), encompassing social, emotional, and physical well-being of patients is widely recognized as an important clinical outcome of medical care, especially among geriatric patients. However, assessments of HRQoL are rare in the ED, and it is unclear which aspects of HRQoL are most important to geriatric patients in the ED. The objective was to identify which domains of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving their HRQoL during an ED visit. Methods: This was a cross-sectional qualitative focus group study of geriatric ED patients from an urban, academic ED with >88,000 total annual visits (16,000 geriatric). Patients were eligible if they were age 65 and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews were performed to finalize the question guide. Focus group participants were asked to describe their experience in the ED and reflect on how that experience affected their physical, emotional and social aspects of health. Three coders experienced in qualitative methods used content and constant comparative methods to analyze focus group transcripts for emergent themes. Results: Three individuals participated in pilot interviews and 30 participated in six focus groups. Median age was 70 years; 70% were women. Five main themes related to HRQoL emerged. (1) Patients expressed concerns about recovering to their baseline physical functioning and (2) placed emphasis on the anxiety and stress that uncertainty (in both diagnosis and regarding recovery) evokes. Specifically, they feared the loss of independence. (3) Patients noted that physical illness had a significant impact on their interpersonal relationships and (4) on their emotional and social quality of life. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. Conclusions: The geriatric patients in this study discussed how their illness or injury not only caused physical symptoms, but also impacted relationships and emotional health. Although patients questioned if the ED was the proper venue to address HRQoL, they desired reassurance in the ED about the impact illness would have on their current quality of life. Evaluation of ED-based interventions for geriatric patients should incorporate measures of HRQoL that align with patient priorities.
Annals of Emergency Medicine S77