- Email: [email protected]
271 Impact of Nursing Short-Staffing and Emergency Department Left Without Being Seen
Research Forum Abstracts
270
Understanding Patient Provider Conversations: What Are We Talking About?
McCarthy DM, Buckley BA, Engel KG, Forth VE, Adams JG, Cameron KA/Northwestern University, Chicago, IL
Study Objectives: Effective patient-provider communication is a critical aspect of the delivery of high quality patient care; however, research regarding the conversational dynamics of an overall emergency, department (ED) visit is lacking. Identifying both patterns and relative frequency of utterances within these interactions will help to guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze audio recordings of complete ED visits to characterize these conversations and determine the proportion of the conversation spent on different functional categories of communication. Methods: Patients at an urban academic ED with 4 diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visit audio-recorded from the time of room placement until discharge. Patients were excluded if they were age ⬍ 18 years, non-English speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each utterance (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for “functional groupings.” The percentage of total utterances in each functional grouping is reported. Results: Twenty-six audio recordings were analyzed. Patient participants had a mean age of 39 years, 30% were male. Inter-coder reliability was good with average inter-coder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median: 239 utterances, Inter-quartile range (IQR): 168, 308) compared to patients (median: 145 utterances, IQR: 80, 198). Providers’ utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (eg, orienting the patient to the next steps in the ED or asking if the patient understood) (30%). Approximately 15% of the provider talk was spent on data gathering, with the majority of data gathering (86%) focusing on biomedical topics rather than psychosocial topics (14%). 22% of providers’ talk focused on building a relationship (eg, social talk, jokes/laughter, showing approval or empathetic statements). Patients’ conversation was mainly focused in 2 areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients’ utterances were devoted to question asking. Conclusion: In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.
271
Impact of Nursing Short-Staffing and Emergency Department Left Without Being Seen
Brown L, Arthur AO, Lynch B, Gray W, Zumwalt N, Goodloe JM, Dixon J, Thomas SH/University of Oklahoma, Tulsa, OK; Hillcrest Medical Center, Tulsa, OK
Study Objectives: In many emergency departments (ED), one of the most important indices of performance is the number of “left without being seen” (LWBS) patients. Since each patient who leaves the ED before generating charges represents a 100% loss of potential revenue, operations groups are keen to minimize LWBS numbers. Some factors, such as ED crowding and volume, are known to contribute to high LWBS. Effects on LWBS of another potentially important factor, nursing (RN) shortage, have been less well characterized. This study’s goal was to assess the impact of day-to-day RN shortages on LWBS. Methods: In July 2011, a new administrative computer system was instituted in a teaching-hospital ED (annual census roughly 50,000). The system allows reliable tracking on a daily basis, of: total numbers of patients checked in (daily census), LWBS numbers, and actual (as compared to scheduled) RN staffing hours. This retrospective study assessed the hospital’s administrative database July 2011-March 2012, to determine (while controlling for weekday, month, and ED census) whether RN shortages were associated with elevated LWBS. RN shortages were defined a priori as being present on any day where the total numbers of RN hours worked, were
Volume , . : October
less than 90% of the scheduled hours (eg, due to “call-ins” or inadequate RN numbers to fill the schedule). The dichotomous dependent variable “high LWBS” was defined as being met on any day in which there were more than 3 LWBS patients (ie, above the median n as reported below). Analysis was conducted with STATA 12MP using multivariate logistic regression, with reporting of covariates’ Wald p values and odds ratios (ORs) with 95% confidence intervals (CIs). Results: During the 9-month study period, the median daily ED census was 132, and the median LWBS n (not percentage) of patients was 3. Univariate logistic regression identified ED daily census as significantly (p⬍.001) and positively (OR 1.06, 95% CI 1.04-1.09) associated with high LWBS. There was no correlation between LWBS and month (p ⫽ 0.389) or day of week (p ⫽ 0.57). Univariate regression found that high LWBS was more likely (p ⫽ .021) on days for which RN staffing was short; the final, most parsimonious model confirmed the association between RN short-staffing and high LWBS, even after adjusting for ED daily census. The dependent variable “high LWBS” had the following predictors: ED census on a continuous scale (OR 1.07, 95% CI 1.04-1.09, p ⬍ .001) and short-staffing of RNs (OR 2.4, 95% CI 1.3-4.5, p ⫽ .006). Conclusion: On days in which the ED RN schedule is less than 90% “filled,” LWBS is 2.4x more likely to be high. Financial planning for RN staffing and scheduling should consider the financial opportunity cost - as represented by LWBS patients - of short-staffing the ED.
272
Predictive Variables Associated With Observation Failures in a 24-hour Clinical Decision Unit
Loftus A, Rosen L, Mounessa J, Polak G, Aziz-Bose R, Persky A, Mongone J, Alagappan K, Ward MF, Rentala M/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: Clinical Decision Units (CDUs) are emergency department (ED) observation units that are emerging as alternatives to inpatient admissions. These units increase patient satisfaction and safety, and decrease unnecessary inpatient admissions, hospital length of stay (LOS), and cost. Few studies have investigated risk factors (RFs) for “observation failures”: inpatient admission following CDU observation. This study aims to identify potential predictive variables such as age, sex, diagnostic testing, and LOS, associated with immediate inpatient admission following CDU observation. Methods: This is a prospective, observational, consecutive sampling study of patients admitted to a 24-hr, 12-bed CDU from 08/23/11 to 04/01/12 at a suburban, academic ED with 80,000 annual visits. Data were obtained from a study registry. Observation failure was defined as admission to an inpatient floor, operating room, or cardiac catheterization lab following CDU observation. Subjects who left against medical advice or returned to the main ED were excluded from analyses. Logistic regression was used to model observation failure as a function of each potential RF of interest (age, sex, diagnostic testing, and LOS). Age was analyzed continuously as well as in two categories (ⱖ65 yrs and ⬍65 yrs); LOS was categorized into three groups (⬍ 8 hrs, 8 – 24 hrs, ⬎ 24 hrs). Those who received diagnostic testing (cardiac stress test, ultrasonography imaging, magnetic resonance imaging, and computed tomography) were categorized into one of two categories: those who did not leave the CDU for diagnostic testing, and those who left the CDU for diagnostic testing. Those who received radiography were excluded from analyses involving diagnostic testing, due to institutional variability in the use of bedside procedures. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for each RF. Results: Of the 2429 consecutive subjects observed, 2401 were either discharged home or admitted to an inpatient unit and were included in the analytic sample (63% female, 50.4 ⫾ 18.1 yrs). Of these, 12 % were admitted (n⫽282). Compared to subjects ⬍ 65 years, subjects ⱖ 65 years were 37% more likely to have an observation failures (OR: 1.37 CI: 1.04 - 1.82). For each 10-yr increase in age, subjects had 7% greater odds of observation failure (OR: 1.07 CI: 1.01 - 1.15). Females had 28% reduced odds of observation failure as compared to males (OR: 0.72; CI: 0.56 0.93). Those who left the CDU for diagnostic testing were 27% less likely to be admitted than those who did not require testing outside the CDU (OR: 0.73; CI: 0.57 - 0.94). Finally, subjects exhibiting an inefficient CDU LOS (⬍ 8 hrs or ⬎ 24 hrs) had over 70% greater odds of an observation failure than those subjects with a LOS between 8 and 24 hrs (⬍ 8 hr LOS OR: 1.76, CI: 1.20, 2.57, P ⬍ 0.0038; ⬎ 24 hrs LOS OR: 1.70, CI: 1.26, 2.31 P ⬍ 0.0006). Conclusion: Inefficient CDU LOS (⬍8 hrs or ⬎24hrs) resulted in the greatest increase in risk of observation failure. Other significant risk factors for observation failure included increased age and male sex. Elderly patients (ⱖ 65 years) had a higher
Annals of Emergency Medicine S97
270
Understanding Patient Provider Conversations: What Are We Talking About?
McCarthy DM, Buckley BA, Engel KG, Forth VE, Adams JG, Cameron KA/Northwestern University, Chicago, IL
Study Objectives: Effective patient-provider communication is a critical aspect of the delivery of high quality patient care; however, research regarding the conversational dynamics of an overall emergency, department (ED) visit is lacking. Identifying both patterns and relative frequency of utterances within these interactions will help to guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze audio recordings of complete ED visits to characterize these conversations and determine the proportion of the conversation spent on different functional categories of communication. Methods: Patients at an urban academic ED with 4 diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visit audio-recorded from the time of room placement until discharge. Patients were excluded if they were age ⬍ 18 years, non-English speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each utterance (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for “functional groupings.” The percentage of total utterances in each functional grouping is reported. Results: Twenty-six audio recordings were analyzed. Patient participants had a mean age of 39 years, 30% were male. Inter-coder reliability was good with average inter-coder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median: 239 utterances, Inter-quartile range (IQR): 168, 308) compared to patients (median: 145 utterances, IQR: 80, 198). Providers’ utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (eg, orienting the patient to the next steps in the ED or asking if the patient understood) (30%). Approximately 15% of the provider talk was spent on data gathering, with the majority of data gathering (86%) focusing on biomedical topics rather than psychosocial topics (14%). 22% of providers’ talk focused on building a relationship (eg, social talk, jokes/laughter, showing approval or empathetic statements). Patients’ conversation was mainly focused in 2 areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients’ utterances were devoted to question asking. Conclusion: In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.
271
Impact of Nursing Short-Staffing and Emergency Department Left Without Being Seen
Brown L, Arthur AO, Lynch B, Gray W, Zumwalt N, Goodloe JM, Dixon J, Thomas SH/University of Oklahoma, Tulsa, OK; Hillcrest Medical Center, Tulsa, OK
Study Objectives: In many emergency departments (ED), one of the most important indices of performance is the number of “left without being seen” (LWBS) patients. Since each patient who leaves the ED before generating charges represents a 100% loss of potential revenue, operations groups are keen to minimize LWBS numbers. Some factors, such as ED crowding and volume, are known to contribute to high LWBS. Effects on LWBS of another potentially important factor, nursing (RN) shortage, have been less well characterized. This study’s goal was to assess the impact of day-to-day RN shortages on LWBS. Methods: In July 2011, a new administrative computer system was instituted in a teaching-hospital ED (annual census roughly 50,000). The system allows reliable tracking on a daily basis, of: total numbers of patients checked in (daily census), LWBS numbers, and actual (as compared to scheduled) RN staffing hours. This retrospective study assessed the hospital’s administrative database July 2011-March 2012, to determine (while controlling for weekday, month, and ED census) whether RN shortages were associated with elevated LWBS. RN shortages were defined a priori as being present on any day where the total numbers of RN hours worked, were
Volume , . : October
less than 90% of the scheduled hours (eg, due to “call-ins” or inadequate RN numbers to fill the schedule). The dichotomous dependent variable “high LWBS” was defined as being met on any day in which there were more than 3 LWBS patients (ie, above the median n as reported below). Analysis was conducted with STATA 12MP using multivariate logistic regression, with reporting of covariates’ Wald p values and odds ratios (ORs) with 95% confidence intervals (CIs). Results: During the 9-month study period, the median daily ED census was 132, and the median LWBS n (not percentage) of patients was 3. Univariate logistic regression identified ED daily census as significantly (p⬍.001) and positively (OR 1.06, 95% CI 1.04-1.09) associated with high LWBS. There was no correlation between LWBS and month (p ⫽ 0.389) or day of week (p ⫽ 0.57). Univariate regression found that high LWBS was more likely (p ⫽ .021) on days for which RN staffing was short; the final, most parsimonious model confirmed the association between RN short-staffing and high LWBS, even after adjusting for ED daily census. The dependent variable “high LWBS” had the following predictors: ED census on a continuous scale (OR 1.07, 95% CI 1.04-1.09, p ⬍ .001) and short-staffing of RNs (OR 2.4, 95% CI 1.3-4.5, p ⫽ .006). Conclusion: On days in which the ED RN schedule is less than 90% “filled,” LWBS is 2.4x more likely to be high. Financial planning for RN staffing and scheduling should consider the financial opportunity cost - as represented by LWBS patients - of short-staffing the ED.
272
Predictive Variables Associated With Observation Failures in a 24-hour Clinical Decision Unit
Loftus A, Rosen L, Mounessa J, Polak G, Aziz-Bose R, Persky A, Mongone J, Alagappan K, Ward MF, Rentala M/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: Clinical Decision Units (CDUs) are emergency department (ED) observation units that are emerging as alternatives to inpatient admissions. These units increase patient satisfaction and safety, and decrease unnecessary inpatient admissions, hospital length of stay (LOS), and cost. Few studies have investigated risk factors (RFs) for “observation failures”: inpatient admission following CDU observation. This study aims to identify potential predictive variables such as age, sex, diagnostic testing, and LOS, associated with immediate inpatient admission following CDU observation. Methods: This is a prospective, observational, consecutive sampling study of patients admitted to a 24-hr, 12-bed CDU from 08/23/11 to 04/01/12 at a suburban, academic ED with 80,000 annual visits. Data were obtained from a study registry. Observation failure was defined as admission to an inpatient floor, operating room, or cardiac catheterization lab following CDU observation. Subjects who left against medical advice or returned to the main ED were excluded from analyses. Logistic regression was used to model observation failure as a function of each potential RF of interest (age, sex, diagnostic testing, and LOS). Age was analyzed continuously as well as in two categories (ⱖ65 yrs and ⬍65 yrs); LOS was categorized into three groups (⬍ 8 hrs, 8 – 24 hrs, ⬎ 24 hrs). Those who received diagnostic testing (cardiac stress test, ultrasonography imaging, magnetic resonance imaging, and computed tomography) were categorized into one of two categories: those who did not leave the CDU for diagnostic testing, and those who left the CDU for diagnostic testing. Those who received radiography were excluded from analyses involving diagnostic testing, due to institutional variability in the use of bedside procedures. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for each RF. Results: Of the 2429 consecutive subjects observed, 2401 were either discharged home or admitted to an inpatient unit and were included in the analytic sample (63% female, 50.4 ⫾ 18.1 yrs). Of these, 12 % were admitted (n⫽282). Compared to subjects ⬍ 65 years, subjects ⱖ 65 years were 37% more likely to have an observation failures (OR: 1.37 CI: 1.04 - 1.82). For each 10-yr increase in age, subjects had 7% greater odds of observation failure (OR: 1.07 CI: 1.01 - 1.15). Females had 28% reduced odds of observation failure as compared to males (OR: 0.72; CI: 0.56 0.93). Those who left the CDU for diagnostic testing were 27% less likely to be admitted than those who did not require testing outside the CDU (OR: 0.73; CI: 0.57 - 0.94). Finally, subjects exhibiting an inefficient CDU LOS (⬍ 8 hrs or ⬎ 24 hrs) had over 70% greater odds of an observation failure than those subjects with a LOS between 8 and 24 hrs (⬍ 8 hr LOS OR: 1.76, CI: 1.20, 2.57, P ⬍ 0.0038; ⬎ 24 hrs LOS OR: 1.70, CI: 1.26, 2.31 P ⬍ 0.0006). Conclusion: Inefficient CDU LOS (⬍8 hrs or ⬎24hrs) resulted in the greatest increase in risk of observation failure. Other significant risk factors for observation failure included increased age and male sex. Elderly patients (ⱖ 65 years) had a higher
Annals of Emergency Medicine S97