- Email: [email protected]
47: Observing the Effects of Medical Students on Patient Length of Stay and Time to Disposition In the Emergency Department
Research Forum Abstracts perceived as shy or reserved. In the end, there does not seem to be an overall negative or positive bias but differences dependent on specific characteristics, which may be valued differently by various residency programs.
47
Observing the Effects of Medical Students on Patient Length of Stay and Time to Disposition In the Emergency Department
Roy N, Farley H L, Resurreccion D, Reed III J/Christiana Care Health System, Newark, DE
Study Objective: The objective of this study was to observe the impact of fourthyear medical students (MS) on patient overall emergency department (ED) length of stay (LOS) and time to disposition (dispo). Methods: This was a retrospective cohort study conducted at an academic ED with an annual volume ⬎100,000 between 9/1/08 and 10/31/08. All emergency severity index (ESI) 2, 3, and 4 patients evaluated by a 4th year MS between 7am and 11pm during the study period were included. Trauma alerts/codes, stroke alerts/codes, and inter-facility transfers were excluded. The mean ED LOS and mean time to dispo of patients seen by an attending ⫹ MS (A/MS) were compared to the same measures for patients of similar ESI levels seen by an attending only (A only) during the same time period. The mean ED LOS and time to dispo of patients seen by an attending ⫹ resident ⫹ MS (A/R/MS) was also compared to the same measures for patients seen by an attending ⫹ resident (A/R) only. Admitted and discharged patients were also analyzed separately. Data was compared using analysis of variance, with a p-value 0.05 considered significant. Results: 230 medical student patients and 3,273 control patient visits were included. There was no difference in LOS between A/MS versus A only (6.62 hrs ⫾ 3.22 versus 6.71 hrs ⫾ 3.50, p ⫽ 0.84); A/R/MS versus A/R (7.44 hrs ⫾ 3.24 versus 7.01 hrs ⫾ 3.58, p ⫽ 0.14), or all patients seen by medical students (A/MS ⫹ A/R/ MS) versus all patients seen without medical students (A/R ⫹ A) (7.19 hrs ⫾ 3.25 versus 6.91 hrs ⫾ 3.56, p ⫽ 0.26). When ED LOS of admitted patients was analyzed separately, there was no difference observed between A/MS versus A only (8.52 hrs ⫾ 3.65 versus 7.47 hrs ⫾ 3.69, p⫽ 0.13), or between A/R/MS versus A/R (7.87 hrs ⫾ 3.49 versus 7.88 hrs ⫾ 4.01, p ⫽ 0.99). There was also no significant difference observed in patient time to dispo between groups for admitted patients (A/MS versus A only: 5.54 hrs ⫾ 2.39 versus 4.84 hrs ⫾ 2.59, p ⫽ 0.16; A/R/MS versus A/R: 5.62 hrs ⫾ 2.51 versus 5.25 hrs ⫾ 2.54, p ⫽ 0.19). For discharged patients, there was no difference between A/MS versus A only for ED LOS (5.31 hrs ⫾ 2.06 versus 5.89 hrs ⫾ 3.09, p ⫽ 0.24). However, there was a significant difference in LOS observed between A/R/MS versus A/R (6.89 hrs ⫾ 2.86 versus 6.05 hrs ⫾ 2.74, p ⫽ 0.01). Conclusion: Discharged patients who were evaluated by an attending, resident, and medical student had a significantly longer ED LOS compared to those evaluated by an attending and resident only. There was no difference between groups in ED LOS or time to dispo for admitted patients, or in ED LOS of all patients, suggesting that precepting medical students does not significantly prolong patients’ ED LOS or time to dispo.
48
The Impact of an Intake Model on Patient Care, Resident Education, and Staff Satisfaction at an Academic Emergency Department
Weichenthal L, Armenian P, Campgane D, Snowden B, Kallsen G/UCSF-Fresno, Fresno, CA; University of California San Francisco, San Francisco, CA
Study Objectives: To evaluate an intake model at an academic emergency department (ED) in regards to a decrease in time to provider (TTP), length of stay (LOS), left without being seen rates (LWBS), patient and staff satisfaction, and perceived impact on resident education. Methods: Study design: a prospective observational study. Setting: Urban level one trauma center associated with a residency training program Participants: Patients seeking emergency care, ED nursing staff, and the emergency medicine residents and faculty. An intake model was instituted at Community Regional Medical Center (CRMC) in Fresno, CA in March, 2009. Intake is an area were non-emergent patients receive an initial screening exam and are either treated and released or have initial orders started while they wait for an available bed in the ED. A pre-implementation convenience survey was conducted of staff, residents and attending physicians in February, 2009 and a postimplementation survey was conducted one year later. Patient satisfaction surveys were
Volume , . : September
collected prior to the implementation of the intake model and continued throughout the study period. The LWBS rate and LOS were extracted from electronic hospital data from December 2008 to May 2009. Pre and post data were compared and averages, student “t” test and confidence intervals were calculated using Excel and GraphPad Software 2007 for LWBS, TTP, LOS, patient and staff satisfaction, and perceived impact on resident education. Results: Pre and post LWBS rates for the intake model were 5.66% and 8.46 % respectively, p⫽0.03. TTP was 110 and 140 minutes, p⫽0.09. Comparison of LOS was 287 versus 273 minutes, p⫽0.37. Patient satisfaction averaged 4.3 and 4.6 respectively, p⫽0.06. Staff satisfaction was 2.9 and 3.25, p⫽0.26 and medical staff satisfaction was 3.8 and 3.9, p⫽0.62. The systems change of creating an intake model was not viewed as significantly impacting resident education (p⫽0.58). Conclusion: An intake model at an academic ED did not positively impact LWBS rates, TTP or LOS; however, patient and staff satisfaction showed trends toward improvement without negatively impacting resident education. An intake model may be effective in an academic setting with further study and model modification.
49
Emergency Department Contrast Practices for Abdominal/Pelvic CT: A National Survey
Broder J S, Hamedani A G, Liu S W, Emerman C L/Duke University Medical Center, Durham, NC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Massachusetts General Hospital, Harvard Medical School, Boston, MA; MetroHealth Medical Center, Cleveland, OH
Study Objectives: Controversy exists in the medical literature regarding the need for oral, intravenous (IV), and/or rectal contrast for abdominal/pelvic computed tomography (CT) in a variety of clinical scenarios. We surveyed academic emergency departments (EDs) in order to document current national practice. We hypothesized wide clinical practice variability in use of contrast for abdominal/pelvic CTs, including variance from national guidelines and published medical evidence. Methods: An electronic survey was sent to the physician leadership of every academic ED in the US, as defined by primary site of an emergency medicine residency program. Respondents were asked to indicate their institution’s use of oral, IV, and rectal contrast in emergency indications for abdominal/pelvic CT. For each indication, survey responses were compared with the approach given the highest appropriateness rating by the American College of Radiology (ACR). Results: 106 of 152 (70%) surveys were completed. IV contrast was the most frequently cited contrast used across all clinical indications (excluding renal colic). ⬎⫽90% reported using IV contrast in 12 of 18 clinical indications. IV contrast use was reported for suspected renal colic by 13% of respondents. Oral contrast use was more variable. In over one-third of indications, only 43-73% of respondents reported oral contrast use, indicating substantial variation. 20-25% of respondents do not use oral contrast for suspected appendicitis, diverticulitis, non-localized abdominal pain, abdominal abscess, and post-operative abdominal pain. 22% of respondents use oral contrast for blunt abdominal trauma, and 9% use oral contrast for suspected abdominal aortic aneurysm. Rectal contrast was rarely used; only 8% of respondents reported using rectal contrast for suspected diverticulitis or fistula. Outside of renal colic, the most common indications for which no contrast agent was used were suspected viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%). Conclusion: Contrast practices for abdominal/pelvic CT vary widely nationally, according to a survey of academic ED physician leadership. For multiple indications, the contrast practices of the substantial number of respondents appeared to deviate from recommendations in published literature or national guidelines. The ACR currently does not recommend IV contrast for suspected renal colic or oral contrast for blunt abdominal trauma and aortic aneurysm, yet a substantial minority of survey respondents indicated use of these contrast agents in these scenarios. The ACR currently recommends oral contrast for suspected diverticulitis, abdominal abscess, and post-operative abdominal pain, but approximately one-fifth of respondents do not use oral contrast for these indications. Debate continues about the role of oral and IV contrast for appendicitis, with the ACR suggesting that institutional preference determine contrast use at this time. Most survey respondents use IV contrast for this indication, while a large minority do not use oral contrast. Given that oral contrast adds significantly to patients’ length of stay in the ED and that IV contrast can result in renal insufficiency or allergic reaction, standardization of contrast use in accordance with medical evidence could improve patient care and operational efficiency.
Annals of Emergency Medicine S17
47
Observing the Effects of Medical Students on Patient Length of Stay and Time to Disposition In the Emergency Department
Roy N, Farley H L, Resurreccion D, Reed III J/Christiana Care Health System, Newark, DE
Study Objective: The objective of this study was to observe the impact of fourthyear medical students (MS) on patient overall emergency department (ED) length of stay (LOS) and time to disposition (dispo). Methods: This was a retrospective cohort study conducted at an academic ED with an annual volume ⬎100,000 between 9/1/08 and 10/31/08. All emergency severity index (ESI) 2, 3, and 4 patients evaluated by a 4th year MS between 7am and 11pm during the study period were included. Trauma alerts/codes, stroke alerts/codes, and inter-facility transfers were excluded. The mean ED LOS and mean time to dispo of patients seen by an attending ⫹ MS (A/MS) were compared to the same measures for patients of similar ESI levels seen by an attending only (A only) during the same time period. The mean ED LOS and time to dispo of patients seen by an attending ⫹ resident ⫹ MS (A/R/MS) was also compared to the same measures for patients seen by an attending ⫹ resident (A/R) only. Admitted and discharged patients were also analyzed separately. Data was compared using analysis of variance, with a p-value 0.05 considered significant. Results: 230 medical student patients and 3,273 control patient visits were included. There was no difference in LOS between A/MS versus A only (6.62 hrs ⫾ 3.22 versus 6.71 hrs ⫾ 3.50, p ⫽ 0.84); A/R/MS versus A/R (7.44 hrs ⫾ 3.24 versus 7.01 hrs ⫾ 3.58, p ⫽ 0.14), or all patients seen by medical students (A/MS ⫹ A/R/ MS) versus all patients seen without medical students (A/R ⫹ A) (7.19 hrs ⫾ 3.25 versus 6.91 hrs ⫾ 3.56, p ⫽ 0.26). When ED LOS of admitted patients was analyzed separately, there was no difference observed between A/MS versus A only (8.52 hrs ⫾ 3.65 versus 7.47 hrs ⫾ 3.69, p⫽ 0.13), or between A/R/MS versus A/R (7.87 hrs ⫾ 3.49 versus 7.88 hrs ⫾ 4.01, p ⫽ 0.99). There was also no significant difference observed in patient time to dispo between groups for admitted patients (A/MS versus A only: 5.54 hrs ⫾ 2.39 versus 4.84 hrs ⫾ 2.59, p ⫽ 0.16; A/R/MS versus A/R: 5.62 hrs ⫾ 2.51 versus 5.25 hrs ⫾ 2.54, p ⫽ 0.19). For discharged patients, there was no difference between A/MS versus A only for ED LOS (5.31 hrs ⫾ 2.06 versus 5.89 hrs ⫾ 3.09, p ⫽ 0.24). However, there was a significant difference in LOS observed between A/R/MS versus A/R (6.89 hrs ⫾ 2.86 versus 6.05 hrs ⫾ 2.74, p ⫽ 0.01). Conclusion: Discharged patients who were evaluated by an attending, resident, and medical student had a significantly longer ED LOS compared to those evaluated by an attending and resident only. There was no difference between groups in ED LOS or time to dispo for admitted patients, or in ED LOS of all patients, suggesting that precepting medical students does not significantly prolong patients’ ED LOS or time to dispo.
48
The Impact of an Intake Model on Patient Care, Resident Education, and Staff Satisfaction at an Academic Emergency Department
Weichenthal L, Armenian P, Campgane D, Snowden B, Kallsen G/UCSF-Fresno, Fresno, CA; University of California San Francisco, San Francisco, CA
Study Objectives: To evaluate an intake model at an academic emergency department (ED) in regards to a decrease in time to provider (TTP), length of stay (LOS), left without being seen rates (LWBS), patient and staff satisfaction, and perceived impact on resident education. Methods: Study design: a prospective observational study. Setting: Urban level one trauma center associated with a residency training program Participants: Patients seeking emergency care, ED nursing staff, and the emergency medicine residents and faculty. An intake model was instituted at Community Regional Medical Center (CRMC) in Fresno, CA in March, 2009. Intake is an area were non-emergent patients receive an initial screening exam and are either treated and released or have initial orders started while they wait for an available bed in the ED. A pre-implementation convenience survey was conducted of staff, residents and attending physicians in February, 2009 and a postimplementation survey was conducted one year later. Patient satisfaction surveys were
Volume , . : September
collected prior to the implementation of the intake model and continued throughout the study period. The LWBS rate and LOS were extracted from electronic hospital data from December 2008 to May 2009. Pre and post data were compared and averages, student “t” test and confidence intervals were calculated using Excel and GraphPad Software 2007 for LWBS, TTP, LOS, patient and staff satisfaction, and perceived impact on resident education. Results: Pre and post LWBS rates for the intake model were 5.66% and 8.46 % respectively, p⫽0.03. TTP was 110 and 140 minutes, p⫽0.09. Comparison of LOS was 287 versus 273 minutes, p⫽0.37. Patient satisfaction averaged 4.3 and 4.6 respectively, p⫽0.06. Staff satisfaction was 2.9 and 3.25, p⫽0.26 and medical staff satisfaction was 3.8 and 3.9, p⫽0.62. The systems change of creating an intake model was not viewed as significantly impacting resident education (p⫽0.58). Conclusion: An intake model at an academic ED did not positively impact LWBS rates, TTP or LOS; however, patient and staff satisfaction showed trends toward improvement without negatively impacting resident education. An intake model may be effective in an academic setting with further study and model modification.
49
Emergency Department Contrast Practices for Abdominal/Pelvic CT: A National Survey
Broder J S, Hamedani A G, Liu S W, Emerman C L/Duke University Medical Center, Durham, NC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Massachusetts General Hospital, Harvard Medical School, Boston, MA; MetroHealth Medical Center, Cleveland, OH
Study Objectives: Controversy exists in the medical literature regarding the need for oral, intravenous (IV), and/or rectal contrast for abdominal/pelvic computed tomography (CT) in a variety of clinical scenarios. We surveyed academic emergency departments (EDs) in order to document current national practice. We hypothesized wide clinical practice variability in use of contrast for abdominal/pelvic CTs, including variance from national guidelines and published medical evidence. Methods: An electronic survey was sent to the physician leadership of every academic ED in the US, as defined by primary site of an emergency medicine residency program. Respondents were asked to indicate their institution’s use of oral, IV, and rectal contrast in emergency indications for abdominal/pelvic CT. For each indication, survey responses were compared with the approach given the highest appropriateness rating by the American College of Radiology (ACR). Results: 106 of 152 (70%) surveys were completed. IV contrast was the most frequently cited contrast used across all clinical indications (excluding renal colic). ⬎⫽90% reported using IV contrast in 12 of 18 clinical indications. IV contrast use was reported for suspected renal colic by 13% of respondents. Oral contrast use was more variable. In over one-third of indications, only 43-73% of respondents reported oral contrast use, indicating substantial variation. 20-25% of respondents do not use oral contrast for suspected appendicitis, diverticulitis, non-localized abdominal pain, abdominal abscess, and post-operative abdominal pain. 22% of respondents use oral contrast for blunt abdominal trauma, and 9% use oral contrast for suspected abdominal aortic aneurysm. Rectal contrast was rarely used; only 8% of respondents reported using rectal contrast for suspected diverticulitis or fistula. Outside of renal colic, the most common indications for which no contrast agent was used were suspected viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%). Conclusion: Contrast practices for abdominal/pelvic CT vary widely nationally, according to a survey of academic ED physician leadership. For multiple indications, the contrast practices of the substantial number of respondents appeared to deviate from recommendations in published literature or national guidelines. The ACR currently does not recommend IV contrast for suspected renal colic or oral contrast for blunt abdominal trauma and aortic aneurysm, yet a substantial minority of survey respondents indicated use of these contrast agents in these scenarios. The ACR currently recommends oral contrast for suspected diverticulitis, abdominal abscess, and post-operative abdominal pain, but approximately one-fifth of respondents do not use oral contrast for these indications. Debate continues about the role of oral and IV contrast for appendicitis, with the ACR suggesting that institutional preference determine contrast use at this time. Most survey respondents use IV contrast for this indication, while a large minority do not use oral contrast. Given that oral contrast adds significantly to patients’ length of stay in the ED and that IV contrast can result in renal insufficiency or allergic reaction, standardization of contrast use in accordance with medical evidence could improve patient care and operational efficiency.
Annals of Emergency Medicine S17