- Email: [email protected]
76
Research Forum Abstracts The majority of deaths were among males (96%), White/Caucasians (46%) and individuals 31-40 years of age (38%). Nearly all subjects (91%) received medical care immediately following the CED firing. Among the 77 subjects, 20 (26%) were armed at some point during the incident including 4 (20%) with a firearm, 8 (40%) with a knife/cutting weapon and 5 (25%) with a club/baton/blunt force weapon. Undesirable behaviors were also common among subjects with 58 (75%) exhibiting non-compliance, 53 (69%) with severe aggression and 39 (51%) with mild aggression. Autopsies were conducted and available on for 69 (90%) individuals. Based on the medical examiner’s report, alcohol was detected in 23 (33%) and illicit drugs in 59 (86%) of the subjects. Contributing factors such as illicit drug use, excited delirium and health problems were reported in 61 (88%) of subjects. Conclusion: Most persons who died after a CED activation were male, had illicit drugs in their system, received immediate medical care and exhibited non-compliance and severe aggression.
76
Does the Presence of a Patient Advocate Improve Patient Satisfaction in the Emergency Department?
Ward MF, D’Amore J, Dahlem KL, Lewis VV, Litroff AH, Ramos AA, Riccardi DM, Kohn N/North Shore University Hospital, Manhasset, NY; NSLIJ Health System, Manhasset, NY
Study Objectives: To determine the impact of a Patient Advocate program on patient satisfaction as assessed by both an internally developed patient satisfaction survey and an externally validated patient satisfaction survey. Methods: This study was a prospective, single-blinded, randomized comparative trial conducted at a university teaching hospital Emergency Department (ED) with an annual census of 65,000. Non-clinical volunteers participated as Advocates and Observers (surveyors) after intensive orientation and training sessions. The study was conducted for six consecutive weeks from July-August 2005, 24 hours a day, 7 days a week with Advocates present on alternating days. Advocate duties included facilitating communication, ensuring comfort and distributing informational packets. Data was collected using an internally developed survey administered in interview form. In addition, data was collected from an external survey vendor, Press Ganey. Press Ganey surveys were mailed to patients after their discharge from the ED. Both surveys were scored on a 1-5 Likert scale (5⫽high) and included questions pertaining to patient satisfaction. Analysis compared days in which the Advocate was present to days with no Advocate for both surveys. p ⬍ .01 was considered significant. Results: 2184 Advocate interventions were recorded; most frequent were comfort care (63.7%) and facilitating communication between patient and staff (20%). Results are presented as percentage of subjects scoring 4 or 5 for Advocate vs NonAdvocate days. Internally developed survey: Desired items easily obtainable: 85.6% vs 75.4% p ⬍ .0001. Staff effort to ensure comfort: 87.2% vs 82.8% p⫽.0079. Satisfaction with medical care received 91.9% vs 88.8% p⫽.028. Staff friendly/helpful 92.4% vs 89.5% p⫽.03. Press Ganey: Overall survey score 87.9% vs 84.1% p⫽.057. Overall ED care 90.1% vs 81.2% p⫽.066. Conclusion: The presence of an Advocate yielded significant increases in patient satisfaction in areas of patient comfort, perception of staff attentiveness and medical care received as measured by the internally developed survey. While not statistically significant, similar increases were noted on an externally validated patient satisfaction survey.
77
Validation of the Emergency Severity Index (ESI) in SelfReferred Patients in a European Emergency Department
Mencl F, Elshove-Bolk J, van Rijswijck BT, Simons M, van Vugt AB/OLVG Hospital, Amsterdam, The Netherlands; Universiteit van Maastricht, Maastricht, The Netherlands; Academisch Ziekenhuis, Nijmegen, The Netherlands
Study Objectives: Previous work has only validated the five level Emergency Severity Index (ESI) triage algorithm in US hospitals, mostly in the original research institutions and none has described the actual resources used. We examine the validity of the ESI system in predicting resource consumption used by self-referred patients in a European Emergency Department (ED). The type of resources, admission rates and discharge referrals are also described. Methods: A prospective, observational cohort study using a convenience sample of self-referred ED patients older than 14 years presenting to a busy urban teaching hospital during a 39 day period (27th May - 4th July 2001) was done. Participating doctors received written instructions on how to perform the ESI triage algorithm, but did not know exactly what was going to be measured. After a pilot phase of 5 days, data collection started. Observed resource use, including blood work, urinalysis, X-
S24 Annals of Emergency Medicine
rays and consultations, was compared to resource utilization predicted by the ESI. Outpatient referrals following discharge were also recorded as were hospitalizations, and compared to the original ESI triage category. Statistical analysis was performed using SPSS for Windows version 13.0. Results: ESI levels were obtained in 1832/3703 (50%) self-referred patients, most of whom were ESI-4 (685, 37%) and ESI-5 (983, 54%). Use of resources was strongly associated with the triage level ranging from a low of 15% in ESI-5 (the least severe) to 97% in ESI-2 and 100% in the two ESI-1 (the most critically ill) patients. The type of resource used also reflected the predicted severity. Only 2% of the ESI-5 patients had blood work done, compared to 76% of the sicker ESI-2, half of whom also had ECGs recorded, compared to only 1% of ESI-5 patients. X-rays where the most commonly used resource in the patient triaged to ESI-4 and ESI-5. Specialty consultations and admissions also rose with increasing ESI severity, with only 5% of ESI-5 patients requiring a specialty consult (surgery or orthopedics) and less than 1% admitted. In contrast 85% of ESI-2 patients received a consult and 56 % were admitted, 26% to a critical care bed. Patients were also more likely to be referred to a specialist for follow up after discharge if they were triaged as ESI-2 while those in ESI-5 were far more likely to be referred to a general practitioner, if at all. Conclusion: The ESI triage category reliably predicts the severity of a patient’s condition, as reflected by resource utilization, consultations, admissions and outpatient referrals in a population of self-referred patients in a European ED. It clearly identifies patients that require minimal resources, or at most an X-ray, and who can be triaged to a Fast Track/Minor Emergency area. Furthermore it also shows that there are patients among the self-referred who will require more resources and admission and who should not be made to wait long. The model can serve as both a triage and a management tool in a European ED.
78
Analysis of Patients Who Leave Without Being Seen From an Academic Community Emergency Department
Crystal CS, Luszczak MH, Herold T, Young SE, Miller MA/Darnall Army Community Hospital, Fort Hood, TX
Study Objectives: As EDs become busier without expanding capacity, the numbers of patients who leave without being seen (LWBS) by the emergency physician will increase. This could have adverse health consequences, or merely indicate that low acuity patients are not willing to wait for non-emergent care. We sought to evaluate the outcome of patients who LWBS from our ED. Methods: Data was collected for a 12-month period beginning in November 2004. We extracted a convenience sample of patients to be called back 48 hours after their initial LWBS visit. We selected days when the total LWBS percentage exceeded the daily average by at least 5%, on average 3 days per month. An administrative assistant called these patients and recorded one of the following outcomes: went to an outpatient clinic, returned to our ED, returned to another ED, desired an outpatient appointment, no appointment was planned or desired, was admitted to a hospital. An electronic hospital database was also queried to verify whether any patients had returned to our ED or been admitted to the hospital 48 hours after their initial visits. Results: 62,239 patients were seen in our 16-bed ED during this time period, of which 6037 LWBS. 1165 patients were identified in this convenience sample. Of these, 668 (57.3%) could be contacted by telephone and 497 (42.7%) were unable to be contacted. Of the patients who were contacted, outcome data was available in 100%. 378 (56.1%) patients either went to an outpatient clinic or planned to go within 24 hours. 197 (29.5%) patients chose not to seek outpatient care and did not desire a future appointment for their current complaint. 40 (6%) patients requested our administrator’s help with scheduling an outpatient appointment. 34 (5.1%) patients returned to our ED. 21 (3.2%) patients presented to another ED. Only 2 (0.3%) patients had been admitted to the hospital within the past 48 hours. Conclusion: Patients who LWBS from our ED had very low ED return and admission rates.
79
Emergency Care Outside of the ED: Creative Utilization of Open Bed Space
Powell ES, Lucenti MJ, Pang PS, Mycyk MB/Northwestern University Feinberg School of Medicine, Chicago, IL
Background: During periods of overcrowding, lack of outflow and limited physical capacity in the ED constrains the ability to see new patients. Study Objective: To determine if emergency care of the moderate acuity patient can be conducted outside of the physical space of the main ED. Methods: A feasibility study was completed at an academic, tertiary, urban level I
Volume , . : October
76
Does the Presence of a Patient Advocate Improve Patient Satisfaction in the Emergency Department?
Ward MF, D’Amore J, Dahlem KL, Lewis VV, Litroff AH, Ramos AA, Riccardi DM, Kohn N/North Shore University Hospital, Manhasset, NY; NSLIJ Health System, Manhasset, NY
Study Objectives: To determine the impact of a Patient Advocate program on patient satisfaction as assessed by both an internally developed patient satisfaction survey and an externally validated patient satisfaction survey. Methods: This study was a prospective, single-blinded, randomized comparative trial conducted at a university teaching hospital Emergency Department (ED) with an annual census of 65,000. Non-clinical volunteers participated as Advocates and Observers (surveyors) after intensive orientation and training sessions. The study was conducted for six consecutive weeks from July-August 2005, 24 hours a day, 7 days a week with Advocates present on alternating days. Advocate duties included facilitating communication, ensuring comfort and distributing informational packets. Data was collected using an internally developed survey administered in interview form. In addition, data was collected from an external survey vendor, Press Ganey. Press Ganey surveys were mailed to patients after their discharge from the ED. Both surveys were scored on a 1-5 Likert scale (5⫽high) and included questions pertaining to patient satisfaction. Analysis compared days in which the Advocate was present to days with no Advocate for both surveys. p ⬍ .01 was considered significant. Results: 2184 Advocate interventions were recorded; most frequent were comfort care (63.7%) and facilitating communication between patient and staff (20%). Results are presented as percentage of subjects scoring 4 or 5 for Advocate vs NonAdvocate days. Internally developed survey: Desired items easily obtainable: 85.6% vs 75.4% p ⬍ .0001. Staff effort to ensure comfort: 87.2% vs 82.8% p⫽.0079. Satisfaction with medical care received 91.9% vs 88.8% p⫽.028. Staff friendly/helpful 92.4% vs 89.5% p⫽.03. Press Ganey: Overall survey score 87.9% vs 84.1% p⫽.057. Overall ED care 90.1% vs 81.2% p⫽.066. Conclusion: The presence of an Advocate yielded significant increases in patient satisfaction in areas of patient comfort, perception of staff attentiveness and medical care received as measured by the internally developed survey. While not statistically significant, similar increases were noted on an externally validated patient satisfaction survey.
77
Validation of the Emergency Severity Index (ESI) in SelfReferred Patients in a European Emergency Department
Mencl F, Elshove-Bolk J, van Rijswijck BT, Simons M, van Vugt AB/OLVG Hospital, Amsterdam, The Netherlands; Universiteit van Maastricht, Maastricht, The Netherlands; Academisch Ziekenhuis, Nijmegen, The Netherlands
Study Objectives: Previous work has only validated the five level Emergency Severity Index (ESI) triage algorithm in US hospitals, mostly in the original research institutions and none has described the actual resources used. We examine the validity of the ESI system in predicting resource consumption used by self-referred patients in a European Emergency Department (ED). The type of resources, admission rates and discharge referrals are also described. Methods: A prospective, observational cohort study using a convenience sample of self-referred ED patients older than 14 years presenting to a busy urban teaching hospital during a 39 day period (27th May - 4th July 2001) was done. Participating doctors received written instructions on how to perform the ESI triage algorithm, but did not know exactly what was going to be measured. After a pilot phase of 5 days, data collection started. Observed resource use, including blood work, urinalysis, X-
S24 Annals of Emergency Medicine
rays and consultations, was compared to resource utilization predicted by the ESI. Outpatient referrals following discharge were also recorded as were hospitalizations, and compared to the original ESI triage category. Statistical analysis was performed using SPSS for Windows version 13.0. Results: ESI levels were obtained in 1832/3703 (50%) self-referred patients, most of whom were ESI-4 (685, 37%) and ESI-5 (983, 54%). Use of resources was strongly associated with the triage level ranging from a low of 15% in ESI-5 (the least severe) to 97% in ESI-2 and 100% in the two ESI-1 (the most critically ill) patients. The type of resource used also reflected the predicted severity. Only 2% of the ESI-5 patients had blood work done, compared to 76% of the sicker ESI-2, half of whom also had ECGs recorded, compared to only 1% of ESI-5 patients. X-rays where the most commonly used resource in the patient triaged to ESI-4 and ESI-5. Specialty consultations and admissions also rose with increasing ESI severity, with only 5% of ESI-5 patients requiring a specialty consult (surgery or orthopedics) and less than 1% admitted. In contrast 85% of ESI-2 patients received a consult and 56 % were admitted, 26% to a critical care bed. Patients were also more likely to be referred to a specialist for follow up after discharge if they were triaged as ESI-2 while those in ESI-5 were far more likely to be referred to a general practitioner, if at all. Conclusion: The ESI triage category reliably predicts the severity of a patient’s condition, as reflected by resource utilization, consultations, admissions and outpatient referrals in a population of self-referred patients in a European ED. It clearly identifies patients that require minimal resources, or at most an X-ray, and who can be triaged to a Fast Track/Minor Emergency area. Furthermore it also shows that there are patients among the self-referred who will require more resources and admission and who should not be made to wait long. The model can serve as both a triage and a management tool in a European ED.
78
Analysis of Patients Who Leave Without Being Seen From an Academic Community Emergency Department
Crystal CS, Luszczak MH, Herold T, Young SE, Miller MA/Darnall Army Community Hospital, Fort Hood, TX
Study Objectives: As EDs become busier without expanding capacity, the numbers of patients who leave without being seen (LWBS) by the emergency physician will increase. This could have adverse health consequences, or merely indicate that low acuity patients are not willing to wait for non-emergent care. We sought to evaluate the outcome of patients who LWBS from our ED. Methods: Data was collected for a 12-month period beginning in November 2004. We extracted a convenience sample of patients to be called back 48 hours after their initial LWBS visit. We selected days when the total LWBS percentage exceeded the daily average by at least 5%, on average 3 days per month. An administrative assistant called these patients and recorded one of the following outcomes: went to an outpatient clinic, returned to our ED, returned to another ED, desired an outpatient appointment, no appointment was planned or desired, was admitted to a hospital. An electronic hospital database was also queried to verify whether any patients had returned to our ED or been admitted to the hospital 48 hours after their initial visits. Results: 62,239 patients were seen in our 16-bed ED during this time period, of which 6037 LWBS. 1165 patients were identified in this convenience sample. Of these, 668 (57.3%) could be contacted by telephone and 497 (42.7%) were unable to be contacted. Of the patients who were contacted, outcome data was available in 100%. 378 (56.1%) patients either went to an outpatient clinic or planned to go within 24 hours. 197 (29.5%) patients chose not to seek outpatient care and did not desire a future appointment for their current complaint. 40 (6%) patients requested our administrator’s help with scheduling an outpatient appointment. 34 (5.1%) patients returned to our ED. 21 (3.2%) patients presented to another ED. Only 2 (0.3%) patients had been admitted to the hospital within the past 48 hours. Conclusion: Patients who LWBS from our ED had very low ED return and admission rates.
79
Emergency Care Outside of the ED: Creative Utilization of Open Bed Space
Powell ES, Lucenti MJ, Pang PS, Mycyk MB/Northwestern University Feinberg School of Medicine, Chicago, IL
Background: During periods of overcrowding, lack of outflow and limited physical capacity in the ED constrains the ability to see new patients. Study Objective: To determine if emergency care of the moderate acuity patient can be conducted outside of the physical space of the main ED. Methods: A feasibility study was completed at an academic, tertiary, urban level I
Volume , . : October