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Bridging Orders and a Dedicated Admission Nurse Decreases Emergency Department Turnaround Times While Increasing Patient Satisfaction
CORRESPONDENCE
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager™ (http:// www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A manuscript submission agreement, signed by all authors, must be faxed to the Annals office at the time of submission. Financial association or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
0196-0644/$-see front matter Copyright © 2007 by the American College of Emergency Physicians.
Bridging Orders and a Dedicated Admission Nurse Decreases Emergency Department Turnaround Times While Increasing Patient Satisfaction To the Editor: Although many solutions to the problem of emergency department (ED) crowding have been proposed, there are few data on the use of an expedited admissions protocol (EAP) to decrease ED turnaround times. We performed a before-andafter study to determine whether the institution of a protocol utilizing bridging orders and a dedicated patient admission nurse improved ED turnaround times and measures of patient satisfaction. We conducted the study at a community teaching hospital with an ED census of 55,000 and a Level I Trauma designation. Patients are seen by board certified ED attendings, emergency medicine residents and off service residents; there are no midlevel providers. Patients are admitted to both teaching and nonteaching services. The expedited admissions protocol was instituted over a 3-week period, being fully in effect by January 2006. The protocol mandated that all stable admitted patients (as determined by the ED attending physician) have bridging orders given to the ED nurse by phone without the patient being seen by the admitting physician or resident team in the ED. These 11 preprinted orders specify only the basic orders needed for interim care (including immediate medication needs) and patient safety. After receiving the bridging orders, a dedicated nurse (available 24 hours per day and without Volume , . : September
clinical responsibilities) locates an available bed; the patient is transported without further physician intervention. We evaluated turnaround times, Press Ganey scores, and number of patients who left without being seen both before (JanuaryMarch 2005) and after (January-March 2006) institution of the EAP protocol. There were no changes in ED staffing or number of ED or inpatient beds. Turnaround times (minutes) for all categories of patients decreased significantly (p⬍.005) over the study period: all patients: 223 to 174, mean difference 30.26, 95% confidence interval [CI]: 20.46-40.06; discharged patients: 181 to 154, mean difference 26.94, 95% CI: 18.08-35.81; admitted patients: 350 – 240, mean difference 110.60, 95% CI: 89.08132.12; fast track patients: 136 ⫺106, mean difference 48.48,
Figure. Turnaround times before and after protocol. Annals of Emergency Medicine 351
Correspondence 95% CI: 37.78-59.20 (Figure). Press Ganey “Overall ED Patient Satisfaction” scores showed a clinically and statistically significant improvement (78.1 versus 82.1; mean difference: 4.0, 95%; CI: 3.59-4.41.). The absolute number of patients who left without being seen decreased from 281 to 190, although this did not reach statistical significance (0.8%, 95% CI⫽⫺1.5 to 3.0%), despite an increase in ED census of 10.2%. Although our interventions were specifically targeted toward admitted patients, it is not surprising that turnaround times for all patient categories improved. Clearly, acute care patients who were ultimately discharged could be seen more expeditiously as turnaround times for admitted patients decreased. We believe the turnaround times for fast track patients declined because the acute and fast track areas are not physically separate in our department, allowing for flexibility in both bed assignments and staffing between the 2 areas. As admitted acute patients moved through the department more quickly, there were more beds and staff available for the fast track area of the department. In hospitals where the acute and fast track areas are completely separate and staffing is not flexible between the 2, similar improvements in fast track patient turnaround times may not be seen. Although much has been written about ED crowding, there are few studies which suggest solutions to the problem.1,2 In 2003 JCAHO called on hospitals to incorporate solutions to ED crowding into performance improvement activities.3 The Institute of Medicine states that although forces beyond the department impact operations, the solution may lie in system design and communication improvements.4 The American College of Emergency Physicians has called for further monitoring and data collection efforts to analyze the problem in order to find effective solutions.5 As the causes of ED crowding are complex, it is unlikely the problem will be resolved with systems improvements alone. However, the process improvements in the current study decreased ED turnaround times during a period of increasing census and improved patient satisfaction. These results suggest a partial solution may lie in process improvements within our own departments. John Patterson, MD Lisa Dutterer, MSPT Mary Rutt, RN Kay Marsteller, RN, MN, MBA Jeanne Jacoby, MD Michael Heller, MD Emergency Medicine Residency St. Luke’s Hospital Bethlehem, PA doi:10.1016/j.annemergmed.2007.03.042 1. Chan TC, Killeen JP, Kelly D. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait
352 Annals of Emergency Medicine
2.
3. 4.
5.
times, lengths of stay, and rate of left without being seen. Ann Emerg Med. 2005;46:491-497. Gorelick MH, Yen K, Yun HJ. The effect of in-room registration on emergency department length of stay. Ann Emerg Med. 2005;45: 128-133. Institute of Medicine to overwhelmed ED managers: ‘you’re not alone’. ED Manag. 2006;187:73-75. American College of Emergency Physicians. Fact sheet on ambulance diversion and ED crowding. Available at: http://www. acep.org/webportal/PatientsConsumers/critissues/overcrowding/ FactSheetAmbulanceDiversionandEDOvercrowding. Accessed January 1, 2007. Yancer DA, Foshee D, Cole H, et al. Managing capacity to reduce emergency department overcrowding and ambulance diversions. Jt Comm J Qual Patient Saf. 2006;32:239-245.
Heroin: What’s In the Mix? To the Editor: Heroin abuse is a public health problem within the United States. Heroin intoxication has a well-recognized toxicity syndrome involving central nervous system depression, respiratory depression, and pupillary constriction. However, over the past decade, our poison control center has encountered several heroin adulterants that changed the toxicity syndrome observed after overdose. In the late 1990s, contamination of heroin with the anticholinergic drug scopolamine led to heroin overdose victims presenting with unusual manifestations of hallucination, mydriasis, tachycardia, and dry mucous membranes.1 More recently, a heroin-laced acetaminophen and diphenhydramine mixture known as “cheese” has become a popularized heroin source for inexperienced users, and may also produce notable anticholinergic features.2 An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007. At our poison control center, xylazine, an alpha-2 adrenergic agonist which may produce pupil constriction and somnolence mimicking heroin effects, has also been found as an occasional contaminant of heroin. Most recently, clenbuterol, a long-acting beta-2 adrenergic agonist, has again surfaced in an epidemic of unusual heroin overdoses with symptoms and signs including tachycardia, tremor, diaphoresis, and laboratory findings of hyperglycemia, hypokalemia, and lactic acidosis.3,4 Additionally, quinine has been detected in the urine of heroin abusers presenting with tinnitus. Many agents can be added to heroin to bulk its volume or to change or enhance its pharmacology. In the latter case, the heroin may be marketed on the street by attractive “brand” names such as Polo, Homicide, etc. Health care professionals confronted with atypical heroin overdoses are cautioned to consider the effects of potential adulterant drugs and chemicals, Volume , . : September
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager™ (http:// www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A manuscript submission agreement, signed by all authors, must be faxed to the Annals office at the time of submission. Financial association or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
0196-0644/$-see front matter Copyright © 2007 by the American College of Emergency Physicians.
Bridging Orders and a Dedicated Admission Nurse Decreases Emergency Department Turnaround Times While Increasing Patient Satisfaction To the Editor: Although many solutions to the problem of emergency department (ED) crowding have been proposed, there are few data on the use of an expedited admissions protocol (EAP) to decrease ED turnaround times. We performed a before-andafter study to determine whether the institution of a protocol utilizing bridging orders and a dedicated patient admission nurse improved ED turnaround times and measures of patient satisfaction. We conducted the study at a community teaching hospital with an ED census of 55,000 and a Level I Trauma designation. Patients are seen by board certified ED attendings, emergency medicine residents and off service residents; there are no midlevel providers. Patients are admitted to both teaching and nonteaching services. The expedited admissions protocol was instituted over a 3-week period, being fully in effect by January 2006. The protocol mandated that all stable admitted patients (as determined by the ED attending physician) have bridging orders given to the ED nurse by phone without the patient being seen by the admitting physician or resident team in the ED. These 11 preprinted orders specify only the basic orders needed for interim care (including immediate medication needs) and patient safety. After receiving the bridging orders, a dedicated nurse (available 24 hours per day and without Volume , . : September
clinical responsibilities) locates an available bed; the patient is transported without further physician intervention. We evaluated turnaround times, Press Ganey scores, and number of patients who left without being seen both before (JanuaryMarch 2005) and after (January-March 2006) institution of the EAP protocol. There were no changes in ED staffing or number of ED or inpatient beds. Turnaround times (minutes) for all categories of patients decreased significantly (p⬍.005) over the study period: all patients: 223 to 174, mean difference 30.26, 95% confidence interval [CI]: 20.46-40.06; discharged patients: 181 to 154, mean difference 26.94, 95% CI: 18.08-35.81; admitted patients: 350 – 240, mean difference 110.60, 95% CI: 89.08132.12; fast track patients: 136 ⫺106, mean difference 48.48,
Figure. Turnaround times before and after protocol. Annals of Emergency Medicine 351
Correspondence 95% CI: 37.78-59.20 (Figure). Press Ganey “Overall ED Patient Satisfaction” scores showed a clinically and statistically significant improvement (78.1 versus 82.1; mean difference: 4.0, 95%; CI: 3.59-4.41.). The absolute number of patients who left without being seen decreased from 281 to 190, although this did not reach statistical significance (0.8%, 95% CI⫽⫺1.5 to 3.0%), despite an increase in ED census of 10.2%. Although our interventions were specifically targeted toward admitted patients, it is not surprising that turnaround times for all patient categories improved. Clearly, acute care patients who were ultimately discharged could be seen more expeditiously as turnaround times for admitted patients decreased. We believe the turnaround times for fast track patients declined because the acute and fast track areas are not physically separate in our department, allowing for flexibility in both bed assignments and staffing between the 2 areas. As admitted acute patients moved through the department more quickly, there were more beds and staff available for the fast track area of the department. In hospitals where the acute and fast track areas are completely separate and staffing is not flexible between the 2, similar improvements in fast track patient turnaround times may not be seen. Although much has been written about ED crowding, there are few studies which suggest solutions to the problem.1,2 In 2003 JCAHO called on hospitals to incorporate solutions to ED crowding into performance improvement activities.3 The Institute of Medicine states that although forces beyond the department impact operations, the solution may lie in system design and communication improvements.4 The American College of Emergency Physicians has called for further monitoring and data collection efforts to analyze the problem in order to find effective solutions.5 As the causes of ED crowding are complex, it is unlikely the problem will be resolved with systems improvements alone. However, the process improvements in the current study decreased ED turnaround times during a period of increasing census and improved patient satisfaction. These results suggest a partial solution may lie in process improvements within our own departments. John Patterson, MD Lisa Dutterer, MSPT Mary Rutt, RN Kay Marsteller, RN, MN, MBA Jeanne Jacoby, MD Michael Heller, MD Emergency Medicine Residency St. Luke’s Hospital Bethlehem, PA doi:10.1016/j.annemergmed.2007.03.042 1. Chan TC, Killeen JP, Kelly D. Impact of rapid entry and accelerated care at triage on reducing emergency department patient wait
352 Annals of Emergency Medicine
2.
3. 4.
5.
times, lengths of stay, and rate of left without being seen. Ann Emerg Med. 2005;46:491-497. Gorelick MH, Yen K, Yun HJ. The effect of in-room registration on emergency department length of stay. Ann Emerg Med. 2005;45: 128-133. Institute of Medicine to overwhelmed ED managers: ‘you’re not alone’. ED Manag. 2006;187:73-75. American College of Emergency Physicians. Fact sheet on ambulance diversion and ED crowding. Available at: http://www. acep.org/webportal/PatientsConsumers/critissues/overcrowding/ FactSheetAmbulanceDiversionandEDOvercrowding. Accessed January 1, 2007. Yancer DA, Foshee D, Cole H, et al. Managing capacity to reduce emergency department overcrowding and ambulance diversions. Jt Comm J Qual Patient Saf. 2006;32:239-245.
Heroin: What’s In the Mix? To the Editor: Heroin abuse is a public health problem within the United States. Heroin intoxication has a well-recognized toxicity syndrome involving central nervous system depression, respiratory depression, and pupillary constriction. However, over the past decade, our poison control center has encountered several heroin adulterants that changed the toxicity syndrome observed after overdose. In the late 1990s, contamination of heroin with the anticholinergic drug scopolamine led to heroin overdose victims presenting with unusual manifestations of hallucination, mydriasis, tachycardia, and dry mucous membranes.1 More recently, a heroin-laced acetaminophen and diphenhydramine mixture known as “cheese” has become a popularized heroin source for inexperienced users, and may also produce notable anticholinergic features.2 An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007. At our poison control center, xylazine, an alpha-2 adrenergic agonist which may produce pupil constriction and somnolence mimicking heroin effects, has also been found as an occasional contaminant of heroin. Most recently, clenbuterol, a long-acting beta-2 adrenergic agonist, has again surfaced in an epidemic of unusual heroin overdoses with symptoms and signs including tachycardia, tremor, diaphoresis, and laboratory findings of hyperglycemia, hypokalemia, and lactic acidosis.3,4 Additionally, quinine has been detected in the urine of heroin abusers presenting with tinnitus. Many agents can be added to heroin to bulk its volume or to change or enhance its pharmacology. In the latter case, the heroin may be marketed on the street by attractive “brand” names such as Polo, Homicide, etc. Health care professionals confronted with atypical heroin overdoses are cautioned to consider the effects of potential adulterant drugs and chemicals, Volume , . : September