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Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds
YAJEM-58215; No of Pages 6 American Journal of Emergency Medicine xxx (xxxx) xxx
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American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds☆ Moon O. Lee, MD MPH a,⁎, Rudolph Arthofer, RN BSN MHA b, Patrice Callagy, RN MSN MPA b, Michael A. Kohn, MD MPP a, Kian Niknam, MS a, Carlos A. Camargo Jr, MD DrPH c, Sam Shen, MD MBA a a b c
Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, United States of America Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA 02114, United States of America.
a r t i c l e
i n f o
Article history: Received 20 February 2019 Received in revised form 12 April 2019 Accepted 30 April 2019 Available online xxxx Keywords: Crowding Inpatient hallway beds Patient safety Mortality Accidental falls Hospital readmission
a b s t r a c t Background: Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission. Methods: Retrospective cohort study of patients age N18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014–3/ 31/2015, transition 9/1/2015–3/31/2016, and post-intervention 9/1/2016–3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order. Results: The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU −10.6 (95%CI: −18.3, −2.8) and HAI −13.4 (95%CI: −20.3, −6.5) compared to standard inpatient beds. Conclusion: Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Emergency department (ED) crowding is defined by the Institute of Medicine as when the number of patients exceeds the ED treatment space capacity [1]. ED crowding leads to higher morbidity and mortality, delayed pain control, and time to antibiotics [2-6]. The primary cause of ED crowding is the inability to move admitted patients to inpatient beds, which is known as boarding [7]. “Boarding” is defined as when patients are physically located in the ED for more than two hours after the ☆ Presentation: Presented at American College of Emergency Medicine Physician Conference October 1, 2018, San Diego, CA. ⁎ Corresponding author at: 900 Welch Road, MC 5119, Suite 350, Palo Alto, CA 94304, United States of America. E-mail addresses: [email protected] (M.O. Lee), [email protected] (R. Arthofer), [email protected] (P. Callagy), [email protected] (M.A. Kohn), [email protected] (K. Niknam), [email protected] (C.A. Camargo), [email protected] (S. Shen).
admission order has been placed [8]. The boarding of admitted patients in the ED remains a national challenge [9]. Boarding is associated with increased inpatient length of stay, delays in medication administration, missed orders and increased inpatient mortality [10-15]. Boarding is a hospital-wide problem that needs to be addressed from multiple angles. A solution to reduce ED crowding is to increase inpatient bed capacity by using inpatient hallway beds. Although this countermeasure has been endorsed by the American College of Emergency Physicians and by health policy experts, there is little evidence to show it has become a widely-accepted solution to ED boarding [8,9]. In fact, only one study by Viccellio et al. examined hallway beds and two specific clinical patient outcomes: transfer to the Intensive Care Unit (ICU) and inhospital mortality rates. They found transfers to the ICU and inhospital mortality rates were higher among patients admitted to standard inpatient beds than hallway beds [16]. This study compared standard inpatient beds with hallway beds and did not adjust risk for patient acuity or changes that occurred in the hospital over time.
https://doi.org/10.1016/j.ajem.2019.04.052 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
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M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
What is unknown is the relationship between inpatient hallway beds and patient outcomes when accounting for patient acuity and hospital-wide changes that occurred over time. In October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a payment change to selected hospital-acquired conditions that developed during the hospital stay in order to improve patient safety and quality. The current list of hospital-acquired conditions includes: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, manifestations of poor glycemic control, catheter-associated urinary tract infections, vascular catheter-associated infections, surgical site infections, deep vein thrombosis and/or pulmonary embolism after certain orthopedic procedures, and iatrogenic pneumothorax with venous catheterization [17]. With the emphasis on preventing hospital-acquired conditions, some hospitals may hesitant to initiate use of inpatient hallway beds without further evidence that they do not lead to harm. Our hospital also experienced similar challenges with boarding patients in the ED with subsequent ED crowding. In 2015, we implemented use of Alternative Care Area (AltCA) inpatient beds which included inpatient hallway beds, the cardiac catheterization lab, and the endoscopy suite. The AltCA beds were used only during high inpatient census days. This new process led to concerns about using AltCA beds given the lack of published literature on the association between inpatient hallway beds and patient safety and quality outcomes. In this retrospective study, our primary hypothesis was to determine whether AltCA beds were associated with increased risk of transfer to ICU and mortality than standard inpatient beds. Our secondary hypothesis was to determine whether AltCA beds were associated with increased risk of hospital-acquired infections, falls, and 72-hour hospital readmission than standard inpatient beds. 2. Methods 2.1. Study design For this study, we performed a before and after study consisting of all adult patients (age ≥ 18 years) admitted to a non-ICU bed from the ED at an urban, academic hospital. The intervention, use of AltCA beds, was implemented in 2015 when a new hospital protocol allowed for temporary use of AltCA beds when standard inpatient beds reached capacity. AltCA beds were used primarily during high patient census months, which were September to March of each fiscal year. Patient data were obtained from the electronic medical record for three study periods. The study periods demonstrated gradual increase in use of AltCA beds from the pre-intervention period (9/1/2014 to 3/31/2015) to the transition period (9/1/2015 to 3/31/2016) and was fully operational by the post-intervention period (9/1/2016 to 3/31/2017). The study was approved by the Institutional Review Board at Stanford University. 2.2. Study setting and population Stanford Hospital has 613 licensed beds and is the primary teaching hospital for medical students and residents for Stanford University School of Medicine. The hospital case-mix index was 2.26 in Fiscal Year (FY) 2015 and increased to 2.46 in FY 2017. Most of the standard inpatient beds are located in semi-private, shared patient rooms and with approximately 165 private rooms. The hospital has a patient and family-centered care policy which means visitors can visit patients at any time and stay overnight in the patient's room. The ED is a Level 1 Adult and Level 1 Pediatric Trauma Center, and a comprehensive stroke center. The main ED has 35 beds, the Pediatric ED has 9 beds, and Fast Track has 4 beds. The annual ED census increased from 62,344 in 2014 to 73,767 in 2017. The ED has a 25% admission rate and 47% of the hospital inpatient admissions originate from the ED.
2.3. AltCA bed inclusion criteria We examined all patients who were admitted to an AltCA bed during September 2014–March 2018. Patients were eligible to be in AltCA beds if age ≥ 18 years, and admitted to the hospital from ED to the inpatient floor. The protocol excluded patients admitted to the ICU. 2.4. AltCA bed exclusion criteria Patients were excluded from AltCA beds if they met the following criteria: dementia, active gastrointestinal bleeding, bowel obstruction, use of nasogastric tube, contact isolation, airborne isolation (droplet isolation was not included), supplemental oxygen requirement N4 l by nasal cannula, requiring frequent respiratory interventions (i.e. suctioning or continuous positive airway pressure), psychiatric patients on involuntary holds, or inability to ambulate. 2.5. AltCA bed implementation In 2014, preliminary work was conducted to determine potential location of AltCA beds. Each location was assessed to see what staff would be available and the skill set determined what type of patient could be placed in that AltCA bed location. This process established the total number of AltCA beds that could be used in a surge event. Starting in 2014, AltCA beds were first utilized on a pilot basis. The activation criteria for using AltCA beds were not clearly defined. As the number of available inpatient beds decreased during the day, AltCA beds were often “activated” late at night when many resources were not available to support implementation of AltCA beds. In 2015, a multi-disciplinary group comprised of physicians, nurses, and hospital leadership established criteria to activate AltCA beds. The initial criteria required: 1) having 20 admitted patients boarding in the ED; 2) ten patients waiting to be seen by a physician in the waiting room; and 3) patients in the waiting room were waiting N60 min to be roomed. In 2016, the criteria were simplified to 20 patients boarding in the ED, which meant a third of the ED beds were occupied by boarding patients. A standardized workflow with ten levels was developed to decide how boarding patients would be distributed among the AltCA beds. At Level 1, the first 20 ED boarding patients would be held in the ED. At Level 2, the next ten ED boarding patients were held in the cardiac catheterization lab or endoscopy suite. Preferentially, patients held in the cardiac catheterization lab or endoscopy suite were patients who would receive procedures the following day. At Level 3, the next ten ED boarding patients would be placed in the inpatient hallway beds. At Level 4, the process starts over with the ED boarding the next five admitted patients. This tiered process prevented any one area from getting too many patients all at once. In addition to the standardized workflow, the Hospital Operations Center (HOC) developed a daily report to be sent to the hospital and ED leadership team every morning at 7:00 am. The HOC daily report described the hospital's inpatient capacity for a given day. The report used a predictive model that showed projected admissions based on historical admission data from each intake sources: ED, procedural areas, direct admissions, and transfer center. The hospital had daily huddles at 8:15 am and 1:45 pm with the patient flow leadership team comprised of managers, directors, vice presidents, and executive officers. They reviewed the number of boarding patients and HOC daily report to evaluate bed capacity each day. During the huddles a decision was made whether or not to activate the AltCA beds and an additional huddle was added at 4:00 pm to determine if AltCA beds would be activated later in the day. The activation of AltCA beds was done through a system-wide paging through text, e-mail, and phone which was sent to inpatient floor charge nurses, housekeeping, and other personnel needed to implement AltCA beds. The Charge Nurse from each unit was responsible
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
for obtaining the supplies necessary for each AltCA bed. The hospital transporters brought hospital beds from central supply to each area and General Services transported equipment to the AltCA beds, including the temporary, portable, privacy screen to surround each AltCA bed for privacy. 2.6. Department of Public Health Services regulatory requirement The Hospital Compliance Department formally requested approval for AltCA bed usage through the Department of Public Health Services (DHS). A DHS representative inspected the implementation process and physical spaces prior to granting approval. Approval was granted on a month-to-month basis and DHS was able to inspect AltCA beds, unannounced, at any time. In California, the nurse to patient ratio is 1:4 for non-ICU patients and is strictly maintained at all times. 2.7. Data collection, definition, and outcomes Stanford Hospital uses a paperless, electronic medical record system called EPIC (Verona, WI). The ED triage Emergency Service Index (ESI) Level is assigned by an ED nurse at the time of triage. Trauma patients who arrived by ambulance did not receive an ESI level and trauma patients were classified separately. The use of telemetry was tracked using an electronic order for telemetry. The ED length of stay (LOS) was defined as the time from when the patient arrives in the ED to when the first admission order was placed. The ED boarding hours were calculated from when the first admission order was placed while
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the patient was in the ED to when the patient physically left the ED. The AltCA LOS was the amount of time patients spent in the AltCA bed. The hospital LOS started from the first admission order placed in the ED to when the patient was discharged from the hospital. Our primary patient safety and quality outcomes were: transfer to ICU and inpatient mortality. Transfers to ICU were tracked using an electronic order “Transfer to ICU.” We examined the list of hospital-acquired conditions and chose to focus on conditions that could occur in standard inpatient beds as well as AltCA beds. Since patients were excluded from AltCA beds if they went from the ED directly to the operating room or if they could not ambulate, we did not examine hospital-acquired conditions related to surgeries or pressure ulcers. Our secondary patient safety and quality outcomes were: hospital-acquired infections, falls, and 72-hour hospital readmission. Hospital-acquired infections were defined as catheter associated urinary tract infections, central line associated bacterial infections, surgical site infections, and organism-specific infections such as Clostridium difficile, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus. Patients falls were tracked by electronic reports filed by nurses. We examined 72-hour hospital readmission as a safety outcome rather than hospital LOS since hospital LOS has many factors related to discharge planning rather than a direct patient safety issue. 2.8. Primary data analysis Data analysis was performed using STATA 15/SE, StataCorp LLC, College Station, TX. The exclusion criteria ensured that more lower acuity
Table 1 Demographics and sample characteristics by study period. Characteristics
Entire cohort
Pre-intervention
Transition
Intervention
n (%) AltCA bed (%) Yes No Sex (%) Male Female Age (mean, SD) Race (%) White Asian African-American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Unknown Ethnicity (%) Hispanic/Latino Non-Hispanic/Non-Latino Unknown Insurance (%) MediCare MediCal/MedicAid Managed Care Blue Shield/Blue Cross Other ESI level (%) ESI 2 (emergent) ESI 3 (urgent) Trauma ESI 4 (semi-urgent) Telemetry (%) Yes No Length of stay ED length of stay, hours (median, IQR) ED boarding, hours (median, IQR) AltCA length of stay, hours (median, IQR) Hospital length of stay, days (median, IQR)
16,801
5480 (32.6)
5588 (33.3)
5733 (34.1)
622 (3.7) 16,179 (96.3)
14 (0.3) 5466 (99.7)
71 (1.3) 5517 (98.7)
537 (9.4) 5196 (90.6)
8178 (48.7) 8622 (51.3) 61.5 (19.6)
2695 (49.2) 2785 (50.8) 61.5 (19.7)
2688 (48.1) 2899 (51.9) 61.6 (19.6)
2795 (48.8) 2938 (51.2) 61.6 (19.4)
8791 (52.3) 2488 (14.8) 1228 (7.3) 402 (2.4) 58 (0.4) 3713 (22.1) 121 (0.7)
2930 (53.5) 780 (14.2) 419 (7.7) 119 (2.2) 25 (0.5) 1181 (21.6) 26 (0.5)
2914 (52.2) 848 (15.2) 422 (7.6) 134 (2.4) 14 (0.3) 1214 (21.7) 42 (0.8)
2947 (51.4) 860 (15.0) 387 (6.8) 149 (2.6) 19 (0.3) 1318 (23) 53 (0.9)
2894 (17.2) 13,794 (82.1) 113 (0.7)
916 (16.7) 4540 (82.9) 24 (0.4)
975 (17.5) 4577 (81.9) 36 (0.6)
1003 (17.5) 4677 (81.6) 53 (0.9)
8831 (52.6) 3196 (19.0) 2027 (12.1) 2503 (14.9) 244 (1.4)
2855 (52.1) 2855 (52.1) 662 (12.1) 847 (15.5) 92 (1.7)
2968 (53.1) 1054 (18.9) 650 (11.6) 847 (15.2) 69 (1.2)
3008 (52.5) 1118 (19.5) 715 (12.5) 809 (14.1) 83 (1.4)
4341 (25.8) 11,717 (69.7) 624 (3.7) 743 (4.4)
1501 (27.4) 3744 (68.3) 204 (3.7) 235 (4.3)
1507 (27) 3813 (68.2) 225 (4) 268 (4.8)
1333 (23.3) 4160 (72.6) 195 (3.4) 240 (4.2)
9932 (59.1) 6869 (40.9)
3087 (56.3) 2393 (43.7)
3325 (59.5) 2263 (40.5)
3520 (61.4) 2213 (38.6)
3.5 (2.3, 5.0) 3.2 (1.8, 6.9) 9.6 (3.7, 15.8) 3.4 (1.9, 5.9)
3.4 (1.9, 5.9) 3.1 (1.8, 5.9) 2.3 (0.5, 9.6) 3.1 (1.8, 5.7)
3.5 (2.3, 5.1) 2.9 (1.6, 7.4) 5.2 (2.2, 12.5) 3.4 (1.9, 5.9)
3.5 (2.3, 5.0) 3.5 (1.9, 8.2) 10.1 (4.4, 16.3) 3.6 (2.0, 6.1)
p-Value b0.001⁎
0.58
0.94 0.02⁎
0.02⁎
0.21
b0.001⁎
b0.001⁎
0.63 b0.001⁎ b0.001⁎ b0.001⁎
Abbreviations: AltCA beds = alternative care area beds, ESI = emergency service index. ⁎ Indicates significant p values.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
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M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
patients are admitted to AltCA beds than standard inpatient beds. To adjust for patient acuity and changes over time, we looked at preintervention, transition, and post-intervention periods and compared the outcome rates between the three periods. The AltCA bed utilization and patient safety and quality outcomes for the study periods were compared in unadjusted and multivariable analyses. In the latter, we controlled for age, sex, race, ethnicity, ED triage Emergency Service Index (ESI) Level, and telemetry order. For ESI Level, we excluded patients with ESI Level 1 since none of the AltCA bed patients were classified as ESI Level 1 and all ESI Level 1 patients were admitted to the ICU. Trauma patients often arrived by ambulance and did not consistently receive an ESI Level on arrival and they were placed in a separate category. We performed an instrumental variable analysis using study period as the instrument and the same covariates. To illustrate the need for adjustment, we reported unadjusted relative risk differences between AltCA beds and standard beds. We compared the three study periods with regard to use of AltCA beds, patient demographics, insurance status, ESI Level, and telemetry order. Categorical variables were compared using chi-square test and continuous variables using Wilcoxon rank-sum test, ANOVA or Kruskall-Wallis as appropriate. Our primary patient safety and quality outcomes were transfer to ICU and mortality. Our secondary patient
safety and quality outcomes were hospital-acquired infections, falls, and 72-hour hospital readmission. These outcomes were compared using a two-stage least squares instrumental variable analysis with period as the instrument. The first stage used probit regression with AltCA bed as the dependent variable and study period, age, sex, ESI level, and telemetry order as the independent variables. The second stage used the outcome, e.g., mortality, as the dependent variable and the same covariates, except for period. This analysis estimated the effect of AltCA bed use on overall patient safety and quality outcomes. 3. Results The study included 16,801 patients, of whom 622 patients (3.7%) were admitted to AltCA beds. Table 1 described demographics and sample characteristics by study period. AltCA beds usage increased from 14 beds to 537 over the study period (p b 0.001). The number of ESI 3 (Urgent) increased while the number of ESI 2 (Emergent) decreased. Telemetry use increased from 56.3% to 61.4% over the study periods. Table 2 compared the demographics and sample characteristics of standard inpatient beds with AltCA beds. AltCA beds had younger patients (57.7 years) than standard inpatient beds (61.7 years). AltCA beds had fewer white patients and fewer Medicare and Blue Shield/
Table 2 Demographics and sample characteristics: AltCA beds and standard inpatient beds. Characteristics
Entire cohort
AltCA beds
Standard inpatient beds
n (%) Sex (%) Male Female Age (mean, SD) Race (%) White Asian African-American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Unknown Ethnicity (%) Hispanic/Latino Non-Hispanic/Non-Latino Unknown Insurance (%) MediCare MediCal/MedicAid Managed Care Blue Shield/Blue Cross Other ESI level (%) ESI 2 (emergent) ESI 3 (urgent) Trauma ESI 4 (semi-urgent) Telemetry (%) Yes No Length of stay ED length of stay, hours (median, IQR) ED boarding, hours (median, IQR) Hospital length of stay, days (median, IQR) Admitting service (%) Medicine Surgery Neurology Orthopedics Trauma Obstetrics and Gynecology Neurosurgery Urology Other (Dental, Palliative, Pain)
16,801
622 (3.7)
16,179 (96.3)
8178 (48.7) 8622 (51.3) 61.5 (19.6)
293 (47.1) 329 (52.9) 57.7 (19.2)
7885 (48.7) 8293 (51.3) 61.7 (19.6)
8791 (52.3) 2488 (14.8) 1228 (7.3) 402 (2.4) 58 (0.4) 3713 (22.1) 121 (0.7)
285 (45.8) 91 (14.6) 46 (7.4) 20 (3.2) 2 (0.3) 175 (28.1) 3 (0.5)
8506 (52.6) 2397 (14.8) 1182 (7.3) 382 (2.4) 56 (0.4) 3538 (21.9) 118 (0.7)
2894 (17.2) 13,794 (82.1) 113 (0.7)
129 (20.7) 490 (78.8) 3 (0.5)
2765 (17.1) 13,304 (82.2) 110 (0.7)
8831 (52.6) 3196 (19.0) 2027 (12.1) 2503 (14.9) 244 (1.4)
296 (47.6) 146 (23.5) 93 (15.0) 75 (12.1) 12 (1.9)
8535 (52.8) 3050 (18.9) 1934 (11.9) 2428 (15.0) 232 (1.4)
4341 (25.8) 11,717 (69.7) 624 (3.7) 743 (4.4)
100 (16.1) 487 (78.3) 24 (3.9) 35 (5.6)
4241 (26.2) 11,230 (69.4) 600 (3.7) 708 (4.4)
9932 (59.1) 6869 (40.9)
301 (48.4) 321 (51.6)
9631 (59.5) 6548 (40.5)
3.5 (2.3, 5.0) 3.2 (1.8, 6.9) 3.4 (1.9, 5.9)
3.8 (2.5, 5.2) 4.3 (2.2, 10.2) 2.7 (1.2, 4.8)
3.4 (2.3, 5.0) 3.1 (1.8, 6.8) 3.4 (1.9, 5.9)
12,929 (77.0) 1472 (8.8) 729 (4.3) 489 (2.9) 336 (2.0) 315 (1.9) 207 (1.2) 96 (0.6) 228 (1.4)
421 (67.7) 81 (13.0) 36 (5.8) 13 (2.1) 14 (2.3) 14 (2.3) 8 (1.3) 8 (1.3) 19 (3.1)
12,508 (77.3) 1391 (8.6) 693 (4.3) 476 (2.9) 322 (2.0) 293 (1.8) 199 (1.2) 88 (0.5) 209 (1.3)
p-Value 0.42
b0.001⁎ 0.006⁎
0.06
0.001⁎
b0.001⁎
b0.001⁎
0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎
Abbreviations: AltCA = alternative care area beds, ESI = emergency service index. ⁎ Indicates significant p values.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx Table 3 Number of days alternative care bed activated each month and total number of beds activated. Month/year
Number of days AltCA bed activated
Total number of AltCA beds used
Pre-intervention period 09/2015 – 10/2015 – 11/2015 – 12/2015 – 01/2016 3 02/2016 1 03/2016 5
– – – – 4 1 9
Transition period 09/2016 10/2016 11/2016 12/2016 01/2017 02/2017 03/2017
– 8 3 6 24 13 17
– 3 3 2 10 4 5
Post-intervention period 09/2017 4 10/2017 16 11/2017 15 12/2017 18 01/2018 20 02/2018 20 03/2018 19
10 103 64 83 112 87 78
– none.
Blue Cross insurance than standard inpatient beds. AltCA beds used less telemetry (48.4%) than standard inpatient beds (59.3%). AltCA beds had fewer ESI 2 (26.2%) than standard inpatient beds (16.1%). AltCA beds had more admission by the following services: surgery, neurology, obstetrics and gynecology, and “other” which included dental, palliative, and pain services. Median ED Length of Stay (LOS) remained the same throughout the study period. AltCA beds had longer ED Length of Stay (LOS) (3.8 h) than standard inpatient beds (3.4 h). ED boarding hours increased in the study period. AltCA beds had more ED boarding hours (4.3 h) than standard inpatient beds (3.1 h). The median AltCA LOS increased from 2.3 h to 10.1 h in the study period. Median hospital LOS increased from 3.1 days to 3.6 days in the study period. AltCA beds had shorter hospital LOS (2.7 days) than standard inpatient beds (3.4 days). Table 3 shows the number of days AltCA beds were activated each month and the total number of AltCA beds used each month. Table 4 compared the unadjusted and adjusted risk difference for AltCA beds and standard inpatient beds for the patient safety and quality outcomes. For the primary patient safety and quality outcome, AltCA beds had significantly decreased adjusted risk difference for transfer to ICU −10.6 (95%CI: −18.3, −2.8) and no increased risk for mortality than standard inpatient beds. For the secondary patient safety and quality outcome, AltCA beds had significantly decreased adjusted risk difference for hospital-acquired infections −13.4 (95%CI: −20.3, −6.5) and
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no increased risk for falls and 72-hour readmission than standard inpatient beds. 4. Discussion We found that AltCA beds did not lead to increased transfers to ICU or mortality compared to standard inpatient beds. In fact, we found that AltCA beds were associated with lower risk of transfers to ICU and hospital-acquired infections than standard inpatient beds. Only one published study has examined the safety of using hallway beds compared to standard inpatient beds, but did not consider potential confounders [16]. Our study had three strengths that are not found in the previous study. First, our study adds new information about the safety of implementing AltCA beds to temporarily increase inpatient bed capacity. Our analysis adjusted for patient illness severity and changes that may have occurred with patient safety and quality outcomes naturally over the study period. For instance, our unadjusted analysis showed similar results as Viccello et al. [16] and found AltCA beds had decreased risk of transfers to ICU and mortality. We also found the number of transfers to ICU decreased significantly during the 3-year study period. With the adjusted analysis, we accounted for the decreasing trend in transfers to ICU over time and still found AltCA beds had decreased risk of transfers to ICU, but not for mortality. Previous studies on hallway beds have been limited to these two outcomes and patient preference for inpatient boarding [16,18-21]. Second, our study examined additional key patient safety and quality outcomes: hospital-acquired infections, falls, and 72-hour hospital readmission. Hospital-acquired infections are particularly important measures that are reported to CMS. This study showed AltCA beds had decreased risk of hospital-acquired infections and had no change in risk with falls and 72-hour hospital readmission. A potential explanation for this finding is the Hawthorne effect which is the change in individual behavior in response to being observed [22]. The AltCA beds located in inpatient hallways may have led to nurses and physicians to increase their hand-washing due to the greater visibility and physical proximity of these patients to the nurses' and physicians' work stations. It is also possible the physical environment of the AltCA beds was less infectious compared to standard inpatient beds which can be located in semi-private rooms; whereas the AltCA beds in the cardiac catheterization lab and endoscopy suite may only have one or two patients in a larger space. Third, this study reported patient LOS metrics for the ED and inpatient setting. AltCA beds may have had longer median ED LOS and ED boarding hours, but had decreased median hospital LOS than standard inpatient beds. This study suggests we could lower the activation criteria to allow for AltCA beds to be used sooner given the significantly longer median ED LOS for AltCA beds compared to standard inpatient beds. The median length of time patients spent in the AltCA beds was 10.1 h in the post-intervention period. This process of “activating” AltCA beds can temporarily increase inpatient bed capacity to alleviate ED crowding due to admitted patients boarding in the ED. This study had three limitations. First, our study design was a before and after study design which means we are limited to the data that is
Table 4 Patient safety and quality outcomes.
Primary outcomes Transfers to ICU (%) Inpatient mortality (%)
Entire cohort Pre-intervention Transition
Intervention p-Value Unadjusted relative risk difference Adjusted relative risk difference
905 (5.4) 434 (2.6)
280 (4.9) 135 (2.4)
Secondary outcomes Hospital-acquired infections (%) 694 (4.1) Falls (%) 165 (1.0) 72-hour hospital readmission (%) 2478 (14.8)
332 (6.1) 149 (2.7)
293 (5.2) 150 (2.7)
252 (4.6) 51 (0.9) 834 (15.2)
244 (4.4) 198 (3.4) 67 (1.2) 47 (0.8) 820 (14.7) 824 (14.4)
0.02⁎ 0.4
−29.1 (95% CI −52.4, 5.4) −69.7 (95% CI −87.4, −27.1)
−10.6 (95% CI −18.3, −2.8) −2.3 (95% CI −7.8, 3.1)
0.005⁎ 0.11 0.44
−42.5 (95% CI −65.3, −4.8) −35.4 (95% CI −76.0, 73.7) −19.9 (95% CI −35.6, −0.5)
−13.4 (95% CI −20.3, −6.5) −1.3 (95% CI −4.7, 2.1) −5.5 (95% CI −17.8, 6.7)
Abbreviations: ICU = intensive care unit. ⁎ Indicates significant p values.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
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M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
documented in the electronic medical record and we did not prospectively control which patients were assigned to AltCA beds. We used instrumental variable analysis to account for unknown confounders. Second, our study was limited to one urban, academic center, with a complex patient population which may not be generalizable in other settings with different resources and hospital layout. Third, California has a law that mandates minimum nurse to patient ratio which varies based on patient acuity and must be maintained at all times, even with AltCA beds [23]. The nurse to patient ratio is 1:4 for medical and surgical patients on the floor and the results of the study may be different in other states that do not have a nurse to patient ratio. We recommend further studies are needed to determine the best criteria for patients who are assigned AltCA beds and to see if AltCA bed location contributes to specific patient safety and quality outcomes. 5. Conclusion In summary, AltCA beds were not associated with increased risk of adverse patient safety and quality outcomes than standard inpatient beds without compromising hospital LOS. AltCA beds were associated with decreased risk of transfer to ICU and hospital-acquired infections than standard inpatient beds after adjusting for confounding. This study gives further evidence to the safety of AltCA beds when used to mitigate ED crowding due to boarding of admitted patients. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of interest None. References0 [1] Hospital-based emergency care: at the breaking point. Institute of Medicine. Washington DC: National Academies Press; 2006. [2] Bernstein SL, Aronsky D, Duseja R, et al. Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009;16(1):1–10. https://doi.org/10.1111/j.1553-2712.2008.00295.x Jan. [3] Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000 Jan;35(1):63–8. Review. doi:https://doi.org/10.1016/S0196-0644(00)70105–3. [4] Chatterjee P, Cucchiara BL, Lazarciuc N, et al. Emergency department crowding and time to care in patients with acute stroke. Stroke 2011;42(4):1074–80. https://doi. org/10.1161/STROKEAHA.110.586610 Apr. [5] Hwang U, Richardson L, Livote E, et al. Emergency department crowding and decreased quality of pain care. Acad Emerg Med 2008;15:1248–55. https://doi.org/ 10.1111/j.1553-2712.2008.00267.x.
[6] Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006;184:213–6. https://doi.org/10.5694/j. 1326-5377.2006.tb00204.x. [7] Government Accountability Office. Hospital emergency departments; crowding continues to occur, and some patients wait longer than recommended time frames. Washington DC: GAO; 2009 [Pub No. GAO-09-347]. [8] Rabin E, Kocher K, McClelland M, et al. Solutions to emergency department ‘boarding’ and crowding are underused and may need to be legislated. Health Aff 2012;31(8):1757–66. https://doi.org/10.1377/hlthaff.2011.0786 Aug. [9] Boarding of admitted and intensive care patients in the emergency department. Ann Emerg Med 2017;70(6):940–1. https://doi.org/10.1016/j.annemergmed.2017.08. 027 Dec. [10] Singer AJ, Thode Jr HC, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011;18(12):1324–9. https://doi.org/10.1111/j.1553-2712.2011.01236.x Dec. [11] Johnson KD, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J 2011;33(1):39–54. https://doi.org/ 10.1097/TME.0b013e318207e86a Jan-Mar. [12] Coil CJ, Flood JD, Belyeu BM, et al. The effect of emergency department boarding on order completion. Ann Emerg Med 2016;67(6):730–736.e2. https://doi.org/10. 1016/j.annemergmed.2015.09.018 Jun. [13] Leisman D, Huang V, Zhou Q, et al. Delayed second dose antibiotics for patients admitted from the emergency department with sepsis: prevalence, risk factors, and outcomes. Crit Care Med 2017;45(6):956–65. https://doi.org/10.1097/CCM. 0000000000002377 Jun. [14] Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med 2006;13 (8):873–8. https://doi.org/10.1197/j.aem.2006.03.568 Aug. [15] Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184(5):208–12 Mar 6. Erratum in: Med J Aust. 2006 Jun 19;184(12):616 https://doi.org/10.5694/j.1326-5377.2006.tb00203. x. [16] Viccellio A, Santora C, Singer AJ, et al. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med 2009;54(4):487–91. https://doi.org/10.1016/j.annemergmed.2009.03. 005 Oct. [17] https://www.cms.gov/medicare/medicare-fee-for-service-payment/ hospitalacqcond/hospital-acquired_conditions.html (Accessed January 15, 2019). [18] Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med 2013;45(6):942–6. https://doi.org/10.1016/j.jemermed.2013.07.018 Dec. [19] Garson C, Hollander JE, Rhodes KV, et al. Emergency department patient preferences for boarding locations when hospitals are at full capacity. Ann Emerg Med 2008 Jan; 51(1):9–12 12.e1-3 https://doi.org/10.1016/j.annemergmed.2007.03.016. [20] Richards JR, Ozery G, Notash M, et al. Patients prefer boarding in inpatient hallways: correlation with the national emergency department overcrowding score. Emerg Med Int 2011;2011:840459. https://doi.org/10.1155/2011/840459. [21] Pines JM, Iyer S, Disbot M, et al. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med 2008;15(9):825–31. https://doi.org/10.1111/j.1553-2712.2008.00200.x Sep. [22] Franke RH, Kaul JD. The Hawthorne experiments: first statistical interpretation. Am Sociol Rev 1978;43:623–43. https://doi.org/10.2307/2094540. [23] Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res 2010;45(4):904–21. https://doi.org/10. 1111/j.1475-6773.2010.01114.x Aug.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds☆ Moon O. Lee, MD MPH a,⁎, Rudolph Arthofer, RN BSN MHA b, Patrice Callagy, RN MSN MPA b, Michael A. Kohn, MD MPP a, Kian Niknam, MS a, Carlos A. Camargo Jr, MD DrPH c, Sam Shen, MD MBA a a b c
Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, MC 5119, Suite 350, Stanford, CA 94304, United States of America Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford, CA 94305, United States of America Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA 02114, United States of America.
a r t i c l e
i n f o
Article history: Received 20 February 2019 Received in revised form 12 April 2019 Accepted 30 April 2019 Available online xxxx Keywords: Crowding Inpatient hallway beds Patient safety Mortality Accidental falls Hospital readmission
a b s t r a c t Background: Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission. Methods: Retrospective cohort study of patients age N18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014–3/ 31/2015, transition 9/1/2015–3/31/2016, and post-intervention 9/1/2016–3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order. Results: The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU −10.6 (95%CI: −18.3, −2.8) and HAI −13.4 (95%CI: −20.3, −6.5) compared to standard inpatient beds. Conclusion: Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Emergency department (ED) crowding is defined by the Institute of Medicine as when the number of patients exceeds the ED treatment space capacity [1]. ED crowding leads to higher morbidity and mortality, delayed pain control, and time to antibiotics [2-6]. The primary cause of ED crowding is the inability to move admitted patients to inpatient beds, which is known as boarding [7]. “Boarding” is defined as when patients are physically located in the ED for more than two hours after the ☆ Presentation: Presented at American College of Emergency Medicine Physician Conference October 1, 2018, San Diego, CA. ⁎ Corresponding author at: 900 Welch Road, MC 5119, Suite 350, Palo Alto, CA 94304, United States of America. E-mail addresses: [email protected] (M.O. Lee), [email protected] (R. Arthofer), [email protected] (P. Callagy), [email protected] (M.A. Kohn), [email protected] (K. Niknam), [email protected] (C.A. Camargo), [email protected] (S. Shen).
admission order has been placed [8]. The boarding of admitted patients in the ED remains a national challenge [9]. Boarding is associated with increased inpatient length of stay, delays in medication administration, missed orders and increased inpatient mortality [10-15]. Boarding is a hospital-wide problem that needs to be addressed from multiple angles. A solution to reduce ED crowding is to increase inpatient bed capacity by using inpatient hallway beds. Although this countermeasure has been endorsed by the American College of Emergency Physicians and by health policy experts, there is little evidence to show it has become a widely-accepted solution to ED boarding [8,9]. In fact, only one study by Viccellio et al. examined hallway beds and two specific clinical patient outcomes: transfer to the Intensive Care Unit (ICU) and inhospital mortality rates. They found transfers to the ICU and inhospital mortality rates were higher among patients admitted to standard inpatient beds than hallway beds [16]. This study compared standard inpatient beds with hallway beds and did not adjust risk for patient acuity or changes that occurred in the hospital over time.
https://doi.org/10.1016/j.ajem.2019.04.052 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
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M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
What is unknown is the relationship between inpatient hallway beds and patient outcomes when accounting for patient acuity and hospital-wide changes that occurred over time. In October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a payment change to selected hospital-acquired conditions that developed during the hospital stay in order to improve patient safety and quality. The current list of hospital-acquired conditions includes: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, manifestations of poor glycemic control, catheter-associated urinary tract infections, vascular catheter-associated infections, surgical site infections, deep vein thrombosis and/or pulmonary embolism after certain orthopedic procedures, and iatrogenic pneumothorax with venous catheterization [17]. With the emphasis on preventing hospital-acquired conditions, some hospitals may hesitant to initiate use of inpatient hallway beds without further evidence that they do not lead to harm. Our hospital also experienced similar challenges with boarding patients in the ED with subsequent ED crowding. In 2015, we implemented use of Alternative Care Area (AltCA) inpatient beds which included inpatient hallway beds, the cardiac catheterization lab, and the endoscopy suite. The AltCA beds were used only during high inpatient census days. This new process led to concerns about using AltCA beds given the lack of published literature on the association between inpatient hallway beds and patient safety and quality outcomes. In this retrospective study, our primary hypothesis was to determine whether AltCA beds were associated with increased risk of transfer to ICU and mortality than standard inpatient beds. Our secondary hypothesis was to determine whether AltCA beds were associated with increased risk of hospital-acquired infections, falls, and 72-hour hospital readmission than standard inpatient beds. 2. Methods 2.1. Study design For this study, we performed a before and after study consisting of all adult patients (age ≥ 18 years) admitted to a non-ICU bed from the ED at an urban, academic hospital. The intervention, use of AltCA beds, was implemented in 2015 when a new hospital protocol allowed for temporary use of AltCA beds when standard inpatient beds reached capacity. AltCA beds were used primarily during high patient census months, which were September to March of each fiscal year. Patient data were obtained from the electronic medical record for three study periods. The study periods demonstrated gradual increase in use of AltCA beds from the pre-intervention period (9/1/2014 to 3/31/2015) to the transition period (9/1/2015 to 3/31/2016) and was fully operational by the post-intervention period (9/1/2016 to 3/31/2017). The study was approved by the Institutional Review Board at Stanford University. 2.2. Study setting and population Stanford Hospital has 613 licensed beds and is the primary teaching hospital for medical students and residents for Stanford University School of Medicine. The hospital case-mix index was 2.26 in Fiscal Year (FY) 2015 and increased to 2.46 in FY 2017. Most of the standard inpatient beds are located in semi-private, shared patient rooms and with approximately 165 private rooms. The hospital has a patient and family-centered care policy which means visitors can visit patients at any time and stay overnight in the patient's room. The ED is a Level 1 Adult and Level 1 Pediatric Trauma Center, and a comprehensive stroke center. The main ED has 35 beds, the Pediatric ED has 9 beds, and Fast Track has 4 beds. The annual ED census increased from 62,344 in 2014 to 73,767 in 2017. The ED has a 25% admission rate and 47% of the hospital inpatient admissions originate from the ED.
2.3. AltCA bed inclusion criteria We examined all patients who were admitted to an AltCA bed during September 2014–March 2018. Patients were eligible to be in AltCA beds if age ≥ 18 years, and admitted to the hospital from ED to the inpatient floor. The protocol excluded patients admitted to the ICU. 2.4. AltCA bed exclusion criteria Patients were excluded from AltCA beds if they met the following criteria: dementia, active gastrointestinal bleeding, bowel obstruction, use of nasogastric tube, contact isolation, airborne isolation (droplet isolation was not included), supplemental oxygen requirement N4 l by nasal cannula, requiring frequent respiratory interventions (i.e. suctioning or continuous positive airway pressure), psychiatric patients on involuntary holds, or inability to ambulate. 2.5. AltCA bed implementation In 2014, preliminary work was conducted to determine potential location of AltCA beds. Each location was assessed to see what staff would be available and the skill set determined what type of patient could be placed in that AltCA bed location. This process established the total number of AltCA beds that could be used in a surge event. Starting in 2014, AltCA beds were first utilized on a pilot basis. The activation criteria for using AltCA beds were not clearly defined. As the number of available inpatient beds decreased during the day, AltCA beds were often “activated” late at night when many resources were not available to support implementation of AltCA beds. In 2015, a multi-disciplinary group comprised of physicians, nurses, and hospital leadership established criteria to activate AltCA beds. The initial criteria required: 1) having 20 admitted patients boarding in the ED; 2) ten patients waiting to be seen by a physician in the waiting room; and 3) patients in the waiting room were waiting N60 min to be roomed. In 2016, the criteria were simplified to 20 patients boarding in the ED, which meant a third of the ED beds were occupied by boarding patients. A standardized workflow with ten levels was developed to decide how boarding patients would be distributed among the AltCA beds. At Level 1, the first 20 ED boarding patients would be held in the ED. At Level 2, the next ten ED boarding patients were held in the cardiac catheterization lab or endoscopy suite. Preferentially, patients held in the cardiac catheterization lab or endoscopy suite were patients who would receive procedures the following day. At Level 3, the next ten ED boarding patients would be placed in the inpatient hallway beds. At Level 4, the process starts over with the ED boarding the next five admitted patients. This tiered process prevented any one area from getting too many patients all at once. In addition to the standardized workflow, the Hospital Operations Center (HOC) developed a daily report to be sent to the hospital and ED leadership team every morning at 7:00 am. The HOC daily report described the hospital's inpatient capacity for a given day. The report used a predictive model that showed projected admissions based on historical admission data from each intake sources: ED, procedural areas, direct admissions, and transfer center. The hospital had daily huddles at 8:15 am and 1:45 pm with the patient flow leadership team comprised of managers, directors, vice presidents, and executive officers. They reviewed the number of boarding patients and HOC daily report to evaluate bed capacity each day. During the huddles a decision was made whether or not to activate the AltCA beds and an additional huddle was added at 4:00 pm to determine if AltCA beds would be activated later in the day. The activation of AltCA beds was done through a system-wide paging through text, e-mail, and phone which was sent to inpatient floor charge nurses, housekeeping, and other personnel needed to implement AltCA beds. The Charge Nurse from each unit was responsible
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
for obtaining the supplies necessary for each AltCA bed. The hospital transporters brought hospital beds from central supply to each area and General Services transported equipment to the AltCA beds, including the temporary, portable, privacy screen to surround each AltCA bed for privacy. 2.6. Department of Public Health Services regulatory requirement The Hospital Compliance Department formally requested approval for AltCA bed usage through the Department of Public Health Services (DHS). A DHS representative inspected the implementation process and physical spaces prior to granting approval. Approval was granted on a month-to-month basis and DHS was able to inspect AltCA beds, unannounced, at any time. In California, the nurse to patient ratio is 1:4 for non-ICU patients and is strictly maintained at all times. 2.7. Data collection, definition, and outcomes Stanford Hospital uses a paperless, electronic medical record system called EPIC (Verona, WI). The ED triage Emergency Service Index (ESI) Level is assigned by an ED nurse at the time of triage. Trauma patients who arrived by ambulance did not receive an ESI level and trauma patients were classified separately. The use of telemetry was tracked using an electronic order for telemetry. The ED length of stay (LOS) was defined as the time from when the patient arrives in the ED to when the first admission order was placed. The ED boarding hours were calculated from when the first admission order was placed while
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the patient was in the ED to when the patient physically left the ED. The AltCA LOS was the amount of time patients spent in the AltCA bed. The hospital LOS started from the first admission order placed in the ED to when the patient was discharged from the hospital. Our primary patient safety and quality outcomes were: transfer to ICU and inpatient mortality. Transfers to ICU were tracked using an electronic order “Transfer to ICU.” We examined the list of hospital-acquired conditions and chose to focus on conditions that could occur in standard inpatient beds as well as AltCA beds. Since patients were excluded from AltCA beds if they went from the ED directly to the operating room or if they could not ambulate, we did not examine hospital-acquired conditions related to surgeries or pressure ulcers. Our secondary patient safety and quality outcomes were: hospital-acquired infections, falls, and 72-hour hospital readmission. Hospital-acquired infections were defined as catheter associated urinary tract infections, central line associated bacterial infections, surgical site infections, and organism-specific infections such as Clostridium difficile, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus. Patients falls were tracked by electronic reports filed by nurses. We examined 72-hour hospital readmission as a safety outcome rather than hospital LOS since hospital LOS has many factors related to discharge planning rather than a direct patient safety issue. 2.8. Primary data analysis Data analysis was performed using STATA 15/SE, StataCorp LLC, College Station, TX. The exclusion criteria ensured that more lower acuity
Table 1 Demographics and sample characteristics by study period. Characteristics
Entire cohort
Pre-intervention
Transition
Intervention
n (%) AltCA bed (%) Yes No Sex (%) Male Female Age (mean, SD) Race (%) White Asian African-American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Unknown Ethnicity (%) Hispanic/Latino Non-Hispanic/Non-Latino Unknown Insurance (%) MediCare MediCal/MedicAid Managed Care Blue Shield/Blue Cross Other ESI level (%) ESI 2 (emergent) ESI 3 (urgent) Trauma ESI 4 (semi-urgent) Telemetry (%) Yes No Length of stay ED length of stay, hours (median, IQR) ED boarding, hours (median, IQR) AltCA length of stay, hours (median, IQR) Hospital length of stay, days (median, IQR)
16,801
5480 (32.6)
5588 (33.3)
5733 (34.1)
622 (3.7) 16,179 (96.3)
14 (0.3) 5466 (99.7)
71 (1.3) 5517 (98.7)
537 (9.4) 5196 (90.6)
8178 (48.7) 8622 (51.3) 61.5 (19.6)
2695 (49.2) 2785 (50.8) 61.5 (19.7)
2688 (48.1) 2899 (51.9) 61.6 (19.6)
2795 (48.8) 2938 (51.2) 61.6 (19.4)
8791 (52.3) 2488 (14.8) 1228 (7.3) 402 (2.4) 58 (0.4) 3713 (22.1) 121 (0.7)
2930 (53.5) 780 (14.2) 419 (7.7) 119 (2.2) 25 (0.5) 1181 (21.6) 26 (0.5)
2914 (52.2) 848 (15.2) 422 (7.6) 134 (2.4) 14 (0.3) 1214 (21.7) 42 (0.8)
2947 (51.4) 860 (15.0) 387 (6.8) 149 (2.6) 19 (0.3) 1318 (23) 53 (0.9)
2894 (17.2) 13,794 (82.1) 113 (0.7)
916 (16.7) 4540 (82.9) 24 (0.4)
975 (17.5) 4577 (81.9) 36 (0.6)
1003 (17.5) 4677 (81.6) 53 (0.9)
8831 (52.6) 3196 (19.0) 2027 (12.1) 2503 (14.9) 244 (1.4)
2855 (52.1) 2855 (52.1) 662 (12.1) 847 (15.5) 92 (1.7)
2968 (53.1) 1054 (18.9) 650 (11.6) 847 (15.2) 69 (1.2)
3008 (52.5) 1118 (19.5) 715 (12.5) 809 (14.1) 83 (1.4)
4341 (25.8) 11,717 (69.7) 624 (3.7) 743 (4.4)
1501 (27.4) 3744 (68.3) 204 (3.7) 235 (4.3)
1507 (27) 3813 (68.2) 225 (4) 268 (4.8)
1333 (23.3) 4160 (72.6) 195 (3.4) 240 (4.2)
9932 (59.1) 6869 (40.9)
3087 (56.3) 2393 (43.7)
3325 (59.5) 2263 (40.5)
3520 (61.4) 2213 (38.6)
3.5 (2.3, 5.0) 3.2 (1.8, 6.9) 9.6 (3.7, 15.8) 3.4 (1.9, 5.9)
3.4 (1.9, 5.9) 3.1 (1.8, 5.9) 2.3 (0.5, 9.6) 3.1 (1.8, 5.7)
3.5 (2.3, 5.1) 2.9 (1.6, 7.4) 5.2 (2.2, 12.5) 3.4 (1.9, 5.9)
3.5 (2.3, 5.0) 3.5 (1.9, 8.2) 10.1 (4.4, 16.3) 3.6 (2.0, 6.1)
p-Value b0.001⁎
0.58
0.94 0.02⁎
0.02⁎
0.21
b0.001⁎
b0.001⁎
0.63 b0.001⁎ b0.001⁎ b0.001⁎
Abbreviations: AltCA beds = alternative care area beds, ESI = emergency service index. ⁎ Indicates significant p values.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
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M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
patients are admitted to AltCA beds than standard inpatient beds. To adjust for patient acuity and changes over time, we looked at preintervention, transition, and post-intervention periods and compared the outcome rates between the three periods. The AltCA bed utilization and patient safety and quality outcomes for the study periods were compared in unadjusted and multivariable analyses. In the latter, we controlled for age, sex, race, ethnicity, ED triage Emergency Service Index (ESI) Level, and telemetry order. For ESI Level, we excluded patients with ESI Level 1 since none of the AltCA bed patients were classified as ESI Level 1 and all ESI Level 1 patients were admitted to the ICU. Trauma patients often arrived by ambulance and did not consistently receive an ESI Level on arrival and they were placed in a separate category. We performed an instrumental variable analysis using study period as the instrument and the same covariates. To illustrate the need for adjustment, we reported unadjusted relative risk differences between AltCA beds and standard beds. We compared the three study periods with regard to use of AltCA beds, patient demographics, insurance status, ESI Level, and telemetry order. Categorical variables were compared using chi-square test and continuous variables using Wilcoxon rank-sum test, ANOVA or Kruskall-Wallis as appropriate. Our primary patient safety and quality outcomes were transfer to ICU and mortality. Our secondary patient
safety and quality outcomes were hospital-acquired infections, falls, and 72-hour hospital readmission. These outcomes were compared using a two-stage least squares instrumental variable analysis with period as the instrument. The first stage used probit regression with AltCA bed as the dependent variable and study period, age, sex, ESI level, and telemetry order as the independent variables. The second stage used the outcome, e.g., mortality, as the dependent variable and the same covariates, except for period. This analysis estimated the effect of AltCA bed use on overall patient safety and quality outcomes. 3. Results The study included 16,801 patients, of whom 622 patients (3.7%) were admitted to AltCA beds. Table 1 described demographics and sample characteristics by study period. AltCA beds usage increased from 14 beds to 537 over the study period (p b 0.001). The number of ESI 3 (Urgent) increased while the number of ESI 2 (Emergent) decreased. Telemetry use increased from 56.3% to 61.4% over the study periods. Table 2 compared the demographics and sample characteristics of standard inpatient beds with AltCA beds. AltCA beds had younger patients (57.7 years) than standard inpatient beds (61.7 years). AltCA beds had fewer white patients and fewer Medicare and Blue Shield/
Table 2 Demographics and sample characteristics: AltCA beds and standard inpatient beds. Characteristics
Entire cohort
AltCA beds
Standard inpatient beds
n (%) Sex (%) Male Female Age (mean, SD) Race (%) White Asian African-American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Unknown Ethnicity (%) Hispanic/Latino Non-Hispanic/Non-Latino Unknown Insurance (%) MediCare MediCal/MedicAid Managed Care Blue Shield/Blue Cross Other ESI level (%) ESI 2 (emergent) ESI 3 (urgent) Trauma ESI 4 (semi-urgent) Telemetry (%) Yes No Length of stay ED length of stay, hours (median, IQR) ED boarding, hours (median, IQR) Hospital length of stay, days (median, IQR) Admitting service (%) Medicine Surgery Neurology Orthopedics Trauma Obstetrics and Gynecology Neurosurgery Urology Other (Dental, Palliative, Pain)
16,801
622 (3.7)
16,179 (96.3)
8178 (48.7) 8622 (51.3) 61.5 (19.6)
293 (47.1) 329 (52.9) 57.7 (19.2)
7885 (48.7) 8293 (51.3) 61.7 (19.6)
8791 (52.3) 2488 (14.8) 1228 (7.3) 402 (2.4) 58 (0.4) 3713 (22.1) 121 (0.7)
285 (45.8) 91 (14.6) 46 (7.4) 20 (3.2) 2 (0.3) 175 (28.1) 3 (0.5)
8506 (52.6) 2397 (14.8) 1182 (7.3) 382 (2.4) 56 (0.4) 3538 (21.9) 118 (0.7)
2894 (17.2) 13,794 (82.1) 113 (0.7)
129 (20.7) 490 (78.8) 3 (0.5)
2765 (17.1) 13,304 (82.2) 110 (0.7)
8831 (52.6) 3196 (19.0) 2027 (12.1) 2503 (14.9) 244 (1.4)
296 (47.6) 146 (23.5) 93 (15.0) 75 (12.1) 12 (1.9)
8535 (52.8) 3050 (18.9) 1934 (11.9) 2428 (15.0) 232 (1.4)
4341 (25.8) 11,717 (69.7) 624 (3.7) 743 (4.4)
100 (16.1) 487 (78.3) 24 (3.9) 35 (5.6)
4241 (26.2) 11,230 (69.4) 600 (3.7) 708 (4.4)
9932 (59.1) 6869 (40.9)
301 (48.4) 321 (51.6)
9631 (59.5) 6548 (40.5)
3.5 (2.3, 5.0) 3.2 (1.8, 6.9) 3.4 (1.9, 5.9)
3.8 (2.5, 5.2) 4.3 (2.2, 10.2) 2.7 (1.2, 4.8)
3.4 (2.3, 5.0) 3.1 (1.8, 6.8) 3.4 (1.9, 5.9)
12,929 (77.0) 1472 (8.8) 729 (4.3) 489 (2.9) 336 (2.0) 315 (1.9) 207 (1.2) 96 (0.6) 228 (1.4)
421 (67.7) 81 (13.0) 36 (5.8) 13 (2.1) 14 (2.3) 14 (2.3) 8 (1.3) 8 (1.3) 19 (3.1)
12,508 (77.3) 1391 (8.6) 693 (4.3) 476 (2.9) 322 (2.0) 293 (1.8) 199 (1.2) 88 (0.5) 209 (1.3)
p-Value 0.42
b0.001⁎ 0.006⁎
0.06
0.001⁎
b0.001⁎
b0.001⁎
0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎
Abbreviations: AltCA = alternative care area beds, ESI = emergency service index. ⁎ Indicates significant p values.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx Table 3 Number of days alternative care bed activated each month and total number of beds activated. Month/year
Number of days AltCA bed activated
Total number of AltCA beds used
Pre-intervention period 09/2015 – 10/2015 – 11/2015 – 12/2015 – 01/2016 3 02/2016 1 03/2016 5
– – – – 4 1 9
Transition period 09/2016 10/2016 11/2016 12/2016 01/2017 02/2017 03/2017
– 8 3 6 24 13 17
– 3 3 2 10 4 5
Post-intervention period 09/2017 4 10/2017 16 11/2017 15 12/2017 18 01/2018 20 02/2018 20 03/2018 19
10 103 64 83 112 87 78
– none.
Blue Cross insurance than standard inpatient beds. AltCA beds used less telemetry (48.4%) than standard inpatient beds (59.3%). AltCA beds had fewer ESI 2 (26.2%) than standard inpatient beds (16.1%). AltCA beds had more admission by the following services: surgery, neurology, obstetrics and gynecology, and “other” which included dental, palliative, and pain services. Median ED Length of Stay (LOS) remained the same throughout the study period. AltCA beds had longer ED Length of Stay (LOS) (3.8 h) than standard inpatient beds (3.4 h). ED boarding hours increased in the study period. AltCA beds had more ED boarding hours (4.3 h) than standard inpatient beds (3.1 h). The median AltCA LOS increased from 2.3 h to 10.1 h in the study period. Median hospital LOS increased from 3.1 days to 3.6 days in the study period. AltCA beds had shorter hospital LOS (2.7 days) than standard inpatient beds (3.4 days). Table 3 shows the number of days AltCA beds were activated each month and the total number of AltCA beds used each month. Table 4 compared the unadjusted and adjusted risk difference for AltCA beds and standard inpatient beds for the patient safety and quality outcomes. For the primary patient safety and quality outcome, AltCA beds had significantly decreased adjusted risk difference for transfer to ICU −10.6 (95%CI: −18.3, −2.8) and no increased risk for mortality than standard inpatient beds. For the secondary patient safety and quality outcome, AltCA beds had significantly decreased adjusted risk difference for hospital-acquired infections −13.4 (95%CI: −20.3, −6.5) and
5
no increased risk for falls and 72-hour readmission than standard inpatient beds. 4. Discussion We found that AltCA beds did not lead to increased transfers to ICU or mortality compared to standard inpatient beds. In fact, we found that AltCA beds were associated with lower risk of transfers to ICU and hospital-acquired infections than standard inpatient beds. Only one published study has examined the safety of using hallway beds compared to standard inpatient beds, but did not consider potential confounders [16]. Our study had three strengths that are not found in the previous study. First, our study adds new information about the safety of implementing AltCA beds to temporarily increase inpatient bed capacity. Our analysis adjusted for patient illness severity and changes that may have occurred with patient safety and quality outcomes naturally over the study period. For instance, our unadjusted analysis showed similar results as Viccello et al. [16] and found AltCA beds had decreased risk of transfers to ICU and mortality. We also found the number of transfers to ICU decreased significantly during the 3-year study period. With the adjusted analysis, we accounted for the decreasing trend in transfers to ICU over time and still found AltCA beds had decreased risk of transfers to ICU, but not for mortality. Previous studies on hallway beds have been limited to these two outcomes and patient preference for inpatient boarding [16,18-21]. Second, our study examined additional key patient safety and quality outcomes: hospital-acquired infections, falls, and 72-hour hospital readmission. Hospital-acquired infections are particularly important measures that are reported to CMS. This study showed AltCA beds had decreased risk of hospital-acquired infections and had no change in risk with falls and 72-hour hospital readmission. A potential explanation for this finding is the Hawthorne effect which is the change in individual behavior in response to being observed [22]. The AltCA beds located in inpatient hallways may have led to nurses and physicians to increase their hand-washing due to the greater visibility and physical proximity of these patients to the nurses' and physicians' work stations. It is also possible the physical environment of the AltCA beds was less infectious compared to standard inpatient beds which can be located in semi-private rooms; whereas the AltCA beds in the cardiac catheterization lab and endoscopy suite may only have one or two patients in a larger space. Third, this study reported patient LOS metrics for the ED and inpatient setting. AltCA beds may have had longer median ED LOS and ED boarding hours, but had decreased median hospital LOS than standard inpatient beds. This study suggests we could lower the activation criteria to allow for AltCA beds to be used sooner given the significantly longer median ED LOS for AltCA beds compared to standard inpatient beds. The median length of time patients spent in the AltCA beds was 10.1 h in the post-intervention period. This process of “activating” AltCA beds can temporarily increase inpatient bed capacity to alleviate ED crowding due to admitted patients boarding in the ED. This study had three limitations. First, our study design was a before and after study design which means we are limited to the data that is
Table 4 Patient safety and quality outcomes.
Primary outcomes Transfers to ICU (%) Inpatient mortality (%)
Entire cohort Pre-intervention Transition
Intervention p-Value Unadjusted relative risk difference Adjusted relative risk difference
905 (5.4) 434 (2.6)
280 (4.9) 135 (2.4)
Secondary outcomes Hospital-acquired infections (%) 694 (4.1) Falls (%) 165 (1.0) 72-hour hospital readmission (%) 2478 (14.8)
332 (6.1) 149 (2.7)
293 (5.2) 150 (2.7)
252 (4.6) 51 (0.9) 834 (15.2)
244 (4.4) 198 (3.4) 67 (1.2) 47 (0.8) 820 (14.7) 824 (14.4)
0.02⁎ 0.4
−29.1 (95% CI −52.4, 5.4) −69.7 (95% CI −87.4, −27.1)
−10.6 (95% CI −18.3, −2.8) −2.3 (95% CI −7.8, 3.1)
0.005⁎ 0.11 0.44
−42.5 (95% CI −65.3, −4.8) −35.4 (95% CI −76.0, 73.7) −19.9 (95% CI −35.6, −0.5)
−13.4 (95% CI −20.3, −6.5) −1.3 (95% CI −4.7, 2.1) −5.5 (95% CI −17.8, 6.7)
Abbreviations: ICU = intensive care unit. ⁎ Indicates significant p values.
Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052
6
M.O. Lee et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
documented in the electronic medical record and we did not prospectively control which patients were assigned to AltCA beds. We used instrumental variable analysis to account for unknown confounders. Second, our study was limited to one urban, academic center, with a complex patient population which may not be generalizable in other settings with different resources and hospital layout. Third, California has a law that mandates minimum nurse to patient ratio which varies based on patient acuity and must be maintained at all times, even with AltCA beds [23]. The nurse to patient ratio is 1:4 for medical and surgical patients on the floor and the results of the study may be different in other states that do not have a nurse to patient ratio. We recommend further studies are needed to determine the best criteria for patients who are assigned AltCA beds and to see if AltCA bed location contributes to specific patient safety and quality outcomes. 5. Conclusion In summary, AltCA beds were not associated with increased risk of adverse patient safety and quality outcomes than standard inpatient beds without compromising hospital LOS. AltCA beds were associated with decreased risk of transfer to ICU and hospital-acquired infections than standard inpatient beds after adjusting for confounding. This study gives further evidence to the safety of AltCA beds when used to mitigate ED crowding due to boarding of admitted patients. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of interest None. References0 [1] Hospital-based emergency care: at the breaking point. Institute of Medicine. Washington DC: National Academies Press; 2006. [2] Bernstein SL, Aronsky D, Duseja R, et al. Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009;16(1):1–10. https://doi.org/10.1111/j.1553-2712.2008.00295.x Jan. [3] Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000 Jan;35(1):63–8. Review. doi:https://doi.org/10.1016/S0196-0644(00)70105–3. [4] Chatterjee P, Cucchiara BL, Lazarciuc N, et al. Emergency department crowding and time to care in patients with acute stroke. Stroke 2011;42(4):1074–80. https://doi. org/10.1161/STROKEAHA.110.586610 Apr. [5] Hwang U, Richardson L, Livote E, et al. Emergency department crowding and decreased quality of pain care. Acad Emerg Med 2008;15:1248–55. https://doi.org/ 10.1111/j.1553-2712.2008.00267.x.
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Please cite this article as: M.O. Lee, R. Arthofer, P. Callagy, et al., Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.04.052