scholarly journals Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
Charles W. Hwang ◽  
Thomas Payton ◽  
Emily Weeks ◽  
Michelle Plourde
Keyword(s):  
Emergency Department ◽  
Retrospective Cohort ◽  
Medical Decision Making ◽  
Medical Director ◽  
Diagnostic Assessment ◽  
Medical Decision ◽  
Ed Crowding ◽  
Assessment Strategies ◽  
The Impact ◽  
Disposition Time

Emergency departments (EDs) throughout USA have improvised various processes to curb the “national epidemic” termed ED “crowding.” Standing orders (SOs), one such process, are medical orders approved by the medical director and entered by nurses when patients cannot be seen expeditiously, expediting medical decision-making and decreasing length of stay (LOS) and time to disposition. This retrospective cohort study evaluates the impact of SOs on ED LOS and disposition time at a large university ED. Results indicate that SOs significantly improve ED throughput by reducing disposition time by up to 16.9% (p=0.04), which is especially significant in busy ED settings. SOs by themselves are not sufficient for a complete diagnostic assessment. Strategies such as having a provider in the waiting area may help make key decisions earlier.

scholarly journals The Effects of Implementing a “Waterfall” Emergency Physician Attending Schedule

2021 ◽  
Vol 22 (4) ◽  
pp. 882-889
Author(s):  
Lindsey Spiegelman ◽  
Maxwell Jen ◽  
Danielle Matonis ◽  
Ryan Gibney ◽  
Saadat Soheil ◽  
...  
Keyword(s):  
Emergency Department ◽  
Intervention Period ◽  
Post Intervention ◽  
Physician Staffing ◽  
Left Without Being Seen ◽  
Ed Visits ◽  
Waterfall Model ◽  
Ed Crowding ◽  
The Impact ◽  
Disposition Time

Introduction: Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies. Methods: This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits. Results: The change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001). Conclusion: Implementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.

scholarly journals P140: Emergency department decision-making for incapacitated and unrepresented patients: a comprehensive review of the literature

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S124-S125
Author(s):  
J.L. Willinsky ◽  
I. Hyun
Keyword(s):  
Decision Making ◽  
Emergency Department ◽  
Medical Decision Making ◽  
Hospital Setting ◽  
Ethics Committees ◽  
Medical Decision ◽  
Review Of The Literature ◽  
Comprehensive Review ◽  
Patient Cohort ◽  
Decision Making Processes

Introduction: Incapacitated patients who lack substitute decision-makers (SDM) are commonly encountered in the emergency department (ED). The number of these patients will rise dramatically as the Baby Boomers age. We can expect an influx of elderly patients who lack decisional capacity due to dementia and other illnesses, and who present without family. It is estimated that 3 to 4 percent of U.S. nursing home residents have no SDM or advance directives. Medical decision-making for this cohort poses an ethical challenge, particularly in the ED setting. Methods: A comprehensive review of the literature was conducted surrounding decision-making for incapacitated and unrepresented patients in the hospital setting. Articles were identified using MEDLINE (1946-October 2015) and Embase (1974-October 2015). The reference lists of relevant articles were hand searched. Articles describing decision-making processes that have been proposed, tested or applied in practice were chosen for full review. The aim of this review was to outline recognized medical decision-making processes for incapacitated and unrepresented patients, and to identify areas for future research. Results: The search yielded 20 articles addressing decision-making for incapacitated and unrepresented patients in the hospital setting. All of these articles focus on the intensive care unit and other hospital wards; no literature on the ED setting was found. Five types of formal consulting bodies exist to assist physicians in applying the best interest standard for this patient cohort: internal hospital ethics committees, external ethics committees, public guardians, court-appointed guardians, or judges. The majority of decisions for these patients, however, are made informally by a single physician or by a healthcare team, although it is well recognized that this approach lacks appropriate safeguards. There is no consensus surrounding the optimal approach to decision-making in these cases, and as such there is significant inconsistency in how medical decisions are made for these patients. Conclusion: There are several articles describing decision-making processes for incapacitated and unrepresented patients, none of which focus on the ED. These processes are not practical for use in the ED. Further inquiry is needed into the most ethical and respectful method of decision-making for this patient cohort in the ED.

scholarly journals (P2-74) Does Implementation of Protocols Improve the Red Area Disposition Time of Emergency Department at a Level-1 Trauma Center?

2011 ◽  
Vol 26 (S1) ◽  
pp. s160-s160
Author(s):  
R. Kumar ◽  
K. Shyamla ◽  
S. Bhoi ◽  
T.P. Sinha ◽  
S. Chauhan ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Emergency Department ◽  
Trauma Center ◽  
Safety Issues ◽  
Ed Visits ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center ◽  
Final Disposition ◽  
Disposition Time

BackgroundAcute care addresses immediate resuscitation and early disposition to definitive care. Delay in final disposition from the emergency department (ED) affects outcomes in terms of morbidity and mortality. An audit was performed to assess the impact of protocols on red area disposition time.MethodsAn audit of red (resuscitation) area disposition time was performed among patients with compromised airway, breathing, and circulation. The red area disposition time was defined as the time from ED arrival to red area disposition. Pre-protocol data from nursing report books were reviewed for ED to operating room (OR), ED to intensive care unit (ICU), and overall disposition time between September 2007 and January 2008. Similar outcomes were documented after implementation of protocols during February to December 2008.ResultsIn the pre-protocol period, 992 red area patients were enrolled out of 10,000 ED visits. Out of which 527 (53.1%) were shifted to the OR and 222 (22.3%) to ICU. The average ED disposition time was 3.5 hours (range 2–5). Similarly, 1797 red area patients were enrolled in the post-protocol period out of 25,928. Of these, 453 (25.2%) patients were shifted to the OR, and 423 (23.7%) were shifted to the ICU. The average ED disposition time was 1.5 hours (range 10 minutes–3 hours).ConclusionsImplementation of protocols improves the red area disposition time of the ED. Auditing is an important tool to address patient safety issues.

scholarly journals Indirect impact of the COVID-19 pandemic on emergency department presentations and hospital admissions for urgent early pregnancy conditions: a population-based retrospective cohort study

2021 ◽  
Author(s):  
Lisa Hui ◽  
Wanyu Chu ◽  
Elizabeth McCarthy ◽  
Mary McCarthy ◽  
Paddy Moore ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Early Pregnancy ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Linear Prediction ◽  
Hospital Admissions ◽  
Population Based ◽  
Termination Of Pregnancy ◽  
The Impact

Objective: To compare emergency department (ED) presentations and hospital admissions for urgent early pregnancy conditions in Victoria before and after the onset of COVID-19 lockdown on 31 March 2020. Design: Population-based retrospective cohort study Setting: Australian state of Victoria Population: Pregnant women presenting to emergency departments or admitted to hospital Methods: We obtained state-wide hospital separation data from the Victorian Emergency Minimum Dataset and the Victorian Admitted Episodes Dataset from January 1, 2018, to October 31, 2020. A linear prediction model based on the pre-COVID period was used to identify the impact of COVID restrictions. Main outcome measures: Monthly ED presentations for miscarriage and ectopic pregnancy, hospital admissions for termination of pregnancy, with subgroup analysis by region, socioeconomic status, disease acuity, hospital type. Results: There was an overall decline in monthly ED presentations and hospital admissions for early pregnancy conditions in metropolitan areas where lockdown restrictions were most stringent. Monthly ED presentations for miscarriage during the COVID period were consistently below predicted, with the nadir in April 2020 (790 observed vs 985 predicted, 95% CI 835-1135). Monthly admissions for termination of pregnancy were also below predicted throughout lockdown, with the nadir in August 2020 (893 observed vs 1116 predicted, 95% CI 905-1326). There was no increase in ED presentations for complications following abortion, ectopic or molar pregnancy during the COVID period. Conclusions: Fewer women in metropolitan Victoria utilized hospital-based care for early pregnancy conditions during the first seven months of the pandemic, without any observable increase in maternal morbidity.

scholarly journals MP38: The impact of physician handoffs on the outcomes of emergency department patients: a medical administrative database retrospective cohort study

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S56-S56
Author(s):  
A. Mokhtari ◽  
D. Simonyan ◽  
A. Pineault ◽  
M. Mallet ◽  
S. Blais ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Emergency Physician ◽  
Retrospective Cohort ◽  
Independent Predictor ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Emergency Physicians ◽  
Icu Admission ◽  
The Impact

Introduction: A physician handoff is the process through which physicians transfer the primary responsibility of a care unit. The emergency department (ED) is a fast-paced and crowded environment where the risk of information loss between shifts is significant. Yet, the impact of handoffs between emergency physicians on patient outcomes remains understudied. We performed a retrospective cohort study in the ED to determine if handed-off patients, when compared to non-handed-off patients, were at higher risk of negative outcomes. Methods: We included every adult patient first assessed by an emergency physician and subsequently admitted to hospital in one of the five sites of the CHU de Québec-Université Laval during fiscal year 2016-17. Data were extracted from the local hospital discharge database and the ED information system. Primary outcome was mortality. Secondary outcomes were incidence of ICU admission and surgery and hospital length of stay. We conducted multilevel multivariate regression analyses, accounting for patient and hospital clusters and adjusting for demographics, CTAS score, comorbidities, admitting department delay before evaluation by an emergency physician and by another specialty, emergency department crowding, initial ED orientation and handoff timing. We conducted sensitivity analyses excluding patients that had an ED length of stay > 24 hours or events that happened after 72 hours of hospitalization. Results: 21,136 ED visits and 17,150 unique individuals were included in the study. Median[Q1-Q3] age, Charlson index score, door-to-emergency-physician time and ED length of stay were 71[55-83] years old, 3[1-4], 48 [24,90] minutes, 20.8[9.9,32.7] hours, respectively. In multilevel multivariate analysis (OR handoff/no handoff [CI95%] or GMR[SE]), handoff status was not associated with mortality 0.89[0.77,1.02], surgery 0.95[0.85,1.07] or hospital length of stay (-0.02[0.03]). Non-handed-off patients had an increased risk of ICU admission (0.75[0.64,0.87]). ED occupancy rate was an independent predictor of mortality and ICU admission rate irrespectively of handoff status. Sensitivity and sub-group based analyses yielded no further information. Conclusion: Emergency physicians’ handoffs do not seem to increase the risk of severe in-hospital adverse events. ED occupancy rate is an independent predictor of mortality. Further studies are needed to explore the impact of ED handoffs on adverse events of low and moderate severity.

The impact of “significant others” on breast cancer patients’ treatment decision making.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 20-20
Author(s):  
Suepattra G. May ◽  
Katharine Rendle ◽  
Meghan Halley ◽  
Nicole Ventre ◽  
Allison W. Kurian ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Decision Making ◽  
Cancer Patients ◽  
Medical Decision Making ◽  
Treatment Decision ◽  
Significant Others ◽  
Medical Decision ◽  
Breast Cancer Patients ◽  
Treatment Decision Making ◽  
The Impact

20 Background: Shared medical decision making (SDM) has been lauded by advocates for its potential to democratize the patient-physician relationship. However, the practice of SDM is still conceived of as largely a dyadic moment that exists between the patient and the physician. Few studies have looked at the role of significant others (spouses, partners, family members and friends) in decision making or considered how discussions and actions outside the consultation room affect a patient’s medical decisions. This prospective study investigated the impact of significant others on the decision making deliberations of newly diagnosed breast cancer patients. Methods: Forty-one newly diagnosed breast cancer patients were interviewed at four critical time points throughout treatment to explore how they deliberated decisions with both care providers and significant others. Surveys assessing HRQOL, role preferences and treatment satisfaction along with EHR abstraction augmented interview data. Grounded theory analysis was used to identify recurrent themes in the qualitative data, and survey data were analyzed using IBM SPSS Statistics 20. Results: Emergent themes from our analysis identified several factors that patients consider when faced with cancer treatment decisions, including 1) presentation of treatment options 2) patient or significant other conflict/concordance with care team recommendations 3) perceived risk of recurrence and 4) short and long term impact of treatment on daily life. Participants stressed the need for clinicians to view patients beyond diagnosis and recognize their larger care network as influential factors in their decision making. Conclusions: Our interviews highlight how the current healthcare delivery structure rarely acknowledges the circles of care that can exert influence on decision making. Lack of attention to non-clinical others can lead to sub-optimal medical decision making because these influences are not adequately understood by clinicians. Findings from this study suggest the need to enhance clinicians’ and researchers’ understanding of the influence of others in patients’ treatment decision making, enabling them to intervene in these practices.

scholarly journals The association between the transfer of emergency department admitted patients to inpatient hallways and outcomes of oncology patients

2015 ◽  
Vol 4 (2) ◽  
pp. 1 ◽  
Author(s):  
Charles Lim ◽  
Matthew C. Cheung ◽  
Maureen E. Trudeau ◽  
Kevin R. Imrie ◽  
Ben De Mendonca ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Patient Flow ◽  
Vital Signs ◽  
Medication Administration ◽  
Oncology Patients ◽  
Flow Quality ◽  
Ed Crowding ◽  
The Impact

Objective: A protocol was implemented to ease Emergency Department (ED) crowding by moving suitable admitted patients into inpatient hallway beds (HALL) or off-service beds (OFF) when beds on an admitting service’s designated ward (ON) were not available. This study assessed the impact of hallway and off-service oncology admissions on ED patient flow, quality of care and patient satisfaction.Methods: Retrospective and prospective data were collected on patients admitted to the medical oncology service from Jan 1 to Dec 31, 2011. Data on clinician assessments and time performance measures were collected. Satisfaction surveys were prospectively administered to all patients. Results: Two hundred and ninty-seven patients (117 HALL, 90 OFF, 90 ON) were included in this study. There were no significant differences between groups for frequency of physician assessments, physical exam maneuvers at initial physician visit, time to complete vital signs or time to medication administration. The median (IQR) time spent admitted in the ED prior to departure from the ED was significantly longer for HALL patients (5.53 hrs [1.59-13.03 hrs]) compared to OFF patients (2.00 hrs [0.37-3.69 hrs]) and ON patients (2.18 hrs [0.15-5.57 hrs]) (p < .01). Similarly, the median (IQR) total ED length of stay was significantly longer for HALL patients (13.82 hrs [7.43-20.72 hrs]) compared to OFF patients (7.18 hrs [5.72-11.42 hrs]) and ON patients (9.34 hrs [5.43-14.06 hrs]) (p < .01). HALL patients gave significantly lower overall satisfaction scores with mean (SD) satisfaction scores for HALL, OFF and ON patients being 3.58 (1.20), 4.23 (0.58) and 4.29 (0.69) respectively (p < .01). Among HALL patients, 58% were not comfortable being transferred into the hallway and 4% discharged themselves against medical advice. Conclusions: The protocol for transferring ED admitted patients to inpatient hallway beds did not reduce ED length of stay for oncology patients. The timeliness and frequency of clinical assessments were not compromised; however, patient satisfaction was decreased.

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