3,613 research outputs found
Preventing Emergency Department Overutilization for Florida’s Seasonal Resident Population
Background/Local Problem: Seasonal migration of elderly patients to Lee County, Florida result in overcrowding and prolonged wait times in emergency departments. Many of these seasonal residents dissociate the management of their chronic health conditions with a local provider, therefore utilizing the emergency department for non-urgent needs. Purpose: The Seasonal Resident Navigator Program was intended to enhance the coordination of primary care services for elderly seasonal residents by establishing appointments with local primary care providers (PCP) in order to reduce the overutilization of emergency services and improve patient throughput. Methods: A residency and provider assessment tool was incorporated into the Healthpark Medical Center Emergency Department (ED) nurse triage workflow between November 2017-February 2018 in order to identify seasonal residents, age 65 or greater, without an assigned local provider and facilitate proper follow up appointments. Interventions: The percentage of all seasonal resident encounters at Healthpark Medical Center ED pre-and-post intervention were evaluated as well as the percentage of all seasonal residents that maintained their assigned PCP follow up appointment. Open commentary from patients was evaluated to identify perceived barriers from outpatient follow up. Results/Conclusion: The Seasonal Resident Navigator program will contribute to future trends in emergency department utilization and seasonal resident access to care through enhanced coordination between the acute care and primary care sector
Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room
Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the
consequences of diagnostic error vary widely and little is known about the factors predicting error. Our
objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and
discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors
predicting them.
Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary
care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance
through the emergency room and classified as similar or discrepant according to a predefined scheme by
two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of
diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of
patients, diagnosing physicians, and context predicted diagnostic discrepancy.
Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included.
The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic
discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95%
confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05
to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s
assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009).
Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the
emergency room because they occur in every ninth patient and are associated with increased in-hospital
mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention
should focus on context
Comparison of Nurse Staffing Based on Changes in Unit-level Workload Associated with Patient Churn
Aim
This analysis compares the staffing implications of three measures of nurse staffing requirements: midnight census, turnover adjustment based on length of stay, and volume of admissions, discharges and transfers. Background
Midnight census is commonly used to determine registered nurse staffing. Unit-level workload increases with patient churn, the movement of patients in and out of the nursing unit. Failure to account for patient churn in staffing allocation impacts nurse workload and may result in adverse patient outcomes. Method(s)
Secondary data analysis of unit-level data from 32 hospitals, where nursing units are grouped into three unit-type categories: intensive care, intermediate care, and medical surgical. Result
Midnight census alone did not account adequately for registered nurse workload intensity associated with patient churn. On average, units were staffed with a mixture of registered nurses and other nursing staff not always to budgeted levels. Adjusting for patient churn increases nurse staffing across all units and shifts. Conclusion
Use of the discharges and transfers adjustment to midnight census may be useful in adjusting RN staffing on a shift basis to account for patient churn. Implications for nursing management
Nurse managers should understand the implications to nurse workload of various methods of calculating registered nurse staff requirements
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Boarding is Associated with Reduced Emergency Department Efficiency that is not Mitigated by a Provider in Triage
Introduction: Boarding of patients in the emergency department (ED) is associated with decreased ED efficiency. The provider-in-triage (PIT) model has been shown to improve ED throughput, but it is unclear how these improvements are affected by boarding. We sought to assess the effects of boarding on ED throughput and whether implementation of a PIT model mitigated those effects.Methods: We performed a multi-site retrospective review of 955 days of ED operations data at a tertiary care academic ED (AED) and a high-volume community ED (CED) before and after implementation of PIT. Key outcome variables were door to provider time (D2P), total length of stay of discharged patients (LOSD), and boarding time (admit request to ED departure [A2D]).Results: Implementation of PIT was associated with a decrease in median D2P by 22 minutes or 43% at the AED (p < 0.01), and 18 minutes (31%) at the CED (p < 0.01). LOSD also decreased by 19 minutes (5.9%) at the AED and 8 minutes (3.3%) at the CED (p<0.01). After adjusting for variations in daily census, the effect of boarding (A2D) on D2P and LOSD was unchanged, despite the implementation of PIT. At the AED, 7.7 minutes of boarding increased median D2P by one additional minute (p < 0.01), and every four minutes of boarding increased median LOSD by one minute (p < 0.01). At the CED, 7.1 minutes of boarding added one additional minute to D2P (p < 0.01), and 4.8 minutes of boarding added one minute to median LOSD (p < 0.01).Conclusion: In this retrospective, observational multicenter study, ED operational efficiency was improved with the implementation of a PIT model but worsened with boarding. The PIT model was unable to mitigate any of the effects of boarding. This suggests that PIT is associated with increased efficiency of ED intake and throughput, but boarding continues to have the same effect on ED efficiency regardless of upstream efficiency measures that may be designed to minimize its impact
Quantile regression and an application: performance improvement of an emergency department in Eastern Europe
ED (emergency department) overcrowding is a problem faced by hospitals worldwide. Several studies have been performed to find solutions, but only few have proposed to decrease the length of stay by employing a radiologist in the ED. This study aims to improve emergency care in an Eastern European ED by measuring the parameters of crowding, introducing interventions based on the results, and evaluating their outcomes. As the length of stay is a typically skewed distribution variable, robust quantile regression is applied. The number of patients visiting the ED was measured from July 2014 to December 2015. The input, throughput and output parameters of ED crowding were evaluated throughout this period. The time intervals between the various stages of patient visits to the ED significantly decreased during the study period. The continuous measurement of ED process parameters is important to maintain time intervals within a specified range. Decreased process times between the pre- and post-intervention phases of the study were obtained by introducing several staff-centric changes. The presence of a dedicated radiologist in the ED has significantly decreased the turnaround times of imaging studies
A survey of health care models that encompass multiple departments
In this survey we review quantitative health care models to illustrate the extent to which they encompass multiple hospital departments. The paper provides general overviews of the relationships that exists between major hospital departments and describes how these relationships are accounted for by researchers. We find the atomistic view of hospitals often taken by researchers is partially due to the ambiguity of patient care trajectories. To this end clinical pathways literature is reviewed to illustrate its potential for clarifying patient flows and for providing a holistic hospital perspective
Reducing Emergency Department Length-of-Stay and Overcrowding through Team Triage
Emergency department (ED) overcrowding is an internationally studied phenomenon linked to adverse patient outcomes, including death. Early medical screening exams (MSE) may prevent morbidity and mortality. Yet, EDs struggle to evaluate, treat, and discharge patients within recommended and nationally monitored benchmark times. This evidence-based scholarly project explored if stationing an advanced practice provider (APP) in triage would improve door-provider-times, length-of-stay (LOS), and the left without being seen (LWBS) rate at a medical center ED in the southeastern United States. A pre- and post-intervention design compared benchmark times after a provider triaged alongside the registered nurse (RN) during times of high census. The provider performed MSE and ordered diagnostic tests. Comparison of the two triage methods showed a significant reduction of median door-to-provider time, a decrease in LOS, and decline in LWBS rates. These findings indicate that stationing a provider in triage during times of high patient census can improve benchmark times and overcrowding
Implementation of a Hospital-Wide Surge Plan to Reduce Emergency Department Length of Stay
Practice Problem: Suboptimal patient flow throughout the hospital has resulted in an increased length of stay (LOS) for emergency department patients and the potential for adverse events.
PICOT: In admitted and discharged emergency room patients (P), how does a hospital-wide surge plan (I) compared to current throughput plan (C) affect the length of stay (O) within 8 weeks?
Evidence: The literature evidence reviewed supported the implementation of a hospital-wide surge plan approach positively impacts the emergency room length of stay and patient outcomes.
Intervention: The primary intervention for this project was the implementation of a hospital-wide surge policy. Targeted interventions focused on protocols for all areas to expedite processes to improve throughput and decrease the LOS for ED admitted and discharged patients.
Outcome: While the post-data results did not have a statistically significant change in the ED length of stay (LOS) for admitted and discharged patients, the results nevertheless, demonstrated a significant clinical impact on hospital-wide throughput and clinical outcomes.
Conclusion: Using a hospital-wide surge plan effectively improves hospital throughput and can lead to a decrease in ED length of stay for admitted and discharged patients. This project helped the leaders implement new processes to improve collaboration and throughput in the organization
Exit block in emergency departments: a rapid evidence review.
BACKGROUND: Exit block (or access block) occurs when 'patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame'. Exit block is an increasing challenge for Emergency Departments (EDs) worldwide and has been recognised as a major factor in leading to departmental crowding. This paper aims to identify empirical evidence, highlighting causes, effects and strategies to limit exit block. METHODS: A computerised literature search was conducted of English language empirical evidence published between 2008 and 2014 using a combination of terms relating to exit block in ED. RESULTS: 233 references were identified following the computerised search. Of these, 32 empirical articles of varying scientific quality were identified as relevant and results were presented under a number of headings. The majority of studies presented data relating to the impact of exit block on departments, patients and staff. A smaller number of articles evaluated interventions designed to reduce exit block. Evidence suggests that exit block is more likely to occur in more densely populated areas and less likely to occur in paediatric settings. Bed occupancy appears to be associated with exit block. Evidence supporting the impact of initiatives pointed towards increasing workforce and inpatient bed resources within the hospital setting to reduce block. CONCLUSIONS: Further evidence is needed, especially within the NHS setting to increase the understanding around factors that cause exit block, and interventions that are shown to relieve it without compromising patient outcomes
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