Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians

Introduction: We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs’ perceptions about ongoing critical care delivery in the ED while awaiting ICU admission.Methods: Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients “boarding” in the ED for >4-6 hours.Results: We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs’ ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients.Conclusion: Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints

Boarding of critically Ill patients in the emergency department

ObjectivesEmergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.Data sources and study selectionReview article.Data extraction and data synthesisEmergency department- based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department- based interventions, hospital- based interventions, and emergency department- based resuscitation care units.ConclusionsEmergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department- based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156455/2/emp212107_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156455/1/emp212107.pd

Improving Patient Satisfaction with the Virtual Handoff Process through the Utilization of Educational Pamphlets in the Emergency Department

Boarding patients in the emergency room while waiting to transfer the patient to the proper unit can be harmful to clinical care and have significant financial opportunity costs. At one local hospital it was found that on average patients were being boarded in the emergency room (ED) for approximately 85 minutes waiting to be transferred. Several barriers that caused this delay were found including, delay in room cleaning, nurse staff shortage, and inability to give report to the nurse receiving the patient. In an attempt to combat this delay which may be caused by a difficulty in giving patient report, this organization is rolling out a virtual bedside handoff process. While virtual technology is not a new concept, there are many patients that may not be comfortable with the technology. The purpose of the evidence-based project was to provide a written educational pamphlet that details the how’s and why’s of the virtual handoff process to the patient to be given upon admission. The goal of the educational pamphlet was to increase the patients’ satisfaction with the process. A pre-survey was given to a group of patients after they experienced the virtual handoff process to assess their comfort level. These results were compared to the post-survey results of patients that received the educational pamphlet prior to experiencing the virtual handoff process. Ten pre-surveys and seven post-surveys were analyzed utilizing SPSS and descriptive statistics. The analysis concluded that the participants who received the educational pamphlet felt more prepared for the virtual handoff process

Associations of Emergency Department Length of Stay With Publicly Reported Quality-of-care Measures.

OBJECTIVE: The Institute of Medicine identified emergency department (ED) crowding as a critical threat to patient safety. We assess the association between changes in publicly reported ED length of stay (LOS) and changes in quality-of-care measures in a national cohort of hospitals. METHODS: Longitudinal analysis of 2012 and 2013 data from the American Hospital Association (AHA) Survey, Center for Medicare and Medicaid Services (CMS) Cost Reports, and CMS Hospital Compare. We included hospitals reporting Hospital Compare timeliness measure of LOS for admitted patients. We used AHA and CMS data to incorporate hospital predictors of interest. We used the method of first differences to test for relationships in the change over time between timeliness measures and six hospital-level measures. RESULTS: The cohort consisted of 2,619 hospitals. Each additional hour of ED LOS was associated with a 0.7% decrease in proportion of patients giving a top satisfaction rating, a 0.7% decrease in proportion of patients who would definitely recommend the hospital, and a 6-minute increase in time to pain management for long bone fracture (p \u3c 0.01 for all). A 1-hour increase in ED LOS is associated with a 44% increase in the odds of having an increase in left without being seen (95% confidence interval = 25% to 68%). ED LOS was not associated with hospital readmissions (p = 0.14) or time to percutaneous coronary intervention (p = 0.14). CONCLUSION: In this longitudinal study of hospitals across the United States, improvements in ED timeliness measures are associated with improvements in the patient experience

Diagnosis and management of pneumonia in the emergency department.

Pneumonia is a condition that is often treated by emergency physicians. This article reviews the diagnosis and management of pneumonia in the emergency department and highlights dilemmas in diagnostic testing, use of blood and sputum cultures, hospital admission decisions, infection control, quality measures for pneumonia care, and empiric antimicrobial therapy

Telemedicine coverage for post-operative ICU patients.

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical care service from January 1st 2008 to July 31st 2011 was conducted at an urban, academic, tertiary centre and level 1 trauma centre. Results Compared to the SICU group ( n = 6652), patients in the VICU group ( n = 1037) were slightly older (median age 60 (IQR 47-69) versus 58 (IQR 44-70) years, p = 0.002) and had lower acute physiology and chronic health evaluation (APACHE) II scores (median 10 (IQR 7-14) versus 15 (IQR 11-21), p \u3c 0.001). The average amount of time patients spent in the VICU was 13.7 + /-9.6 hours. In the VICU group, 750 (72%) of patients were able to be transferred directly to the floor; 287 (28%) required subsequent admission to the surgical intensive care unit. All patients in the VICU group were alive upon transfer out of the PACU while mortality in the surgical intensive unit cohort was 5.5%. Discussion A collaborative care model between a surgical critical care service and a telemedicine ICU service may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation

Look right! A retrospective study of pedestrian accidents involving overseas visitors to London

Introduction: Research within the European Union has shown international visitors to have a higher injury mortality than residents. Traffic accidents are the leading cause of injury-related death among overseas visitors and evidence suggests overseas visitors are at a greater risk of being involved in road traffic accidents than the resident population. Little information looks specifically at pedestrian injuries to overseas visitors. Pedestrian deaths account for 21% of all UK road deaths. Methods: A retrospective database review of London helicopter emergency medical service (HEMS) missions was undertaken to examine the number and type of missions to overseas visitors, specifically examining pedestrian incidents. Results: Of 121 missions to overseas visitors, 74 (61%) involved the visitor as a pedestrian struck by a vehicle. Thirty-five pedestrians (47%) were struck by a bus and 20 by a car (27%). Fourteen patients (19%) had an initial Glasgow coma scale score of 3–8, suggesting severe head injury and half of all patients required prehospital intubation (38/74, 51%). Mortality was 16% (12/74%) and 62 patients (84%) survived to hospital discharge. Of 39 patients admitted to the Royal London Hospital, the average injury severity score (ISS%) was 23.0 (ISS >15 denotes severe trauma) with a mean inpatient stay of 17.9 days. Conclusion: During the 7-year period studied, 61% of HEMS missions to overseas visitors involved a pedestrian being struck by a vehicle, compared with 16% of missions to UK residents. For HEMS missions, serious trauma to pedestrians is disproportionally more common among the visitor population to London

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