ED I-PASS: A Streamlined Version of the I-PASS Patient Handoff Tool for the Emergency Department

Audience: The target audience for this presentation includes attendings, residents, advanced practice providers, and medical students who work in the emergency department (ED). Introduction: The Joint Commission estimates that 80% of serious medical errors are related to miscommunication between providers during transitions of care (also known as patient “handoffs” or “sign-outs”)1. An organized approach to patient handoffs has the potential to significantly improve patient safety in the ED. The multicenter I-PASS study2 showed that implementing the I-PASS handoff process3 significantly decreased medical errors and adverse events. However, these studies were conducted on inpatient wards, subject to different workflows than the ED. The attached curriculum presents a streamlined version of I-PASS that can be performed efficiently in the ED. Objectives: The purpose of this presentation is to provide ED providers with a tool that may improve the safety of their patient handoffs. By the end of this presentation, the learner will be able to 1) describe the importance of safe and efficient handoffs, 2) recall each element of the I-PASS mnemonic, and 3) demonstrate an understanding of how it can be feasibly performed in a busy ED setting. Method: This educational module features 1) a PowerPoint presentation with an embedded audio track and hyperlinks to videos, and 2) a multiple-choice question (MCQ) exam. Two appendices are also provided as additional resources: 1) an “ED-IPASS Fast Facts” quick reference guide, and 2) a transcript of the videos with optional debriefing exercises. Topics: This presentation includes a comprehensive, self-contained ED handoff training module utilizing I-PASS streamlined for the ED. It outlines the importance of effective communication in patient handoffs, reviews the I-PASS mnemonic, and illustrates examples of how it may be adapted to the ED setting

ED I-PASS: A Streamlined Version of the I-PASS Patient Handoff Tool for the Emergency Department

Audience: The target audience for this presentation includes attendings, residents, advanced practice providers, and medical students who work in the emergency department (ED). Introduction: The Joint Commission estimates that 80% of serious medical errors are related to miscommunication between providers during transitions of care (also known as patient “handoffs” or “sign-outs”)1. An organized approach to patient handoffs has the potential to significantly improve patient safety in the ED. The multicenter I-PASS study2 showed that implementing the I-PASS handoff process3 significantly decreased medical errors and adverse events. However, these studies were conducted on inpatient wards, subject to different workflows than the ED. The attached curriculum presents a streamlined version of I-PASS that can be performed efficiently in the ED. Objectives: The purpose of this presentation is to provide ED providers with a tool that may improve the safety of their patient handoffs. By the end of this presentation, the learner will be able to 1) describe the importance of safe and efficient handoffs, 2) recall each element of the I-PASS mnemonic, and 3) demonstrate an understanding of how it can be feasibly performed in a busy ED setting. Method: This educational module features 1) a PowerPoint presentation with an embedded audio track and hyperlinks to videos, and 2) a multiple-choice question (MCQ) exam. Two appendices are also provided as additional resources: 1) an “ED-IPASS Fast Facts” quick reference guide, and 2) a transcript of the videos with optional debriefing exercises. Topics: This presentation includes a comprehensive, self-contained ED handoff training module utilizing I-PASS streamlined for the ED. It outlines the importance of effective communication in patient handoffs, reviews the I-PASS mnemonic, and illustrates examples of how it may be adapted to the ED setting

Compliance with an Ordinance Requiring the Use of Personal Flotation Devices by Children in Public Waterways

INTRODUCTION: For children ages 1–14, 21.6% of drowning cases involve swimming, wading, or playing in natural bodies of water, such as rivers and lakes. Personal flotation devices (PFDs) are believed to be an effective prevention measure. We measure compliance with city and county ordinances, publicized but not actively enforced, requiring that PFDs be worn by children accessing public bodies of water in Sacramento County, California. METHODS: During June–August 2010, volunteers conducted 79 observation sessions at three popular local river beaches where PFDs were available for use at no cost. They recorded personal characteristics and PFD use for 1,727 children in or very near the water and believed to be 0–13 years of age (the age covered by the ordinances). We used logistic regression to quantify differences in use by subject characteristics and study site. RESULTS: The prevalence of PFD use was 29.9% overall, with large and significant differences by age: < 1, 55.6%; 1–4, 37.6%; 5–10, 29.4%; 10–13, 14.6%; P < 0.0001. Usage did not vary significantly by sex or race/ethnicity, and was somewhat higher at one study site (33.1%) than at the others (25.9% and 27.3%), P = 0.009. CONCLUSION: The combination of a statutory requirement and a cost-elimination strategy was associated with moderate rates of PFD use that were highest among young children

Compliance with an Ordinance Requiring the Use of Personal Flotation Devices by Children in Public Waterways

Introduction: For children ages 1-14, 21.6% of drowning cases involve swimming, wading, or playing in natural bodies of water, such as rivers and lakes. Personal flotation devices (PFDs) are believed to be an effective prevention measure. We measure compliance with city and county ordinances, publicized but not actively enforced, requiring that PFDs be worn by children accessing public bodies of water in Sacramento County, California.Methods: During June-August 2010, volunteers conducted 79 observation sessions at three popular local river beaches where PFDs were available for use at no cost. They recorded personal characteristics and PFD use for 1,727 children in or very near the water and believed to be 0-13 years of age (the age covered by the ordinances). We used logistic regression to quantify differences in use by subject characteristics and study site.Results: The prevalence of PFD use was 29.9% overall, with large and significant differences by age: &lt; 1, 55.6%; 1-4, 37.6%; 5-10, 29.4%; 10-13, 14.6%; P &lt; 0.0001. Usage did not vary significantly by sex or race/ethnicity, and was somewhat higher at one study site (33.1%) than at the others (25.9% and 27.3%), P = 0.009.Conclusion: The combination of a statutory requirement and a cost-elimination strategy was associated with moderate rates of PFD use that were highest among young children. [West J Emerg Med 2013;14(2):200-203.

Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income

Introduction: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities.Methods: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March–June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019.Results: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P &lt; 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods &lt;300% federal poverty levels (FPL), visits were –3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at &gt;400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased.Conclusion: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities

Patient Age, Race and Emergency Department Treatment Area Associated with “Topbox” Press Ganey Scores

Introduction: Hospitals commonly use Press Ganey (PG) patient satisfaction surveys forbenchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest,which is known as the “topbox” score. Our objective was to identify patient and physician factorsassociated with topbox PG scores in the emergency department (ED).Methods: We looked at PG surveys from January 2015–December 2017 at an academic, urbanhospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions:“Likelihood of your recommending our ED to others”; and “Courtesy of the doctor.” We analyzedtopbox scores using generalized estimating equation models clustered by physician and adjustedfor patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED areawhere patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical(urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physicianfactors included age, gender, race, ethnicity, and number of years at current institution.Results: We analyzed a total of 3,038 surveys. For “Likelihood of your recommending our ED toothers,” topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95%confidence interval [CI], 1.03-1.12); less likely among female compared to male patients (OR 0.81;95% CI, 0.70-0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60-0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54-0.93) and vertical areas (OR 0.71; 95% CI0.53-0.95) compared to fast track. For “Courtesy of the doctor,” topbox scores were more likely withincreasing patient age (OR 1.1; CI, 1.06-1.14); less likely among Asian (OR 0.70; 95% CI, 0.58-0.84),Black (OR 0.66; 95% CI ,0.45-0.96), and Hispanic patients (OR 0.68; 95% CI ,0.55-0.83) compared toWhite patients; and less likely in urgent area (OR 0.69; 95% CI ,0.50-0.95) compared to fast track.Conclusion: Increasing patient age was associated with increased likelihood of topbox scores,while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. Weencourage hospitals that use PG topbox scores as financial incentives to understand the contributionof non-service factors to these scores

Effectiveness, safety, and efficiency of a drive‐through care model as a response to the COVID‐19 testing demand in the United States

Abstract Objectives Here we report the clinical performance of COVID‐19 curbside screening with triage to a drive‐through care pathway versus main emergency department (ED) care for ambulatory COVID‐19 testing during a pandemic. Patients were evaluated from cars to prevent the demand for testing from spreading COVID‐19 within the hospital. Methods We examined the effectiveness of curbside screening to identify patients who would be tested during evaluation, patient flow from screening to care team evaluation and testing, and safety of drive‐through care as 7‐day ED revisits and 14‐day hospital admissions. We also compared main ED efficiency versus drive‐through care using ED length of stay (EDLOS). Standardized mean differences (SMD) >0.20 identify statistical significance. Results Of 5931 ED patients seen, 2788 (47.0%) were walk‐in patients. Of these patients, 1111 (39.8%) screened positive for potential COVID symptoms, of whom 708 (63.7%) were triaged to drive‐through care (with 96.3% tested), and 403 (36.3%) triaged to the main ED (with 90.5% tested). The 1677 (60.2%) patients who screened negative were seen in the main ED, with 440 (26.2%) tested. Curbside screening sensitivity and specificity for predicting who ultimately received testing were 70.3% and 94.5%. Compared to the main ED, drive‐through patients had fewer 7‐day ED revisits (3.8% vs 12.5%, SMD = 0.321), fewer 14‐day hospital readmissions (4.5% vs 15.6%, SMD = 0.37), and shorter EDLOS (0.56 vs 5.12 hours, SMD = 1.48). Conclusion Curbside screening had high sensitivity, permitting early respiratory isolation precautions for most patients tested. Low ED revisit, hospital readmissions, and EDLOS suggest drive‐through care, with appropriate screening, is safe and efficient for future respiratory illness pandemics

Changes in low‐acuity patient volume in an emergency department after launching a walk‐in clinic

Abstract Objective Unscheduled low‐acuity care options are on the rise and are often expected to reduce emergency department (ED) visits. We opened an ED‐staffed walk‐in clinic (WIC) as an alternative care location for low‐acuity patients at a time when ED visits exceeded facility capacity and the impending flu season was anticipated to increase visits further, and we assessed whether low‐acuity ED patient visits decreased after opening the WIC. Methods In this retrospective cohort study, we compared patient and clinical visit characteristics of the ED and WIC patients and conducted interrupted time‐series analyses to quantify the impact of the WIC on low‐acuity ED patient visit volume and the trend. Results There were 27,211 low‐acuity ED visits (22.7% of total ED visits), and 7,058 patients seen in the WIC from February 26, 2018, to November 17, 2019. Low‐acuity patient visits in the ED reduced significantly immediately after the WIC opened (P = 0.01). In the subsequent months, however, patient volume trended back to pre‐WIC volumes such that there was no significant impact at 6, 9, or 12 months (P = 0.07). Had WIC patients been seen in the main ED, low‐acuity volume would have been 27% of the total volume rather than the 22.7% that was observed. Conclusion The WIC did not result in a sustained reduction in low‐acuity patients in the main ED. However, it enabled emergency staff to see low‐acuity patients in a lower resource setting during times when ED capacity was limited