Alecs Chochinov

A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department

INTRODUCTION US emergency personnel cared for 106% more patients in 1990 than they did in 1980, and national emergency department census data show that 60%-80% of those patients presented with non-urgent or minor medical problems. The hiring of nurse practitioners (NPs) is one proposed solution to the ongoing overcrowding and physician shortage facing emergency departments (EDs). METHODS We conducted a systematic review of MEDLINE and Cinahl to find articles that discussed NPs in the ED setting, looking specifically at 4 key outcome measures: wait times, patient satisfaction, quality of care and cost effectiveness. RESULTS Although some questions remain, a review of the literature suggests that NPs can reduce wait times for the ED, lead to high patient satisfaction and provide a quality of care equal to that of a mid-grade resident. Cost, when compared with resident physicians, is higher; however, data comparing to the hiring additional medical professionals is lacking. CONCLUSION The medical community should further explore the use of NPs, particularly in fast track areas for high volume departments. In rural areas, NPs could supplement overextended physicians and allow health centres to remain open when they might otherwise have to close. These strategies could improve access to care and patient satisfaction for selected urban and rural populations as well as make the best use of limited medical resources.

Recovery of a 62-year-old Man From Prolonged Cold Water Submersion

Recovery from prolonged cold water submersion is well documented in children but rare in adults. In the few adult cases reported, significant body cooling occurred (rectal temperature ranging from 22 degrees to 32 degrees C) and the victims were relatively young (< 40 years). We report a case of a 62-year-old man who was submersed in 2 degrees to 3 degrees C water for 15 minutes (time from initial submersion to intubation = 22 minutes). At the time of rescue, he had no vital signs, received prehospital Advanced Life Support, and was transported to hospital. On arrival at hospital, the patient remained in full cardiopulmonary arrest with an agonal ECG rhythm and had an initial pH of 6.77. Initial rectal temperature was near normal (36 degrees C) but subsequently dropped to 33 degrees C. The patient was resuscitated, rewarmed by forced-air warming, and treated for acute myocardial infarction, pulmonary edema, and generalized seizures. He was discharged after 27 days with minor neurologic abnormalities. Given the near-normal initial rectal temperature, preferential brain cooling may have been at least partially responsible for the positive neurologic outcome.

Field Torso-Warming Modalities: A Comparative Study Using a Human Model

Abstrast Objective. To compare four field-appropriate torso-warming modalities that do not require alternating-current (AC) electrical power, using a human model of nonshivering hypothermia. Methods. Five subjects, serving as their own controls, were cooled four times in 8°C water for 10–30 minutes. Shivering was inhibited by buspirone (30 mg) taken orally prior to cooling and intravenous (IV) meperidine (1.25 mg/kg) at the end of immersion. Subjects were hoisted out of the water, dried, and insulated and then underwent 120 minutes of one of the following: spontaneous warming only; a charcoal heater on the chest; two flexible hot-water bags (total 4 liters of water at 55°C, replenished every 20 minutes) applied to the chest and upper back; or two chemical heating pads applied to the chest and upper back. Supplemental meperidine (maximum cumulative dose of 3.5 mg/kg) was administered as required to inhibit shivering. Results. The postcooling afterdrop (i.e., the continued decrease in body core temperature during the early period of warming), compared with spontaneous warming (2.2°C), was less for the chemical heating pads (1.5°C) and the hot-water bags (1.6°C, p < 0.05) and was 1.8°C for the charcoal heater. Subsequent core rewarming rates for the hot-water bags (0.7°C/h) and the charcoal heater (0.6°C/h) tended to be higher than that for the chemical heating pads (0.2°C/h) and were significantly higher than that for spontaneous warming rate (0.1°C/h, p < 0.05). Conclusion. In subjects with shivering suppressed, greater sources of external heat were effective in attenuating core temperature afterdrop, whereas sustained sources of external heat effectively established core rewarming. Depending on the scenario and available resources, we recommend the use of charcoal heaters, chemical heating pads, or hot-water bags as effective means for treating cold patients in the field or during transport to definitive care.

Application of Lean principles to improve early cardiac care in the emergency department

OBJECTIVE To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED). METHODS Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study. RESULTS The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p < 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p  =  0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (p values < 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources. CONCLUSIONS The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED.

Bottleneck detection for improvement of Emergency Department efficiency

Purpose – The purpose of this paper is to introduce a method of the bottleneck detection for Emergency Department (ED) improvement using benchmarking and design of experiments (DOE) in simulation model. Design/methodology/approach – Four procedures of treatments are used to represent ED activities of the patient flow. Simulation modeling is applied as a cost-effective tool to analyze the ED operation. Benchmarking provides the achievable goal for the improvement. DOE speeds up the process of bottleneck search. Findings – It is identified that the long waiting time is accumulated by previous arrival patients waiting for treatment in the ED. Comparing the processing time of each treatment procedure with the benchmark reveals that increasing the treatment time mainly happens in treatment in progress and emergency room holding (ERH) procedures. It also indicates that the to be admitted time caused by the transfer delay is a common case. Research limitations/implications – The current research is conducted in ...

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

Background Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV). Methods Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients. Results The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians. Conclusions PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.

Position Statement on Emergency Medicine Definitions from the Canadian Association of Emergency Physicians

Emergency Medicine (EM) emerged as a specialty with a unique body of medical knowledge and skills in North America in the 1970s. After considerable advocacy by pioneer emergency physician visionaries, Emergency Medicine was designated a medical specialty in Canada in 1981: the first fellowship certificates were granted by the Royal College of Physicians & Surgeons of Canada (Royal College or RCPS) in 1983. Since that time, Canada has been internationally recognized as an EM leader due to its early establishment of the specialty and comprehensive RCPS residency training programs, which are currently five years in duration. Despite these successes, however, it has been a challenge to expand the number of residency training spots in Canada to provide adequate numbers of EM specialists for even the largest academic centers. For over three decades, there has been a parallel route to emergency medicine certification in Canada, through the College of Family Physicians of Canada (CFPC). A Certificate of Special Competence in EM – CCFP (EM) is obtainable following certification in family practice by the CFPC. The CCFP (EM) examination may be written after completing either a year of specific emergency medicine training, or through practice eligibility, following demonstration and assessment of competency. (Beginning in 2015, the CFPC began awarding Certificates of Added Competence (CACs) in place of CCFP (EM) to denote special competence in EM). Although originally intended for family physicians who care for patients in the office, the hospital and the emergency department, the preponderance of physicians who complete this training and certification practice primarily emergency medicine, not family medicine. The reasons for this are multifactorial, but are at least in part related to the undersupply of Royal College training positions and RCPS-certified EPs. The reality is that many clinically and academically accomplished emergency physicians in Canada have been certified by this route. One novel CCFP (EM) program, offered by Dalhousie University in Saint John, New Brunswick warrants mention here; it is an integrated three year family medicine/emergency medicine program with content more heavily weighted to emergency medicine than the one year enhanced skills programs. Pediatric Emergency Medicine (PEM) became a Royal College subspecialty in 2000. PEM specialists are

Comparing the Effect of Throughput and Output Factors on Emergency Department Crowding: A Retrospective Observational Cohort Study

Study objective This study compares how throughput and output factors affect emergency department (ED) median waiting room time. Methods Administrative health care use records were used to identify all daytime (8 am to 8 pm) visits made to adult EDs in Winnipeg, Canada, between April 1, 2012, and March 31, 2013. First, we measured the waiting room time (from patient registration until transfer into the ED) of each index visit (incoming patient). We then linked each index visit to a group of existing patients surrounding it and counted the number of existing patients engaged in throughput processes (radiographs, computed tomography [CT] scans, advanced diagnostic tests) and one output process (waiting to be hospitalized). Regression analysis was used to measure how strongly each factor uniquely affected incoming patient median waiting room time, stratified by the acuity level. Results Analyses were performed on 143,172 index visits. On average, 153.4 radiographs and 48.5 CT scans were conducted daily, whereas 45.3 patients were admitted daily to hospital. Median waiting room time was shortest (8.0 minutes) for the highest‐acuity index visits and was not influenced by these throughput or output factors. For all other index visits, median waiting room time was associated strongly with the number of existing patients receiving radiographs, and, to a lesser extent, with the number of existing patients receiving CT scans and waiting for hospital admission. Conclusion Both throughput and output factors affect how long newly arriving ED patients remain in the waiting room. This suggests that a range of strategies may help to reduce ED wait time, each requiring stronger ED and hospital partnerships.