James G. Adams

The relationship between inpatient discharge timing and emergency department boarding

BACKGROUND Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling. STUDY OBJECTIVE Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m. METHODS A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies. RESULTS A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0. CONCLUSION Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.

Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest?

OBJECTIVES Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes. METHODS This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses. RESULTS The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%). CONCLUSIONS Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.

Increased Blood Pressure in the Emergency Department : Pain, Anxiety, or Undiagnosed Hypertension?

STUDY OBJECTIVE We determine the proportion of patients with increased emergency department (ED) blood pressure and no history of hypertension who have persistently increased blood pressure at home, describe characteristics associated with sustained blood pressure increase, and examine the relationship between pain and anxiety and the change in blood pressure after ED discharge. METHODS This was a prospective cohort study. Patients with no history of hypertension and 2 blood pressure measurements of at least 140/90 mm Hg who were treated in an urban ED were enrolled, provided with home blood pressure monitors, and asked to take their blood pressure twice a day for 1 week. Outcome measures were increased mean home blood pressure (140/90 mm Hg or greater), and correlations between ED anxiety (Spielberger State Anxiety Scale) or pain (10-point scale) and the change in blood pressure after discharge. Potential relevant predictors were recorded and a multivariate model was constructed to assess the relationship between these predictors and increased home blood pressure. RESULTS 189 patients were enrolled and 156 returned the monitors and completed the protocol. Increased mean home blood pressure was present in 79 of 156 (51%) patients and was associated with older age and being black. Of patients with ED blood pressures meeting criteria for stage I hypertension, 6% had home blood pressures meeting stage II hypertension, 36% stage I, and 52% prehypertension, and 6% had normal blood pressure For patients with ED blood pressures meeting stage II criteria, the corresponding percentages were 28%, 31%, 33%, and 8%, respectively. The difference between home and ED systolic blood pressures was not associated with anxiety (r=-.03; P=.69) and showed a slight association with pain in the opposite direction from what was expected (r=.18; P=.03). CONCLUSION Patients without diagnosed hypertension and increased ED blood pressures often have persistently increased home blood pressures, which does not appear to be related to pain or anxiety in the ED.

Virtue in Emergency Medicine

At a time in which the integrity of the medical profession is perceptibly challenged, emergency physicians (EPs) have an opportunity to reaffirm their commitment to both their patients and their practice through acceptance of a virtue-based ethic. The virtue-based ethic transcends legalistic rule following and the blind application of principles. Instead, virtue honors the humanity of patients and the high standards of the profession. Recognizing historical roots that are relevant to the modern context, this article describes 10 core virtues important for EPs. In addition to the long-recognized virtues of prudence, courage, temperance, and justice, 6 additional virtues are offered unconditional positive regard, charity, compassion, trustworthiness, vigilance, and agility. These virtues might serve as ideals to which all EPs can strive. Through these, the honor of the profession will be maintained, the trust of patients will be preserved, and the integrity of the specialty will be promoted.

Emergency Department Overuse: Perceptions and Solutions

A common assertion is that heavy and inappropriate use of hospital emergency departments (EDs) in the United States contributes to waste and inefficiency. One estimate suggests that overuse of the ED costs

Examining Emergency Department Communication Through a Staff-Based Participatory Research Method: Identifying Barriers and Solutions to Meaningful Change

38 billion annually.1 This issue is certainly compelling, but the underlying notion is not necessarily new. Discussions of ED overuse and misuse have been ongoing for more than 4 decades.2- 3 Although ED use, overuse, and misuse have been long-standing policy priorities, even specifically highlighted by Presidents Johnson, Clinton, Bush, and Obama, the number of ED visits in the United States has continued to increase almost unabated from approximately 44 million patients per year in 1968 to approximately 134 million annual visits more recently

Emergency Department Discharge Instructions: Lessons Learned through Developing New Patient Education Materials

STUDY OBJECTIVE We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED). METHODS ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes. RESULTS A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice. CONCLUSION Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Patient Input into the Development and Enhancement of ED Discharge Instructions: A Focus Group Study

Our multidisciplinary team developed a new set of discharge instructions for five common emergency department diagnoses using recommended tools for creating literacy-appropriate and patient-centered education materials. We found that the recommended tools for document creation were essential in constructing the new instructions. However, while the tools were necessary, they were not sufficient. This paper describes the insights gained and lessons learned in this document creation process.

Derivation of a Triage Algorithm for Chest Radiography of Community-acquired Pneumonia Patients in the Emergency Department

OBJECTIVES Previous research indicates that patients have difficulty understanding ED discharge instructions; these findings have important implications for adherence and outcomes. The objective of this study was to obtain direct patient input to inform specific revisions to discharge documents created through a literacy-guided approach and to identify common themes within patient feedback that can serve as a framework for the creation of discharge documents in the future. METHODS Based on extensive literature review and input from ED providers, subspecialists, and health literacy and communication experts, discharge instructions were created for 5 common ED diagnoses. Participants were recruited from a federally qualified health center to participate in a series of 5 focus group sessions. Demographic information was obtained and a Rapid Estimate of Adult Literacy in Medicine (REALM) assessment was performed. During each of the 1-hour focus group sessions, participants reviewed discharge instructions for 1 of 5 diagnoses. Participants were asked to provide input into the content, organization, and presentation of the documents. Using qualitative techniques, latent and manifest content analysis was performed to code for emergent themes across all 5 diagnoses. RESULTS Fifty-seven percent of participants were female and the average age was 32 years. The average REALM score was 57.3. Through qualitative analysis, 8 emergent themes were identified from the focus groups. CONCLUSIONS Patient input provides meaningful guidance in the development of diagnosis-specific discharge instructions. Several themes and patterns were identified, with broad significance for the design of ED discharge instructions.

Clinical operations in academic emergency medicine.

BACKGROUND Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED) patient visits in the United States each year. OBJECTIVES To derive an algorithm for the ED triage setting that facilitates rapid and accurate ordering of chest radiography (CXR) for CAP. METHODS The authors conducted an ED-based retrospective matched case-control study using 100 radiographic confirmed CAP cases and 100 radiographic confirmed influenzalike illness (ILI) controls. Sensitivities and specificities of characteristics assessed in the triage setting were measured to discriminate CAP from ILI. The authors then used classification tree analysis to derive an algorithm that maximizes sensitivity and specificity for detecting patients with CAP in the ED triage setting. RESULTS Temperature greater than 100.4 degrees F (likelihood ratio = 4.39, 95% confidence interval [CI] = 2.04 to 9.45), heart rate greater than 110 beats/minute (likelihood ratio = 3.59, 95% CI = 1.82 to 7.10), and pulse oximetry less than 96% (likelihood ratio = 2.36, 95% CI = 1.32 to 4.20) were the strongest predictors of CAP. However, no single characteristic was adequately sensitive and specific to accurately discriminate CAP from ILI. A three-step algorithm (using optimum cut points for elevated temperature, tachycardia, and hypoxemia on room air pulse oximetry) was derived that is 70.8% sensitive (95% CI = 60.7% to 79.7%) and 79.1% specific (95% CI = 69.3% to 86.9%). CONCLUSIONS No single characteristic adequately discriminates CAP from ILI, but a derived clinical algorithm may detect most radiographic confirmed CAP patients in the triage setting. Prospective assessment of this algorithm will be needed to determine its effects on the care of ED patients with suspected pneumonia.