Michael J. Ward

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

Geographic Access to US Neurocritical Care Units Registered with the Neurocritical Care Society

BackgroundNeurocritical care provides multidisciplinary, specialized care to critically ill neurological patients, yet an understanding of the proportion of the population able to rapidly access specialized Neurocritical Care Units (NCUs) in the United States is currently unknown. We sought to quantify geographic access to NCUs by state, division, region, and for the US as a whole. In addition, we examined how mode of transportation (ground or air ambulance), and prehospital transport times affected population access to NCUs.MethodsData were obtained from the Neurocritical Care Society (NCS), US Census Bureau and the Atlas and Database of Air Medical Services. Empirically derived prehospital time intervals and validated models estimating prehospital ground and air travel times were used to calculate total prehospital times. A discrete total prehospital time interval was calculated for each small unit of geographic analysis (block group) and block group populations were summed to determine the proportion of Americans able to reach a NCU within discrete time intervals (45, 60, 75, and 90xa0min). Results are presented for different geographies and for different modes of prehospital transport (ground or air ambulance).ResultsThere are 73 NCUs in the US using ground transportation alone, 12.8, 20.5, 27.4, and 32.6% of the US population are within 45, 60, 75, and 90xa0min of an NCU, respectively. Use of air ambulances increases access to 36.8, 50.4, 60, and 67.3 within 45, 60, 75, and 90xa0min, respectively. The Northeast has the highest access rates in the US using ground ambulances and for 45, 60, and 75xa0min transport times with the addition of air ambulances. At 90xa0min, the West has the highest access rate. The Southern region has the lowest ground and air access to NCUs access rates for all transport times.ConclusionsUsing NCUs registered with the NCS, current geographic access to NCUs is limited in the US, and geographic disparities in access to care exist. While additional NCUs may exist beyond those identified by the NCS database, we identify geographies with limited access to NCUs and offer a population-based planning perspective on the further development of the US neurocritical care system.

Achieving efficiency in crowded emergency departments: a research agenda.

In 2011, Academic Emergency Medicine convened a consensus conference entitled Interventions to Assure Quality in the Crowded Emergency Department. This article, a product of the breakout session on interventions to safeguard efficiency of care, explores various elements of the research agenda on efficiency and quality in crowded emergency departments (EDs). The authors discuss four areas identified as critical to achieving progress in the research agenda for improving ED efficiency: 1) What measures can be used to understand and improve the efficiency and quality of interventions in the ED? 2) Which factors outside of the EDs control affect ED efficiency? 3) How do workforce factors affect ED efficiency? 4) How do ED design, patient flow structures, and use of technology affect efficiency? Filling these knowledge gaps is vital to identifying interventions that improve the delivery of emergency care in all EDs.

Cost-effectiveness of lower extremity compression ultrasound in emergency department patients with a high risk of hemodynamically stable pulmonary embolism

BACKGROUNDnComputed tomography angiograms (CTAs) for patients with suspected pulmonary embolism (PE) are being ordered with increasing frequency from the emergency department (ED). Strategies are needed to safely decrease the utilization of CTs to control rising health care costs and minimize the associated risks of anaphylaxis, contrast-induced nephropathy, and radiation-induced carcinogenesis. The use of compression ultrasonography (US) to identify deep vein thromboses (DVTs) in hemodynamically stable patients with signs and symptoms suggestive of PE is highly specific for the diagnosis of PE and may represent a cost-effective alternative to CT imaging.nnnOBJECTIVESnu2002 The objective was to analyze the cost-effectiveness of a selective CT strategy incorporating the use of compression US to diagnose and treat DVT in patients with a high pretest probability of PE.nnnMETHODSnThe authors constructed a decision analytic model to evaluate the scenario of an otherwise healthy 59-year-old female in whom PE was being considered as a diagnosis. Two strategies were used. The selective CT strategy began with a screening compression US. Negative studies were followed up with a CTA, while patients with positive studies identifying a DVT were treated as though they had a PE and were anticoagulated. The universal CT strategy used CTA as the initial test, and anticoagulation was based on the CT result. Costs were estimated from the 2009 Medicare data for hospital reimbursement, and professional fees were obtained from the 2009 National Physician Fee Schedule. Clinical probabilities were obtained from existing published data, and sensitivity analyses were performed across plausible ranges for all clinical variables.nnnRESULTSnIn the base case, the selective CT strategy cost

Operational data integrity during electronic health record implementation in the ED

1,457.70 less than the universal CT strategy and resulted in a gain of 0.0213 quality-adjusted life-years (QALYs). Sensitivity analyses confirm that the selective CT strategy is dominant above both a pretest probability for PE of 8.3% and a compression US specificity of 87.4%.nnnCONCLUSIONSnA selective CT strategy using compression US is cost-effective for patients provided they have a high pretest probability of PE. This may reduce the need for, and decrease the adverse events associated with, CTAs.

Performance of a Multi-disciplinary Emergency Department Observation Protocol for Acetaminophen Overdose

OBJECTIVEnOperational data are often used to make systems changes in real time. Inaccurate data, however, transiently, can result in inappropriate operational decision making. Implementing electronic health records (EHRs) is fraught with the possibility of data errors, but the frequency and magnitude of transient errors during this fast-evolving systems upheaval are unknown. This study was done to assess operational data quality in an emergency department (ED) immediately before and after an EHR implementation.nnnMETHODSnDirect observations of standard ED timestamps (arrival, bed placement, clinician evaluation, disposition decision, and exit from ED) were conducted in a suburban ED for 4 weeks immediately before and 4 weeks after EHR implementation. Direct observations were compared with electronic timestamps to assess data quality. Differences in proportions and medians with 95% confidence intervals (CIs) were used to estimate the magnitude of effect.nnnRESULTSnThere were 260 observations: 122 before and 138 after implementation. We found that more systematic data errors were introduced after EHR implementation. The proportion of discrepancies where the observed and electronic timestamp differed by more than 10 minutes was reduced for the disposition timestamp (29.3% vs 16.1%; difference in proportions, -13.2%; 95% CI, -24.4% to -1.9%). The accuracy of the clinician-evaluation timestamp was reduced after implementation (median difference of 3 minutes earlier than observed; 95% CI, -5.02 to -0.98). Multiple service intervals were less accurate after implementation.nnnCONCLUSIONnThis single-center study raises questions about operational data quality in the peri-implementation period of EHRs. Using electronic timestamps for operational assessment and decision making following implementation should recognize the magnitude and compounding of errors when computing service times.

The degree of bandemia in septic ED patients does not predict inpatient mortality

The availability of 20-h N-acetylcysteine (NAC) infusion for low-risk acetaminophen (APAP) overdose enabled our center to implement an Emergency Department observation unit (OU) protocol as an alternative to hospitalization. Our objective was to evaluate our early experience with this protocol. This retrospective cohort study included all patients treated for low-risk APAP overdose in our academic hospital between 2006 and 2011. Cases were identified using OU and pharmacy records. Successful OU discharge was defined as disposition with no inpatient admission. Differences in medians with 95xa0% confidence intervals were used for comparisons. One hundred ninety-six patients received NAC for APAP overdose with a mean age of 35xa0years (SD 14); 73xa0% were white, and 43xa0% were male. Twenty (10xa0%) received care in the OU; 3/20(15xa0%) met criteria for inclusion in the OU protocol and 13/20(65xa0%) were discharged successfully. Out of the 196 patients, 10 met criteria for inclusion in the OU protocol but instead received care in the inpatient setting. The median total length of stay from presentation to ED discharge was 41xa0h for all patients treated in the OU, compared to 68xa0h for ten patients who met criteria for inclusion in the OU protocol but who were admitted (difference 27xa0h, 95xa0% CI 18–72xa0h). ED observation for APAP overdose can be a viable alternative to inpatient admission. Most patients were successfully discharged from the OU. This evaluation identified both over- and under-utilization of the OU. OU treatment resulted in shorter median length of stay than inpatient admission.

The mortality benefit threshold for patients with suspected pulmonary embolism

BACKGROUNDnA delay in diagnosis of sepsis and appropriate treatment increases subsequent mortality. An association with the degree of bandemia, or the presence of immature neutrophils in the white blood cell count, has not been explored in septic patients presenting to the emergency department (ED). We hypothesized that the presenting band levels would be higher in septic patients who die in hospital compared with survivors.nnnMETHODSnThis study reviewed charts of ED patients presenting with sepsis to a single urban, academic, tertiary care ED with an annual census of 80,000 visits. Patients were included if they had bandemia assessed and were eligible for early goal-directed therapy. Reviewers blinded to the study purpose abstracted data using predetermined definitions. The band level was compared between patients who died and those who survived to discharge using the Mann-Whitney U test. Logistic regression was used to estimate the effect of bandemia levels on the odds of death.nnnRESULTSnNinety-six patients meeting inclusion criteria were enrolled; 2 were excluded with incomplete data. Mean age was 59 years, 53% were white, and 51% were male. Thirty-two patients (34%) died during admission. The median band levels in patients who died was 17% (range, 0%-67%); and in patients surviving to discharge, the median band level was 9% (range, 0%-77%) (difference in medians, 8%; CI(95), -27.04 to 11.04; P = .222).nnnCONCLUSIONSnThe band level on presentation was not found to be associated with inpatient mortality in ED patients with sepsis who are eligible for early goal-directed therapy.

Fifty Years of Transformation of Acute and Emergency Care

OBJECTIVESnThe mortality benefit for pulmonary embolism (PE) is the difference in mortality between treated and untreated patients. The mortality benefit threshold is the mortality benefit above which testing for a condition should be initiated and below which it should not. To illustrate this concept, the authors developed a decision model to estimate the mortality benefit threshold at several pretest probabilities for low-risk emergency department (ED) patients with possible PE and compare those thresholds with contemporary management of PE in the United States and what is known and not known about treatment benefits with anticoagulation.nnnMETHODSnThe authors built a decision model of a 25-year-old female with suspected PE. Model inputs were obtained from the literature or clinical judgment when data were unavailable. One-way sensitivity analysis was used to derive the mortality benefit threshold at several fixed pretest probabilities, and two-way sensitivity analysis was used to determine drivers of the mortality benefit threshold.nnnRESULTSnAt a 15% pretest probability, the mortality benefit threshold was 3.7%; at 10% it was 5.2%; at 5% it was 9.8%; at 2% it was 23.5%; at 1% it was 46.3%; and at 0.5% it was 92.1%. In two-way sensitivity analyses, D-dimer specificity, CT angiography (CTA)/CT venography (CTV) sensitivity, annual cancer risk, probability of death from renal failure, and probability of major bleeding were major model drivers.nnnCONCLUSIONSnThe mortality benefit threshold for initiating PE testing is very high at low pretest probabilities of PE, which should be considered by clinicians in their diagnostic approach to PE in the ED. The mortality benefit threshold is a novel way of exploring the benefits and risks of ED-based testing, particularly in situations like PE where testing (i.e., CT use) carries real risks and the benefits of treatment are uncertain.

175: Implementation of Early Goal-Directed Therapy: Which Components Are Not Performed?

In his landmark 1979 piece which defined a specialty, Peter Rosen, MD, called emergency medicine “an unaccountably late development in modern medicine.” Rosen strongly argued for a specialty defined not by an organ system or a particular patient population, but by “initial care . . . of life threat[s].” This fundamental notion is now reflected in the American College of Emergency Physicians’ (ACEP) definition of emergency medicine as “the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury, including the initial evaluation, diagnosis, treatment, coordination of care among multiple providers, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care.” Though the framing of a physician’s expertise in terms of a phase of care was without precedent 50 years ago, today we understand it implicitly.