Pankaj B. Patel

Reduction of Admit Wait Times: The Effect of a Leadership-based Program

OBJECTIVES Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED. METHODS This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured. RESULTS After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001). CONCLUSIONS A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction.

Facilitating Follow‐Up after Emergency Care Using an Appointment Assignment System

Abstract: Many emergency department (ED) patients require urgent follow‐up in primary care. The most effective way to help patients obtain their needed after‐visit care is to secure the appointment on their behalf prior to their departure from the ED. This study describes the development, implementation, and outcomes of an appointment assignment system that facilitates patient follow‐up at two community hospitals in an integrated healthcare system. This patient‐centered system resulted in a high rate of compliance and a very low rate of unscheduled ED recidivism. Improving access in this manner will likely strengthen the continuum of care, improve quality, and increase patient satisfaction.

AMBULANCE DIVERSION REDUCTION AND ELIMINATION: THE 3-2-1 PLAN

BACKGROUND The diversion of ambulances from their intended emergency departments (EDs) occurs frequently, compromising patient care. Previously, we reduced ambulance diversion (AD) by 74% in a large urban area with 17 EDs. OBJECTIVES In this follow-up program, we sought to further reduce and eliminate AD by progressively reducing the duration of each AD event. METHODS Using tight diversion criteria, AD at each ED was limited by protocol to 3h at a stretch, after which incoming ambulances had to be accepted at that ED for at least 1h. After 6 months, AD was limited to 2h per diversion event; after another 6 months, AD was limited to 1h. The monitoring for AD was programmed into a region-wide, Internet-based Emergency Medical Services (EMS) program. RESULTS Total annual AD decreased from 8469 h in 2006 (pre-implementation) to 4592 h in 2007 (during implementation), and finally to 2439 h and 2306 h in 2008 and 2009 (post-implementation), respectively, an 87.4% (95% confidence interval 64.6-95.5%) reduction, and one county within the region eliminated AD altogether. From 2006 to 2009, overall increases were noted in EMS arrivals (7.8%), ED census (13.0%), hospital admissions (6.6%), Intensive Care Unit admissions (17.1%), and overall Sacramento population (1.9%). CONCLUSIONS By limiting the duration of AD events to progressively shorter periods of time using a region-wide, Internet-based EMS program, we reduced AD hours in 17 EDs by 87.4% and eliminated AD in one entire county. This original, collaborative 3-2-1 Plan may be readily reproduced across the country to progressively reduce and eliminate AD.

Emergency Physicians Seek...And Are Finding Their Place

1. National Highway Traffic Safety Administration. Fatalities in traffic crashes involving all-terrain vehicles. Ann Emerg Med. 2016;67: 283-284. 2. Denning GM, Harland KK, Jennissen CA. Age-based risk factors for pediatric ATV-related fatalities. Pediatrics. 2014;134: 1094-1102. 3. Denning G, Harland K, Ellis D, et al. More fatal all-terrain vehicle crashes occur on the roadway than off: increased risk-taking characterises roadway fatalities. Inj Prev. 2013;19:250-256. 4. Denning GM, Jennissen CA. All-terrain vehicle fatalities on paved roads, unpaved roads, and off-road: evidence for informed roadway safety warnings and legislation. Traffic Inj Prev. 2016;17:406-412. 5. Denning G, Jennissen C, Harland K, et al. All-terrain vehicles (ATVs) on the road: a serious traffic safety and public health concern. Traffic Inj Prev. 2013;14:78-85. 6. Weintraub R, Best M. ATVs on roadways: a safety crisis, 2014. Report by the Consumer Federation of America. Available at: http://www. consumerfed.org/pdfs/ATVs-on-roadways-03-2014.pdf. Accessed February 11, 2016.

Informed consent documentation for lumbar puncture in the emergency department.

Introduction: Informed consent is a required process for procedures performed in the emergency department (ED), though it is not clear how often or adequately it is obtained by emergency physicians. Incomplete performance and documentation of informed consent can lead to patient complaints, medico-legal risk, and inadequate education for the patient/guardian about the procedure. We undertook this study to quantify the incidence of informed consent documentation in the ED setting for lumbar puncture (LP) and to compare rates between pediatric (<18 years) and adult patients. Methods: In this retrospective cohort study, we reviewed the ED electronic health records (EHR) for all patients who underwent successful LPs in 3 EDs between April 2010 and June 2012. Specific elements of informed consent documentation were reviewed. These elements included the presence of general ED and LP-specific consent forms, signatures of patient/guardian, witness, and physician, documentation of purpose, risks, benefits, alternatives, and explanation of the LP. We also reviewed the use of educational material about the LP and LP-specific discharge information. Results: Our cohort included 937 patients; 179 (19.1%) were pediatric. A signed general ED consent form was present in the EHR for 809 (86%) patients. A consent form for the LP was present for 524 (56%) patients, with signatures from 519 (99%) patients/guardians, 327 (62%) witnesses, and 349 (67%) physicians. Documentation rates in the EHR were as follows: purpose (698; 74%), risks (742; 79%), benefits (605; 65%), alternatives (635; 68%), and explanation for the LP (57; 6%). Educational material about the LP was not documented as having been given to any of the patients and LP-specific discharge information was documented as given to 21 (2%) patients. No significant differences were observed in the documentation of informed consent elements between pediatric and adult patients. Conclusion: General ED consent was obtained in the vast majority of patients, but use of a specific LP consent form and documentation of the elements of informed consent for LP in the ED were suboptimal, though comparable between pediatric and adult patients. There is significant opportunity for improvement in many aspects of documenting informed consent for LP in the ED. [West J Emerg Med. 2014;15(3):318–324.]

Regarding: Effects of Emergency Department Expansion on Emergency Department Patient Flow

To the Editor: We read with great interest the recent article “Effects of Emergency Department Expansion on Emergency Department Patient Flow” by Mumma et al. Similar to their emergency department (ED) at UC Davis, our ED, located just 20 miles away, also underwent an expansion in 2009 from 35 beds to 61 beds. We studied the effect of this expansion on admit wait times as well as other ED patient flow data. Using multivariable linear regression models and analysis, we found a significant reduction in admit wait time, defined as the percentage of patients who left the ED within 60 minutes of a request for an inpatient bed. However, similar to the current study, we found no significant change in boarding time per admission, lengths of stay (LOS), patient satisfaction, patients leaving without being seen (LWBS), or ambulance diversion hours. Around the same time, at another local ED, we studied the effect of a leadership-based program to reduce admit wait times. We found significant improvements in admit wait times, boarding time per admission, LOS, patient satisfaction, LWBS, and ambulance diversion hours. Interestingly, during the period of study, we actually reduced physical bed capacity at this ED from 45 beds down to 36 beds. We agree with the authors that ED expansion alone is not an adequate solution for ED crowding. Our experience would indicate that process improvement and active leadership support to directly oversee patient flow might be significantly more effective in reducing ED crowding.