Peter Viccellio

The Association Between Length of Emergency Department Boarding and Mortality

OBJECTIVES Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from worse satisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes. The authors expected that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital lengths of stay (LOS). METHODS This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Consecutive patients admitted to the hospital from the ED and discharged between October 2005 and September 2008 were included. An electronic medical record (EMR) system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital LOS, and in-hospital mortality. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities. RESULTS There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors. CONCLUSIONS Hospital mortality and hospital LOS are associated with length of ED boarding.

Introduction of a Stat Laboratory Reduces Emergency Department Length of Stay

OBJECTIVES Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour. METHODS This was a before-and-after study conducted at an academic suburban ED with 75,000 annual patient visits. All patients presenting to the ED during the months of August and October 2006 were considered. A Stat lab located within the central laboratory was introduced in September 2006 to reduce laboratory TAT. The test TATs and ED LOS before (August 2006) and after (October 2006) implementing the Stat lab for all ED patients were the data of interest. ED LOS before and after the Stat lab was introduced was compared with the Mann-Whitney U-test. A sample size of 5,000 patients in each group had 99% power to detect a 1-hour difference in ED LOS. RESULTS There were 5,631 ED visits before and 5,635 visits after implementing the Stat lab. Groups were similar in age (34 years vs. 36 years) and gender (51% males in both). The percentages of patients with laboratory tests before and after Stat lab implementation were 68.7 and 71.3%, respectively. Test TATs for admitted patients were significantly improved after the Stat lab introduction. Implementation of the Stat lab was associated with a significant reduction in the median ED LOS from 466 (interquartile range [IQR] = minutes before to 402 (IQR = 296-553) minutes after implementing the Stat lab. The effects of the Stat lab on ED LOS were less marked for discharged patients. CONCLUSIONS Introduction of a Stat lab dedicated to the ED within the central laboratory was associated with shorter laboratory TATs and shorter ED LOS for admitted patients, by approximately 1 hour.

Practical Implications of Implementing Emergency Department Crowding Interventions: Summary of a Moderated Panel

Emergency department (ED) crowding continues to be a major public health problem in the United States and around the world. In June 2011, the Academic Emergency Medicine consensus conference focused on exploring interventions to alleviate ED crowding and to generate a series of research agendas on the topic. As part of the conference, a panel of leaders in the emergency care community shared their perspectives on emergency care, crowding, and some of the fundamental issues facing emergency care today. The panel participants included Drs. Bruce Siegel, Sandra Schneider, Peter Viccellio, and Randy Pilgrim. The panel was moderated by Dr. Jesse Pines. Dr. Siegels comments focused on his work on Urgent Matters, which conducted two multihospital collaboratives related to improving ED crowding and disseminating results. Dr. Schneider focused on the future of ED crowding measures, the importance of improving our understanding of ED boarding and its implications, and the need for the specialty of emergency medicine (EM) to move beyond the discussion of unnecessary visits. Dr. Viccellios comments focused on several areas, including the need for a clear message about unnecessary ED visits by the emergency care community and potential solutions to improve ED crowding. Finally, Dr. Pilgrim focused on the effect of effective leadership and management in crowding interventions and provided several examples of how these considerations directly affected the success or failure of well-constructed ED crowding interventions. This article describes each panelists comments in detail.

Patients overwhelmingly prefer inpatient boarding to emergency department boarding.

BACKGROUND Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow. OBJECTIVE Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways. METHODS We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data. RESULTS Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED. CONCLUSIONS Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.

Massive subgaleal hematoma following minor head trauma

A 23-month-old child developed massive head swelling secondary to a subgaleal hematoma several days following minor head trauma. When seen in the emergency department, the child was felt to be otherwise well and hemodynamically stable and was discharged with close follow-up. The hematoma subsequently resolved over the ensuing two weeks. This case represents an uncommon, but dramatic complication of minor head trauma and serves to illustrate the need for physicians to recognize this entity as well as manage it effectively. The major pitfalls in managing these patients are failure to recognize this entity and, particularly in the infant, failure to carefully assess the hemodynamic status.

Fractures of the medial orbital wall

Two cases of patients with isolated medial orbital wall fractures are described. Presenting physical findings were minimal; however, both patients were noted to have bleeding into the nasopharynx from unidentified sources. Routine radiographs failed to disclose the fractures, which were clearly shown by computed tomography. Reconstructive surgery was planned for one patient. Frequently overlooked, this injury may be the cause of delayed enophthalmos, meningitis, or blindness. The presentation, diagnosis, and management of medial orbital wall fractures are reviewed.

277: The Association Between Length of Emergency Department Boarding and Mortality: A Multicenter Study

Abstract Study Objectives Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from dissatisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes at three distinct hospital settings. We hypothesized that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital length of stay, but that this effect may differ across hospital settings. Methods Study Design-Retrospective cohort study. Setting-one suburban and one urban academic ED, and one urban community ED with a combined annual ED census of 160,000. Subjects-Consecutive patients visiting the suburban ED from 9/05-9/08 and the other two facilities from 1/04-12/06. Measures and Outcomes-An electronic medical record system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital length of stay (LOS), and inhospital mortality. Boarding was defined as ED LOS >2 hrs after calling in admission. Data Analysis-descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an ICU, and mortality controlling for disease/injury severity. Results There were 15546 admissions in the suburban ED, 9536 in the urban academic ED, and 7350 in the urban community ED. In the suburban setting, mortality generally increased with increasing boarding time from 4.9% in patients boarded less than 2 hours to 6.3% in patients boarding 24 or more hours (p Conclusion The association between length of ED boarding and hospital mortality varies from hospital to hospital. Efforts to mitigate the effect of ED boarding on outcomes should be tailored to local hospital settings.

Informatics in the Emergency Department

It is 3 A.M. at the local hospital. Three victims from a motor vehicle collision are en route to the emergency department. Vital signs and pertinent prehospital findings have already been transmitted. You look at the patient flow screen to see the current census and open rooms.