Thomas Payton

An Assessment of Emergency Department Throughput and Provider Satisfaction after the Implementation of a Scribe Program

Objectives. To assess the impact of a scribe program on an academic, tertiary care facility. Methods. A retrospective analysis of emergency department (ED) data, prior to and after scribe program implementation, was used to quantitatively assess the impact of the scribe program on measures of ED throughput. An electronic survey was distributed to all emergency medicine residents and advanced practice providers to qualitatively assess the impact of the scribe program on providers. Results. Several throughput time measures were significantly lower in the postscribe group, compared to prescribe implementation, including time to disposition. The left without being seen (LWBS) decrease was not statistically significant. A total of 30 providers responded to the survey. 100% of providers indicated scribes are a valuable addition to the department and they enjoy working with scribes. 90% of providers indicated scribes increase their workplace satisfaction and quality of life. Conclusions. Through evaluation of prescribe and postscribe implementation, the postscribe time period reflects many throughput improvements not present before scribes began. Scribe Program implementation led to improved ED throughput for discharged patients with further system-wide challenges needing to be addressed for admitted patients.

Comparison of 3 Symptom Classification Methods to Standardize the History Component of the HEART Score

Objectives: The History, Electrocardiography, Age, Risk factors, Troponin (HEART) score enables rapid risk stratification of emergency department patients presenting with chest pain. However, the subjectivity in scoring introduced by the history component has been criticized by some clinicians. We examined the association of 3 objective scoring models with the results of noninvasive cardiac testing. Methods: Medical records for all patients evaluated in the chest pain center of an academic medical center during a 1-year period were reviewed retrospectively. Each patient’s history component score was calculated using 3 models developed by the authors. Differences in the distribution of HEART scores for each model, as well as their degree of agreement with one another, as well as the results of cardiac testing were analyzed. Results: Seven hundred forty nine patients were studied, 58 of which had an abnormal stress test or computed tomography coronary angiography. The mean HEART scores for models 1, 2, and 3 were 2.97 (SD 1.17), 2.57 (SD 1.25), and 3.30 (SD 1.35), respectively, and were significantly different (P < 0.001). However, for each model, the likelihood of an abnormal cardiovascular test did not correlate with higher scores on the symptom component of the HEART score (P = 0.09, 0.41, and 0.86, respectively). Conclusions: While the objective scoring models produced different distributions of HEART scores, no model performed well with regards to identifying patients with abnormal advanced cardiac studies in this relatively low-risk cohort. Further studies in a broader cohort of patients, as well as comparison with the performance of subjective history scoring, is warranted before adoption of any of these objective models.

Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

Emergency departments (EDs) throughout USA have improvised various processes to curb the “national epidemic” termed ED “crowding.” Standing orders (SOs), one such process, are medical orders approved by the medical director and entered by nurses when patients cannot be seen expeditiously, expediting medical decision-making and decreasing length of stay (LOS) and time to disposition. This retrospective cohort study evaluates the impact of SOs on ED LOS and disposition time at a large university ED. Results indicate that SOs significantly improve ED throughput by reducing disposition time by up to 16.9% (), which is especially significant in busy ED settings. SOs by themselves are not sufficient for a complete diagnostic assessment. Strategies such as having a provider in the waiting area may help make key decisions earlier.

Survey of Patient Knowledge and Expectations about a Free-Standing Emergency Department

Objectives. A free-standing emergency department (FSED) is defined as a facility that is structurally separate and distinct from a hospital and provides emergency care. Nationally, the number of FSEDs continues to grow, but the general public may have limited knowledge about the costs and services associated with FSEDs. The purpose of this paper is to survey patient knowledge and expectations about FSEDs. Methods. A convenience sample of patients presenting to a FSED was given a 19-item survey to complete. Results. 187 surveys were collected; 126 were included for analysis. 40% of respondents thought they could be seen by a specialist at the FSED, and 55% of patients did not know they had to be transferred for hospitalization if required. Most patients did not know that the cost of services at the FSED would be the same as that at the traditional ED. Convenience and perceived shorter wait times were the primary reasons patients selected the FSED for care. Conclusion. In general, patients do not have adequate knowledge about the costs and services associated with FSEDs. Education through marketing and advertising may be helpful in creating more public awareness about FSEDs.

Implementation of an evidence- based algorithm reduces blood culture overuse in an adult emergency department

Bloodstream infections, or bacteremia, continue to be a leading cause of morbidity and mortality in hospitalized patients, particularly in the elderly and in those admitted to the Intensive Care Unit (ICU) [1-4]. Up to 35% of total mortality in ICUs has been attributed to bloodstream infections [1], and the mortality associated with a diagnosis of bacteremia consistently exceeds 20% in the general hospitalized patient population [2,3,5,6]. Moreover, the presence of bacteremia has been shown to affect patients’ longterm outcome and recovery, even after the initial infection has been treated [5-7]. Thus, the timely and accurate diagnosis of bacteremia is essential. Blood cultures are a critical tool in the diagnosis and treatment of bacteremia, showing not only the presence of bacteria in the bloodstream but also identifying the causative pathogen and providing antibiotic sensitivity data that enables providers to optimize antimicrobial therapy to each individual patient. Sets of two to three 20-ml blood cultures have been shown to yield sensitivities of 90% and 98%, respectively, for identifying the causative pathogen in bloodstream infections [8].

An Analysis of Physician Productivity and Self-Sustaining Revenue Generation in a Free-Standing Emergency Department Medical Scribe Model

Objectives. A free-standing emergency department (FSED) is a facility that provides comprehensive emergency medical care similar to a traditional emergency department but is not attached to a hospital campus. Medical scribes are increasingly likely to work in free-standing emergency departments. The purpose of this study was to retrospectively investigate the benefits of a scribe program in an FSED. Methods. A retrospective, Institutional Review Board-approved analysis from December 1, 2013, to February 1, 2015, of free-standing emergency department medical data was extracted to determine if scribed charts resulted in increased revenue and improved throughput. Results. When scribes are present in the FSED there is a small, but statistically significant, decrease in time from patient arrival to provider by 2.74 minutes. Scribed charts collected

Diagnostic Yield of Routine Noninvasive Cardiovascular Testing in Low-Risk Acute Chest Pain Patients

4.69 more per chart and resulted in an increase in productivity. Incremental cost effectiveness ratios resulted in proven cost-utility with a net-positive effect. Conclusion. While there are some gains in terms of operational metrics and provider productivity with the addition of scribes to a free-standing emergency department, there is a net-positive financial impact of scribes. Implementing a scribe program at a FSED is cost-effective and justified from both an operational and a financial analysis.