Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. OBJECTIVE: To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. METHODS: The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. MEASUREMENTS: The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. RESULTS: Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). CONCLUSIONS: The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.

STUDY OBJECTIVE: We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting. METHODS: We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury. RESULTS: The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule. CONCLUSION: This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

Predicting intervention in renal colic patients after emergency department evaluation.

OBJECTIVES: There is no set of prospectively validated criteria to identify the emergency department (ED) patients with renal colic who are most likely to eventually have to undergo an intervention. This study prospectively assessed predictors of intervention in this patient population. METHODS: This prospective cohort study included adult patients with renal colic who presented to 2 tertiary care hospital EDs. Patients had an 18-variable data form completed by an emergency physician and a radiological study to confirm urolithiasis. After discharge, patients were followed at 1 and 4 weeks to assess for intervention. The outcome criteria included the patient having had at least 1 of the following procedures performed: extracorporeal shockwave lithotripsy (ESWL), ureteroscopy, percutaneous nephrostomy or open surgery. Data were analyzed using appropriate univariate techniques, and those variables associated with intervention were combined using logistic regression analysis. RESULTS: Over an 8-month period, 245 patients with confirmed urolithiasis were followed; 20% (95% confidence interval [CI] 15%-25%) eventually had a procedure to remove their calculi. Three variables were significantly correlated with having a procedure: i) size of calculus >or= 6 mm (odds ratio [OR] 10.7, 95% CI 4.6-24.8), ii) location of calculus above mid-ureter (OR 6.9, 95% CI 3.0-15.9), and iii) Visual Analogue Scale score for pain at discharge from the ED >or= 2 cm (OR 2.6, 95% CI 1.0-6.8). The area under receiver operating characteristic curve was 0.77 (95% C I 0.70-0.84) (p < 0.001). If all variables were present there was a 90% probability of the patient having an intervention performed within 4 weeks of discharge from the ED. Conversely, if none of the variables were present there was only a 4% probability of an intervention. Overall, the model had a sensitivity of 92% (95% CI 89%-96%) and a specificity of 63% (95% CI 57%-69%). CONCLUSIONS: This study has identified variables that could potentially be used to identify those renal colic patients who require an intervention after ED evaluation. Future studies will prospectively validate this model.