ED Patient Experience: Does Day of the Week or Time of the Day Matter?

The effect of the arrival day of the week, arrival time of the day, or discharge time of the day on emergency department (ED) patient experience (PE) scores has not been well studied. We performed a retrospective analysis of ED patients between July 1st, 2018 through March 31st, 2021. We recorded demographics, PE scores, arrival day, arrival and discharge times, and total ED and perceived ED times. We performed univariate and multivariable analyses. We sent 49,849 surveys and received back 2423 that we included in our study. The responding patients' median age was 52, with a majority of female gender (62%) and white race (57%). The average arrival time was 1:40 PM, and the average discharge time 2:38 PM. The average total ED time was 261 minutes, while the average perceived ED time was 540 minutes. We found a statistical association between worse PE scores and longer actual ED time but not longer perceived time. A later arrival time was significantly associated with worse PE scores on 4 out of 6 domains of the PE questionnaire. The discharge time and the day of the week were not significantly associated with PE scores. Conclusion: Actual longer ED time was significantly associated with worse PE scores, but not perceived time. Later arrival time was associated with worse PE scores, but not later discharge time. The arrival day of the week was not statistically associated with differences in PE. Further studies are needed to confirm these findings.

Association of Emergency Department Waiting Times With Patient Experience in Admitted and Discharged Patients.

Prolonged waiting times are associated with worse patient experience in patients discharged from the emergency department (ED). However, it is unclear which component of the waiting times is most impactful to the patient experience and the impact on hospitalized patients. We performed a retrospective analysis of ED patients between July 2018 and March 30, 2020. In all, 3278 patients were included: 1477 patients were discharged from the ED, and 1680 were admitted. Discharged patients had a longer door-to-first provider and door-to-doctor time, but a shorter doctor-to-disposition, disposition-to-departure, and total ED time when compared to admitted patients. Some, but not all, components of waiting times were significantly higher in patients with suboptimal experience (<100th percentile). Prolonged door-to-doctor time was significantly associated with worse patient experience in discharged patients and in patients with hospital length of stay ≤4 days. Prolonged ED waiting times were significantly associated with worse patient experience in patients who were discharged from the ED and in inpatients with short length of stay. Door-to-doctor time seems to have the highest impact on the patient's experience of these 2 groups.

Impact of Length of Stay on Readmission in Hospitalized Patients.

Background Readmission and length of stay (LOS) are two hospital-level metrics commonly used to assess the performance of hospitalist groups. Healthcare systems implement strategies aimed at reducing both. It is possible that tactics aimed at improving one measure in individual patients may adversely impact the other.  Objective We sought to analyze the impact of length of stay on readmission risk in an inpatient general medical population to assess whether patients with a lower length of stays were readmitted more frequently to the hospital. Methods We performed a retrospective analysis of inpatient adult patients admitted to our institution between January 2016 and December 2019. We recorded demographic variables and the outcomes of LOS and 30-day readmission. We excluded patients who expired, left against medical advice, or were transferred to other hospitals. We performed both univariate and multivariate analyses. Results There were 91,723 patients included in the study of which 10,598 (11.6%) were readmitted. The geometric LOS for all patients was 5.37 days and was higher in readmitted patients (6.87 vs 5.18 days, respectively, p < 0.001). Patients with higher readmission rates were older, had a higher proportion of male gender, African-American ethnicity, and were more likely to have Medicare or Medicaid payors. After performing a multivariate regression analysis, we found that a high LOS was associated with a higher likelihood of readmission (P < 0.001). Conclusion Contrary to our initial hypothesis, we found that general medical patients with a higher LOS had a higher likelihood of being readmitted to the hospital after adjusting for other variables. It is possible that factors not captured in the current dataset may help explain both the increase in LOS and readmission risk.

Discharge before noon: is the sun half up or half down?

OBJECTIVES: To analyze the impact of discharge before noon (DBN) on length of stay (LOS) and readmission of adult inpatients. STUDY DESIGN: Retrospective analysis of 78,826 patients from a single tertiary care center between January 1, 2016, and December 31, 2018. METHODS: The patient population was divided between patients discharged before and after noon. Outcomes were analyzed with univariate and multivariate analyses. RESULTS: DBN was independently associated with higher likelihood of LOS above the median (odds ratio [OR], 1.26; 95% CI, 1.18-1.35; P < .001) among medical patients. This association was not seen among surgical patients, in whom DBN was associated with a shorter LOS (OR, 0.78; 95% CI, 0.71-0.86; P < .001). Factors associated with higher LOS in both medical and surgical groups included higher case mix index, Medicaid payer, weekday discharges, and discharge to skilled nursing or rehabilitation facilities. For the variable of readmission, DBN in surgical patients was associated with a lower readmission rate (OR, 0.81; 95% CI, 0.69-0.95; P = .008). CONCLUSIONS: The finding that DBN was associated with higher LOS among medical patients suggests that some patients may have been able to be safely discharged the evening prior. In patients with surgical diagnoses, DBN was associated with a lower LOS and a lower risk of readmission. Patients with later discharges were more likely to be sent to a rehabilitation center or skilled nursing facility and were more frequently discharged during a weekday. Identification of these factors may help health systems transition patients safely and efficiently out of the hospital.

Caring for patients in a hospitalist-run clinical decision unit is associated with decreased length of stay without increasing revisit rates.

BACKGROUND: Observation medicine is a growing field with increasing involvement by hospitalists. Little has been written regarding clinical outcomes in hospitalist-run clinical decision units (CDUs). OBJECTIVE: To determine the impact of a hospitalist-run geographic CDU on length of stay (LOS) for observation patients. Secondary objectives included examining the impact on 30-day emergency department (ED) or hospital revisit rates. DESIGN: Retrospective cohort study with pre- and post-implementation analysis. SETTING: Urban, academic, 600-bed teaching hospital in Camden, New Jersey. PATIENTS: Observation patients discharged from medical-surgical units before and after CDU opening and those discharged from the CDU after CDU opening. INTERVENTION: Creation of a hospitalist-run, 20-bed geographic CDU, adjacent to the ED with order sets, protocols, and priority consults and testing. MEASUREMENTS: Median LOS for observation patients was calculated for 7 months pre- and post-CDU implementation. ED and hospital revisits requiring an observation or inpatient stay within 30 days of discharge were measured. RESULTS: CDU observation patients had a lower median LOS than medical-surgical observation patients during the same period (17.6 hours vs 26.1 hours, P < 0.001). CDU LOS was lower than medical-surgical observation LOS in the 7 months 1 year prior to CDU implementation (17.6 hours vs 27.1 hours, P < 0.001). CDU patients had a similar 30-day ED or hospital revisit rate compared with observation patients pre-CDU. CONCLUSIONS: Implementing a hospitalist-run geographic CDU was associated with a 35% decrease in observation LOS for CDU patients compared with a 3.7% decrease for medical-surgical observation patients. CDU LOS decreased without increasing ED or hospital revisit rates.

The impact of hospitalists on length of stay and costs: systematic review and meta-analysis.

BACKGROUND: Hospital medicine has undergone remarkable growth since its creation. Most (but not all) of the published literature demonstrates better outcomes for patients cared for by hospitalists. PURPOSE: We performed a systematic review and meta-analysis to estimate the magnitude of the impact of hospitalists on length of stay (LOS) and cost. DATA SOURCES: Medline/PubMed. STUDY SELECTION: Articles published through February 2011 comparing outcomes (LOS and/or cost) of hospitalists with others. DATA EXTRACTION: Two reviewers independently searched for abstracted information. We also contacted individual authors to provide us with missing data. DATA SYNTHESIS: We used a random-effects model. RESULTS: A total of 502 abstracts were initially identified and 17 studies of 137,561 patients were included in the final analysis. LOS was significantly shorter in the hospitalist group compared with the non-hospitalist group, with a mean difference of -0.44 days (95% confidence interval [CI] -0.68 to -0.20, P < .001). In studies that compared a (non-resident) hospitalist service with a (non-resident) non-hospitalist service, LOS was also significantly shorter in the hospitalist group (mean difference -0.69 days [95% CI -0.93 to -0.46, P < .001]). Cost was not found to be significantly different (11 studies). There was significant heterogeneity between studies and we found no evidence of publication bias. CONCLUSIONS: Despite its limitations, our analysis supports the conclusion that hospitalists significantly reduce LOS without increasing costs. These findings can be used to define and measure expectations of performance for hospital medicine groups.

Health care-associated pneumonia: identification and initial management in the ED.

Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these "risk factors" have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.