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.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List.

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

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.

Managing Shoulder Injuries in the Emergency Department: Fracture, Dislocation, and Overuse.

The complex structures of the shoulder can be injured by fracture, dislocation, and overuse, and correctly identifying and classifying injury is essential to avoiding pain, disability, and life- and limb-threatening complications. This issue presents a systematic approach to classifying shoulder injuries based on the mechanism of injury and clinical presentation, choosing appropriate imaging, and determining the best strategies for treatment, including reduction, surgical consultation, or outpatient referral. Newer recommendations on intra-articular versus intravenous analgesia are presented to increase patient comfort and improve reduction outcomes.

Impact of a teaching attending physician on medical student, resident, and faculty perceptions and satisfaction.

OBJECTIVES: To determine if a dedicated teaching attending for medical student education improves medical student, attending physician, and resident perceptions and satisfaction. METHODS: Two dedicated teaching attending physician shifts were added to the clinical schedule each week. A before-after trial compared medical student evaluations from 2000 to 2004 (preteaching attending physician) to medical student evaluations from 2005 to 2006 (teaching attending physician). Attending physician and resident perceptions and satisfaction with the teaching attending physician shifts using a 5-point Likert-type scale (1  =  poor to 5  =  excellent) were also assessed. RESULTS: Eighty-nine (100%) medical students participated, with 63 preteaching attending physician and 26 teaching attending physician rotation evaluations. The addition of teaching attending physician shifts improved mean medical student satisfaction with bedside teaching (4.1 to 4.5), lecture satisfaction (4.2 to 4.8), preceptor scores (4.3 to 4.8), and perceived usefulness of the rotation (4.5 to 5.0) (all p < 0.05). Thirteen attending physicians (93%) participated in the cross-sectional questionnaire. The addition of teaching attending physician shifts improved faculty ratings of their medical student interactions by ≥ 1.5 points for all items (p ≤ 0.001). Faculty perceptions of their resident interactions improved for quality of bedside teaching (3.1 to 4.0), their availability to hear resident presentations (3.4 to 4.2), and their supervision of residents (3.4 to 4.1) (p ≤ 0.01). Residents (n  =  35) noted minor improvements with the timeliness of patient dispositions, faculty bedside teaching, and attending physician availability. CONCLUSIONS: The addition of select teaching attending physician shifts had the greatest effect on medical student and faculty perceptions and satisfaction, with some improvements for residents.

Scholarly tracks in emergency medicine.

Over the past decade, some residency programs in emergency medicine (EM) have implemented scholarly tracks into their curricula. The goal of the scholarly track is to identify a niche in which each trainee focuses his or her scholarly work during residency. The object of this paper is to discuss the current use, structure, and success of resident scholarly tracks. A working group of residency program leaders who had implemented scholarly tracks into their residency programs collated their approaches, implementation, and early outcomes through a survey disseminated through the Council of Emergency Medicine Residency Directors (CORD) list-serve. At the 2009 CORD Academic Assembly, a session was held and attended by approximately 80 CORD members where the results were disseminated and discussed. The group examined the literature, discussed the successes and challenges faced during implementation and maintenance of the tracks, and developed a list of recommendations for successful incorporation of the scholarly track structure into a residency program. Our information comes from the experience at eight training programs (five 3-year and three 4-year programs), ranging from 8 to 14 residents per year. Two programs have been working with academic tracks for 8 years. Recommendations included creating clear goals and objectives for each track, matching track topics with faculty expertise, protecting time for both faculty and residents, and providing adequate mentorship for the residents. In summary, scholarly tracks encourage the trainee to develop an academic or clinical niche within EM during residency training. The benefits include increased overall resident satisfaction, increased success at obtaining faculty and fellowship positions after residency, and increased production of scholarly work. We believe that this model will also encourage increased numbers of trainees to choose careers in academic medicine.

Performance of a decision rule to predict need for computed tomography among children with blunt head trauma.

OBJECTIVE: To assess the ability of the NEXUS II head trauma decision instrument to identify patients with clinically important intracranial injury (ICI) from among children with blunt head trauma. METHODS: An analysis was conducted of the pediatric cohort involved in the derivation set of National Emergency X-Radiography Utilization Study II (NEXUS II), a prospective, observational, multicenter study of all patients who had blunt head trauma and underwent cranial computed tomography (CT) imaging at 1 of 21 emergency departments. We determined the test performance characteristics of the 8-variable NEXUS II decision instrument, derived from the entire NEXUS II cohort, in the pediatric cohort (0-18 years of age), as well as in the very young children (<3 years). Clinically important ICI was defined as ICI that required neurosurgical intervention (craniotomy, intracranial pressure monitoring, or mechanical ventilation) or was likely to be associated with significant long-term neurologic impairment. RESULTS: NEXUS II enrolled 1666 children, 138 (8.3%) of whom had clinically important ICI. The decision instrument correctly identified 136 of the 138 cases and classified 230 as low risk. A total of 309 children were younger than 3 years, among whom 25 had ICI. The decision instrument identified all 25 cases of clinically important ICI in this subgroup. CONCLUSIONS: The decision instrument derived in the large NEXUS II cohort performed with similarly high sensitivity among the subgroup of children who were included in this study. Clinically important ICI were rare in children who did not exhibit at least 1 of the NEXUS II risk criteria.