Physician in Triage Versus Rotational Patient Assignment.

BACKGROUND: Physician in triage and rotational patient assignment are different front-end processes that are designed to improve patient flow, but there are little or no data comparing them. OBJECTIVE: To compare physician in triage with rotational patient assignment with respect to multiple emergency department (ED) operational metrics. METHODS: Design-Retrospective cohort review. Patients-Patients seen on 23 days on which we utilized a physician in triage with those patients seen on 23 matched days when we utilized rotational patient assignment. RESULTS: There were 1,869 visits during physician in triage and 1,906 visits during rotational patient assignment. In a simple comparison, rotational patient assignment was associated with a lower median length of stay (LOS) than physician in triage (219 min vs. 233 min; difference of 14 min; 95% confidence interval [CI] 5-27 min). In a multivariate linear regression incorporating multiple confounders, there was a nonsignificant reduction in the geometric mean LOS in rotational patient assignment vs. physician in triage (204 min vs. 217 min; reduction of 6.25%; 95% CI -3.6% to 15.2%). There were no significant differences between groups for left before being seen, left subsequent to being seen, early (within 72 h) returns, early returns with admission, or complaint ratio. CONCLUSIONS: In a single-site study, there were no statistically significant differences in important ED operational metrics between a physician in triage model and a rotational patient assignment model after adjusting for confounders.

Emergency Department Rotational Patient Assignment.

STUDY OBJECTIVE: We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion). METHODS: This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio. RESULTS: We analyzed 23,514 visits in the last year of physician self-assignment and 24,112 visits in the first year of rotational patient assignment. Rotational patient assignment was associated with the following improvements (percentage change): median length of stay 232 to 207 minutes (11%), median arrival to provider time 39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left subsequent to being seen, early returns, or early returns with admission. CONCLUSION: In a single facility, the transition from physician self-assignment to rotational patient assignment was associated with improvement in a broad array of ED operational metrics. Rotational patient assignment may be a useful strategy in ED front-end process redesign.

Evaluation of national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients.

BACKGROUND: Diagnostic criteria were proposed at the Second Symposium on the Definition and Management of Anaphylaxis convened by the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN). Validation is needed before these criteria can be widely adapted into clinical practice. OBJECTIVE: Our aim was to retrospectively assess the diagnostic accuracy of the NIAID/FAAN criteria for the diagnosis of anaphylaxis in emergency department (ED) patients. METHODS: A retrospective cohort study of ED patients presenting from April to October 2008 was conducted. Patients given a diagnosis of an allergic reaction or anaphylaxis and a subset of patients with related diagnoses were included. Electronic medical records were reviewed and data were abstracted to determine whether the NIAID/FAAN criteria were met. Records were also independently reviewed in a blinded fashion by 2 experienced attending allergists. Final diagnosis by allergists was considered the reference standard. RESULTS: Of 214 patients, 86 (40.2%) met the NIAID/FAAN criteria for anaphylaxis. Allergists gave 61 (28.5%) patients diagnoses of anaphylaxis, 59 (96.7%) of whom satisfied the NIAID/FAAN criteria. The interrater agreement between allergists was substantial (κ = 0.77). The test characteristics of the NIAID/FAAN criteria were as follows: sensitivity, 96.7% (95% CI, 88.8% to 99.1%); specificity, 82.4% (95% CI, 75.5% to 87.6%); positive predictive value, 68.6% (95% CI, 58.2% to 77.4%); negative predictive value, 98.4% (95% CI, 94.5% to 99.6%); positive likelihood ratio, 5.48; and negative likelihood ratio, 0.04. CONCLUSIONS: These results suggest that the NIAID/FAAN criteria are highly sensitive but less specific and are likely to be useful in the ED for the diagnosis of anaphylaxis.

Anaphylaxis in emergency department patients 50 or 65 years or older.

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction commonly managed in the emergency department (ED). Data describing patients 50 or 65 years or older with anaphylaxis are limited. OBJECTIVE: To describe the presentation and management of patients with anaphylaxis who were 50 or 65 years or older and to compare these findings with those of younger patients. METHODS: A consecutive cohort study of patients presenting to an ED with approximately 80,000 visits per year was conducted. Patients who met diagnostic criteria for anaphylaxis from April 2008 to June 2010 were included. Data were collected on suspected causes, signs and symptoms, management, ED disposition, and follow-up. RESULTS: The study included 220 patients. Food was the most common suspected cause of anaphylaxis for patients younger than 50 (42.2%) or 65 years (38.5%) but was much less common in patients 50 (14.8%, P < .001) or 65 years or older (14.3%, P = .01). Cardiovascular symptoms were more likely to occur in older patients (≥50 years old, 55.6% vs 30.1%, P < .001; ≥65 years old, 64.3% vs 32.3%, P = .002). Patients 50 or 65 years or older were less likely to be dismissed home directly from the ED (≥50 years old, 35.2% vs 56.6%, P = .006; ≥65 years old, 32.1% vs 54.2%, P = .03) and were less likely to be prescribed self-injectable epinephrine (≥50 years old, 40.7% vs 63.3%, P = .004; ≥65 years old, 32.1% vs 61.5%, P = .003). CONCLUSIONS: In ED patients presenting with anaphylaxis, age of 50 or 65 years or older is associated with a decreased likelihood of food-induced anaphylaxis, increased likelihood of experiencing cardiovascular symptoms, decreased dismissal to home directly from the ED, and decreased prescriptions for self-injectable epinephrine.

Medical informatics: an essential tool for health sciences research in acute care.

Medical Informatics has become an important tool in modern health care practice and research. In the present article we outline the challenges and opportunities associated with the implementation of electronic medical records (EMR) in complex environments such as intensive care units (ICU). We share our initial experience in the design, maintenance and application of a customized critical care, Microsoft SQL based, research warehouse, ICU DataMart. ICU DataMart integrates clinical and administrative data from heterogeneous sources within the EMR to support research and practice improvement in the ICUs. Examples of intelligent alarms -- "sniffers", administrative reports, decision support and clinical research applications are presented.

A reexamination of the feasibility of the administration of routine childhood vaccines in emergency departments in the era of electronic vaccine registries.

OBJECTIVES: To determine if electronic vaccine records facilitate successful routine childhood vaccination in the emergency department (ED). METHODS: We sampled consecutively over 2 calendar months children younger than 24 months presenting to the ED. Parents and legal guardians of eligible children were offered enrollment. Those consenting completed a parental survey after a nurse conducted an initial assessment of eligibility. Attending physicians then completed the assessment, and after the visit, the electronic vaccination records, when available, were accessed. No actual routine childhood vaccines were given during the study. RESULTS: Three hundred thirty-four were approached: 17 (5.1%) declined participation; 10 (3.0%) were enrolled, but the data were lost, and 7 (2.1%) were excluded. Of the 300 remaining, 235 (78.3%) had available electronic vaccine records. Only 38 (16.2%) of the 235 were late for at least 1 vaccine. Of note, physicians assessed 22 (57.9%) of the 38 as medically appropriate for vaccination in the ED. The overwhelming majority (81.8%) of the 22 parents and guardians would have assented to vaccination in the ED. Of the 38 patients found late for vaccination, 31 (81.6%) of parents incorrectly reported their children to be up-to-date on their immunizations. CONCLUSIONS: Assuming that the electronic vaccination record performed such as an online vaccine registry, the effort to access the registry might find a substantial number of children late for a routine childhood vaccination. In this setting, we found that approximately one sixth of the children with electronic vaccine records would be found late for vaccination, and based on physician assessment and parental survey, one half of those children would receive that vaccination if available in the ED. These rates offer health care planners a sense of the magnitude of the vaccination rates in the ED as we move toward regional vaccination registries with online capabilities to be accessed by EDs.