Measures of crowding in the emergency department: a systematic review.

OBJECTIVES: Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity. METHODS: This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other). RESULTS: There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria. CONCLUSIONS: Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures.

Intravenous opioid dosing and outcomes in emergency patients: a prospective cohort analysis.

OBJECTIVES: Pain management in emergency department (ED) patients is variable and often inadequate. This study sought to (1) describe the variability in intravenous opioid dosing and (2) compare the outcomes that result from the most commonly prescribed opioid doses. METHODS: This prospective cohort study enrolled emergency patients who were prescribed intravenous morphine or hydromorphone as their initial analgesic. Subjects were interviewed at the time of opioid administration and 1 to 2 hours after opioid administration. Outcomes included the numeric pain score change (using a 0-10 scale), the proportion achieving a 50% pain score reduction, and the proportion developing side effects. Logistic regression was used to assess the effects of demographic, clinical, and treatment variables on outcomes. RESULTS: Six hundred ninety-one patients were analyzed. Initial equianalgesic dosages varied by a factor of 27 (from 1 mg morphine to 4 mg hydromorphone). Opioid dose titration occurred in only 21% of patients. Outcomes were similar across the range of opioid dosages before and after adjusting for potentially confounding variables. Among patients not taking opioids at home who received a total of 4 mg of morphine or less. 48% achieved at least a 50% pain score reduction and 60% did not want additional analgesics. CONCLUSIONS: We found marked opioid dosing variability and infrequent opioid dose titration. A substantial number of ED patients with severe pain responded well to relatively low opioid dosages. Improved ability to predict opioid dose requirements and strategies that increase the use of opioid dose titration in ED patients are needed.

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

Unique sexual assault examiner program utilizing mid-level providers.

BACKGROUND: We implemented a unique sexual assault examiner (SAE) program utilizing Emergency Department (ED)-based mid-level providers. Sexual assault forensic evidence collection processes and training are not uniform in all EDs, with varying models in place. METHODS: Our study evaluated the quality of SAE evidentiary collection in standardized evidence kits (Kits), compared to Kits from other EDs without the SAE program. We prospectively studied Kits from November 2004-October 2005. All Kits were evaluated for quantity (numbers of slides, envelopes, swabs), and quality (compliance with forensic standards) of evidence. RESULTS: Although SAE Kits had similar total numbers of pieces of evidence, they had higher quality as measured by a greater number of compliant envelopes (5.44 vs. 1.44, p < 0.001) and a greater number of compliant slides (6.4 vs. 4.5, p < 0.001). SAE Kits had two measures with higher quality forensic evidence than non-SAE Kits. CONCLUSION: An integrated program of SAE-trained mid-level providers collect sexual assault Kits with a higher quality of forensic evidence than non-SAE providers.

Outcomes after intravenous opioids in emergency patients: a prospective cohort analysis.

OBJECTIVES: Pain management continues to be suboptimal in emergency departments (EDs). Several studies have documented failures in the processes of care, such as whether opioid analgesics were given. The objectives of this study were to measure the outcomes following administration of intravenous (IV) opioids and to identify clinical factors that may predict poor analgesic outcomes in these patients. METHODS: In this prospective cohort study, emergency patients were enrolled if they were prescribed IV morphine or hydromorphone (the most commonly used IV opioids in the study hospital) as their initial analgesic. Patients were surveyed at the time of opioid administration and 1 to 2 hours after the initial opioid dosage. They scored their pain using a verbal 0-10 pain scale. The following binary analgesic variables were primarily used to identify patients with poor analgesic outcomes: 1) a pain score reduction of less than 50%, 2) a postanalgesic pain score of 7 or greater (using the 0-10 numeric rating scale), and 3) the development of opioid-related side effects. Logistic regression analyses were used to study the effects of demographic, clinical, and treatment covariates on the outcome variables. RESULTS: A total of 2,414 were approached for enrollment, of whom 1,312 were ineligible (658 were identified more than 2 hours after IV opioid was administered and 341 received another analgesic before or with the IV opioid) and 369 declined to consent. A total of 691 patients with a median baseline pain score of 9 were included in the final analyses. Following treatment, 57% of the cohort failed to achieve a 50% pain score reduction, 36% had a pain score of 7 or greater, 48% wanted additional analgesics, and 23% developed opioid-related side effects. In the logistic regression analyses, the factors associated with poor analgesia (both <50% pain score reduction and postanalgesic pain score of >or=7) were the use of long-acting opioids at home, administration of additional analgesics, provider concern for drug-seeking behavior, and older age. An initial pain score of 10 was also strongly associated with a postanalgesic pain score of >or=7. African American patients who were not taking opioids at home were less likely to achieve a 50% pain score reduction than other patients, despite receiving similar initial and total equianalgesic dosages. None of the variables we assessed were significantly associated with the development of opioid-related side effects. CONCLUSIONS: Poor analgesic outcomes were common in this cohort of ED patients prescribed IV opioids. Patients taking long-acting opioids, those thought to be drug-seeking, older patients, those with an initial pain score of 10, and possibly African American patients are at especially high risk of poor analgesia following IV opioid administration.

Addition of levalbuterol to a pediatric emergency department automated medication management system does not increase its use.

BACKGROUND: Although adding a drug to an emergency department-based automated medication management system is known to increase how frequently it is ordered, little is known about this effect when the added drug does not offer substantial benefit over a substitute drug that was already available. AIMS: We studied the effect of adding nebulized levalbuterol to a pediatric emergency department-based automated medication management system that already included albuterol. METHODS: All completed orders for nebulized levalbuterol or nebulized albuterol from our academic pediatric emergency department were retrospectively identified using a computerized pharmacy database. We compared ordering of these drugs for the year before levalbuterol was added to the automated medication management system, during which it was available only from the hospital central pharmacy via a pneumatic tube system, with the year following its inclusion in the system. RESULTS: There were 6 orders for nebulized levalbuterol and 1,295 orders for nebulized albuterol during the year that levalbuterol was only available from the hospital central pharmacy, and 7 orders for nebulized levalbuterol and 1,108 orders for nebulized albuterol during the year following levalbuterol's inclusion in the automated medication management system. There was no significant difference (p = 0.78). CONCLUSIONS: Use of nebulized levalbuterol, in relation to that of nebulized albuterol, for which it is a substitute, did not significantly change when it was included in the pediatric emergency department automated medication management system. This may reflect the lack of substantial benefit that levalbuterol offers over nebulized albuterol in managing children in the emergency department.

Care without coverage: is there a relationship between insurance and ED care?

The Institute of Medicine (IOM) has concluded that differences in care exist for hospitalized patients on the basis of insurance; we attempted to determine if these differences begin in the emergency department (ED). We retrospectively studied high-acuity adult visits to one ED over 6 months, utilizing electronic databases. Uninsured patients were more often younger, male, and non-white (n = 3899 visits; 468 uninsured, 3431 insured). Fewer uninsured patients were admitted (9.8% vs. 27.2% insured; p < 0.001). Comparing patients by admission status, there was no evidence of difference for most measures, excepting radiographic studies (admitted patients: 78.3% uninsured vs. 90.5% insured, p = 0.007; treated-and-released patients: 62.3% uninsured vs. 69.4% insured, p = 0.004). In a subset of trauma patients for whom acuity could be evaluated with Injury Severity Scores (ISS), admission rates were similar. In this pilot study of high-acuity patients, there was limited evidence of differences in most measures of ED-based patient care on the basis of insurance status.

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs. The authors conclude that the design of the catheter kit and the Seldinger technique should be critically examined from a human factors standpoint and that radiographic interpretation is still heavily subject to human error.

Point of care pregnancy testing provides staff satisfaction but does not change ED length of stay.

Point of care testing (POCT) is widely viewed as possibly improving ED care and reducing length of stay (LOS). However reports are mixed, and regulatory barriers complicate considerations. We studied a simple urine pregnancy assay (human chorionic gonadotropin-HCG). LOS was evaluated when HCG was moved from central lab (HCGLab) to POCT (HCGED) in 2 pre-post 3-month periods (958 HCGLab and 1075 HCGED). HCG patients were compared with a similar control group, and staff perceptions were evaluated. There was no change in LOS for HCG patients (36.8 v 50.85 min, P = .33), although there was one marginal finding of improved LOS for patients presenting with abdominal pain diagnosed as pregnant (P = .17). Staff (28/53 physicians, 18/81 nurses) reported HCGED as positive. POCT does not improve LOS for broad groups of patients, although POCT does change the ED environment. Further study is needed to evaluate how the information flow of POCT changes patient care.

Where's the beef? The promise and the reality of clinical documentation.

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.

Emergency department digital radiology: moving from photos to pixels.

Emergency department (ED) patient care relies heavily on radiologic imaging. As advances in technologic innovation continue to present opportunities to streamline and simplify the delivery of care, emergency medicine (EM) practitioners face the challenge of transitioning from a system of primarily film-based radiography to one that utilizes digitized images. The move to digital radiology can result in enhanced quality of patient care, reduction of errors, and increased ED efficiency; however, making this transition will necessarily involve changes in EM practice. As the technology evolves, digital radiology will gradually become ingrained into everyday practice because of these and other notable benefits; however, EM practitioners will need to overcome several challenges to make the transition smoothly and consider the potential impacts that this change will have on ED workflow. The authors discuss the benefits, challenges, and other operational considerations involved with the ED implementation of digital radiology and close by presenting guiding principles for current and future users. Despite the unresolved issues, digital radiology will mature as a technology and improve EM practice, making it one of the great information technology advances in EM.

The demands of 24/7 coverage: using faculty perceptions to measure fairness of the schedule.

OBJECTIVES: Ensuring fair, equitable scheduling of faculty who work 24-hour, 7-day-per-week (24/7) clinical coverage is a challenge for academic emergency medicine (EM). Because most emergency department care is at personally valuable times (evenings, weekends, nights), optimizing clinical work is essential for the academic mission. To evaluate schedule fairness, the authors developed objective criteria for stress of the schedule, modified the schedule to improve equality, and evaluated faculty perceptions. They hypothesized that improved equality would increase faculty satisfaction. METHODS: Perceived stress was measured for types of clinical shifts. The seven daily shifts were classified as weekday, weekend, or holiday (plus one unique teaching-conference coverage shift). Faculty assigned perceived stress to shifts (ShiftStress) utilizing visual analog scales (VAS). Faculty schedules were measured (ShiftScores) for two years (1998-1999), and ShiftScore distribution of faculty was determined quarterly. Schedules were modified (1999) to reduce interindividual ShiftScore standard deviation (SD). The survey was performed pre- and postintervention. RESULTS: Preintervention, 26 faculty (100% of eligible) assigned VAS to 22 shifts. Increased stress was perceived in progression (weekday data, 0-10 scale) from day to evening to night (2.07, 5.00, 6.67, respectively) and from weekday to weekend to holiday (day-shift data, 2.07, 4.93, 5.87). The intervention reduced interindividual ShiftScore SD by 21%. Postintervention survey revealed no change in perceived equality or satisfaction. CONCLUSIONS: Faculty perceived no improvement despite scheduling modifications that improved equality of the schedule and provided objective measures. Other predictors of stress, fairness, and satisfaction with the demanding clinical schedule must be identified to ensure the success of EM faculty.

Emergency department crowding: a point in time.

STUDY OBJECTIVE: This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the degree of physical crowding and personnel shortage in our sample. METHODS: A mail survey was sent to a random sample of 250 EDs chosen from a database compiled by the American College of Emergency Physicians of 5,064 EDs in the United States. In addition to demographic information, respondents were asked to count the patients and staff in their EDs at 7 PM local time on Monday, March 12, 2001 (index time). RESULTS: The response rate was 36%. At the index time, there was an average of 1.1 patients per treatment space, and 52% of EDs reported more than 1 patient per treatment space. There was also evidence of personnel shortage, with a mean of 4.2 patients per registered nurse and 49% of EDs having each registered nurse caring for more than 4 patients. There was a mean of 9.7 patients per physician. Sixty-eight percent of EDs had each physician caring for more than 6 patients. There was crowding present in all geographic areas and all hospital types (teaching-nonteaching status of the hospital). Consistent with the crowded conditions, 11% of institutions were on ambulance diversion and not accepting new acute patients. Delays in transfer of admitted patients out of the ED contributed to the physical crowding. Twenty-two percent of patients in the ED were already admitted and were awaiting transfer to an inpatient bed; 73% of EDs were boarding 2 or more inpatients. The amount of crowding quantified by this point prevalence study was confirmed by the amount of crowding reported for the previous week: 48% of EDs were boarding inpatients during the previous week for a mean of 8.9 hours, 4.2 days per week; 31% had been on diversion; 59% had been routinely using their halls for patients; 38% had been doubling their rooms; and 47% had been using nonclinical space for patient care. CONCLUSION: Our low response rate limits this pilot study. Nonetheless, this study, as well as others, demonstrates that EDs throughout the United States are severely crowded. Such crowding raises concerns about the ability of EDs to respond to mass casualty or volume surges.

Clinical operations in academic emergency medicine.

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession. Effective operational processes should ultimately be seen as those which preserve and enhance the patient-physician relationship.

Coping with a crowded ED: an expanded unique role for midlevel providers.

Crowding in the emergency department (ED) has multiple causes, including space and staffing in both inpatient areas and the ED. Waiting for inpatient beds is the primary issue in our ED. Waiting inpatients require continuing care and attention from emergency-medicine (EM) physicians. As a managerial response, we developed a unique role for midlevel practitioners (MLPs) in which they could provide "back-end" work for patients awaiting inpatient beds. After initial EM physician evaluation, patients without ready inpatient beds were grouped in the ED and their care was transferred to the transition team (TT). The TT consisted of an MLP (nurse practitioner or physician assistant) and a registered nurse or licensed practical nurse, all reporting to ED supervisors. MLPs were readily available from the local medical professional market. The TT provided all patient care until a patient was seen by the admitting inpatient service or until the patient left for an inpatient unit. The major TT objectives were a reduction of EM physician work in caring for inpatients, and improved patient care. We demonstrated that the TT assumed a significant patient load, an indirect measure of reduced EM physician work, but this did not improve patient satisfaction. The TT clinical role is less desirable to MLPs than are other traditional clinical roles. The TT is a potentially available, incremental staffing resource for a crowded ED.

An inexpensive modification of the laboratory computer display changes emergency physicians' work habits and perceptions.

STUDY OBJECTIVE: Little is known about how the availability of laboratory data affects emergency physicians' practice habits and satisfaction. We modified our clinical information system to display laboratory test status with continuous updates, similar to an airport arrival display. The objective of this study was to determine whether the laboratory test status display altered emergency physicians' work habits and increased satisfaction compared with the time period before implementation of laboratory test status. METHODS: A retrospective analysis was performed of emergency physicians' actual use of the clinical information system before and after implementation of the laboratory test status display. Emergency physicians were retrospectively surveyed regarding the effect of laboratory test status display on their practice habits and clinical information system use. Survey responses were matched with actual use of the clinical information system. Data were analyzed by using dependent t tests and Pearson correlation coefficients. The study was conducted at a university hospital. RESULTS: Clinical information system use by 46 emergency physicians was analyzed. Twenty-five surveys were returned (71.4% of available emergency physicians). All emergency physicians perceived fewer clinical information system log ons per day after laboratory test status display. The actual average decrease was 19%. Emergency physicians who reported the greatest decrease in log ons per day tended to have the greatest actual decrease (r =-0.36). There was no significant correlation between actual and perceived total time logged on (r =0.08). In regard to effect on emergency physicians' practice habits, 95% reported increased efficiency, 80% reported improved satisfaction with data access, and 65% reported improved communication with patients. CONCLUSION: An inexpensive computer modification, laboratory test status display, significantly increased subjective efficiency, changed work habits, and improved satisfaction regarding data access and patient communication among emergency physicians. Knowledge of the test queue changed emergency physician behavior and improved satisfaction.

The effects of the absence of emergency medicine residents in an academic emergency department.

OBJECTIVE: What are the quality effects of an emergency medicine (EM) residency, and the associated 24/7 supervision of residents by faculty, in an academic emergency department (ED)? The authors evaluated activity and quality indicators when there were no EM residents present. The hypothesis of the study was that there was no difference between the patient care provided by faculty supervising EM residents and that with an alternative model without EM residents (AbsenceEMResident). METHODS: To support the weekly residency educational program (Thursday), EM residents are not scheduled clinically for a 24-hour period (ConfDay). Emergency medicine resident coverage (mean 62.7 hours) was replaced with incremental faculty and mid-level providers (mean 41.0 hours). This study was limited to adult patients (22,527 visits of 39,190 ED total) for six months (January-June 2001) and compared indicators for ConfDay (n = 23) with all other days (NotConfDay, n = 158). RESULTS: Comparing ConfDay (2,842 visits) with NotConfDay (19,685 visits), there was no difference in mean daily visits, inpatient admissions, intensive care unit admissions, or emergency medical services arrivals. ConfDay decision-to-admit time (333 vs. 313 min, p = 0.03) and length of stay for admissions (490 vs. 445 min, p = 0.000) were longer, with no difference for treat/release patients. There was no difference in the numbers of laboratory or radiology tests, consultations, unscheduled return visits, or patient satisfaction. CONCLUSION: During the study period, there was no measurable difference for most of the quality indicators studied. The AbsenceEMResident model is less efficient in admitting patients. Faculty supervision results in the same number of laboratory and radiology tests and consultations. Other specialties may consider this model if off-hours care becomes a concern.

CT in detecting urinary tract calculi: influence on patient imaging and clinical outcomes.

PURPOSE: To determine changes in examination patterns and effectiveness of care since the introduction of unenhanced helical computed tomography (CT) for examination of patients presenting to the emergency department (ED) with symptoms of urinary tract calculi (UTC). MATERIALS AND METHODS: Hospital clinical and radiology information systems were used to retrospectively identify patients presenting with UTC symptoms from January to December 1997 (before introduction of unenhanced CT) and from January to December 1999 (after introduction of unenhanced CT). Chart abstraction was used to confirm the identification of patients with presenting symptoms suggestive of UTC and assess patient outcomes. Two hundred sixty-five patients presented before (1997) and 602 after (1999) unenhanced CT was introduced. Distributions of dichotomous variables were compared between the 1997 and 1999 groups by using logistic regression. Means were compared between the groups by using analysis of variance and mean total numbers of imaging studies by using Poisson regression. RESULTS: Total number of imaging studies increased by 26.7% per patient visit (P <.001). Rates of admission following the initial ED visit (13.7% in 1997 vs 13.4% in 1999), as well as percentage of patients who subsequently returned to the ED (12.0% in 1997 vs 13.7% in 1999) or subsequently were admitted to the hospital (4.5% in 1997 vs 5.3% in 1999) in the month following the initial ED visit, were similar between the two groups. Unsuspected unenhanced CT findings that could affect acute patient care were observed at 5.9% of examinations. CONCLUSION: Use of imaging for suspected UTC has increased markedly since the introduction of unenhanced CT, with little effect on acute care of patients in the ED.