How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

INTRODUCTION: The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. OBJECTIVE: To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. METHODS: We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. RESULTS: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient= -0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar results. When the data were controlled for effect of month of the year, only student test score remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases). CONCLUSION: ED overcrowding does demonstrate a small but negative association with medical student performance on end-of-rotation examinations. Additional studies are recommended to further evaluate this effect.

Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model.

OBJECTIVES: There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients. METHODS: This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe. RESULTS: There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%). CONCLUSIONS: A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.

Decision-making processes of patients who use the emergency department for primary care needs.

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients' decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients' decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients' health care, which are also a prominent part of their decision-making process.

Impact of trauma activation on the ED length of stay for nontraumatic patients.

INTRODUCTION: Trauma activation prioritizes hospital resources for the assessment and treatment of trauma patient over all patients in the emergency department (ED). We hypothesized that length of stay (LOS) is longer for nontrauma patients during a trauma activation. METHODS: A retrospective, case-control chart review was conducted in a level I trauma center. Cases consist of patients who present 1 hour before and after the presentation of the trauma activation. Controls were patients presenting to the ED during the same period exactly 1 week before and after the cases. Confounding variables measured included sex, age, arrivals, and census for the 3 areas. RESULTS: Two hundred ninety-four trauma events occurred from January 1 until September 30, 2009. A significant difference was found between LOS of patients seen during a trauma activation with an average increase of 10.7 minutes in LOS (P =.0082; 95% confidence interval [CI], 2.8-18.7). This difference is attributable to the middle acuity area of the ED, in which the average increase in LOS was 20.3 minutes (P = .0004; 95% CI, 9.1-31.5). Significant LOS difference was not found when a trauma activation had an LOS of less than 60 minutes (P = .30; 95% CI, -7.1-61.7 for trauma LOS <60 minutes vs P = .02; 95% CI, 1.6-18.0 for trauma LOS ≥60 minutes). CONCLUSION: This retrospective case-control chart review identified an increase in ED LOS for patient presenting during trauma activations. Resource prioritization should be accounted for during times when these critical patients enter the ED.

Impact of scribes on performance indicators in the emergency department.

OBJECTIVES: The objective was to quantify the effect of scribes on three measures of emergency physician (EP) productivity in an adult emergency department (ED). METHODS: For this retrospective study, 243 clinical shifts (of either 10 or 12 hours) worked by 13 EPs during an 18-month period were selected for evaluation. Payroll data sheets were examined to determine whether these shifts were covered, uncovered, or partially covered (for less than 4 hours) by a scribe; partially covered shifts were grouped with uncovered shifts for analysis. Covered shifts were compared to uncovered shifts in a clustered design, by physician. Hierarchical linear models were used to study the association between percentage of patients with which a scribe was used during a shift and EP productivity as measured by patients per hour, relative value units (RVUs) per hour, and turnaround time (TAT) to discharge. RESULTS: RVUs per hour increased by 0.24 units (95% confidence interval [CI] = 0.10 to 0.38, p = 0.0011) for every 10% increment in scribe usage during a shift. The number of patients per hour increased by 0.08 (95% CI = 0.04 to 0.12, p = 0.0024) for every 10% increment of scribe usage during a shift. TAT was not significantly associated with scribe use. These associations did not lose significance after accounting for physician assistant (PA) use. CONCLUSIONS: In this retrospective study, EP use of a scribe was associated with improved overall productivity as measured by patients treated per hour (Pt/hr) and RVU generated per hour by EPs, but not as measured by TAT to discharge.

Babesiosis as a rare cause of fever in the immunocompromised patient: a case report.

INTRODUCTION: This is the case of a rare and regional disease not often considered in the immunocompromised patient presenting with a chief complaint of fever. CASE PRESENTATION: A 37-year-old immunocompromised Indian woman presented with a chief complaint of fever, in the absence of localizing signs and symptoms, from an area endemic to Babesia microti. CONCLUSIONS: Our patient's case is instructive in that Babesiosis and other arthropod born illnesses should be considered in immunocompromised patients presenting with fever in the absence of localizing signs or symptoms. This is especially true when he or she presents from an area with known endemic disease. While the management of fever in immunocompromised patients is largely standardized, considering Babesiosis from the beginning may prompt early investigation of a blood smear, which has the potential to alert the emergency department physician to Babesiosis. In addition, considering the disease from the outset has the potential to accelerate administration of the appropriate antimicrobial therapy and thus prevent unnecessary morbidity and possible mortality.

A comparison of the palatability of flavored oral contrasts.

OBJECTIVE: The aim of this study was to compare the taste of computed tomography (CT) oral contrast diluted with various flavored drinks. METHODS: We performed a prospective, blinded, controlled trial in healthy adult volunteers. Subjects were assigned to ingest four 250-mL aliquots of oral contrast media diluted in water, Crystal Light Lemonade (Kraft Food, Northfield, Ill), Tropical Punch Kool-Aid (Kraft Food), and Tropicana orange juice (Pepsi Bottling Company, Sommers, NY) in random order; and the taste of the solution was measured with a 100-mm visual analogue scale and 5-point Likert scale from very worst to best. Between-group comparison of the taste scores was performed with repeated-measures analysis of variance and pairwise t tests. The study had 80% power to detect an effect size 0.75 SDs. RESULTS: There were 23 subjects; mean (SD) age was 33 (7.7) and 30% were female. The mean (SD) taste scores were water 12 (5), lemonade 37 (21), Kool-Aid 44 (20), and orange juice 40 (20) (P < .05). The proportion of subjects completely ingesting the contrast in water (65%) was significantly less than that with other 3 study solutions (100% each, P < .001). CONCLUSIONS: Dilution of oral contrast media with lemonade, fruit punch, or orange juice is tastier than with water. The choice of the specific juice used to dilute the oral contrast should be individualized based on patient preferences and availability.