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STUDY OBJECTIVE: Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding. METHODS: We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care. RESULTS: The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively. CONCLUSION: Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.
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STUDY OBJECTIVE: Improved understanding of factors affecting prolonged emergency department (ED) length of stay is crucial to improving patient outcomes. Our investigation builds on prior work by considering ED length of stay in operationally distinct time periods and using benchmark and novel machine learning techniques applied only to data that would be available to ED operators in real time. METHODS: This study was a retrospective review of patient visits over 1 year at 2 urban EDs, including 1 academic and 1 academically affiliated ED, and 2 suburban, community EDs. ED length of stay was partitioned into 3 components: arrival-to-room, room-to-disposition, and admit disposition to departure. Prolonged length of stay for each component was considered beyond 1, 3, and 2 hours, respectively. Classification models (logistic regression, random forest, and XGBoost) were applied, and important features were evaluated. RESULTS: In total, 135,044 unique patient encounters were evaluated for the arrival-to-room, room-to-disposition, and admit disposition-to-departure models, which had accuracy ranges of 84% to 96%, 66% to 77%, and 62% to 72%, respectively. Waiting room and ED volumes were important features in all arrival-to-room models. Room-to-disposition results identified patient characteristics and ED volume as the most important features for prediction. Boarder volume was an important feature of the admit disposition-to-departure models for all sites. Academic site models noted nurse staffing ratios as important, whereas community site models noted hospital capacity and surgical volume as important for admit disposition-to-departure prediction. CONCLUSION: This study identified granular capacity, flow, and nurse staffing predictors of ED length of stay not previously reported in the literature. Our novel methodology allowed for more accurate and operationally meaningful findings compared to prior modeling methods.
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Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model. Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule. Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture. Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.
