RESUMEN
BACKGROUND: Boarding of inpatients in the Emergency Department (ED) has been widely recognized as a major contributor to ED crowding and a cause of adverse outcomes. We hypothesize that these deleterious effects extend to those patients who are discharged from the ED by increasing their length of stay (LOS). STUDY OBJECTIVES: This study investigates the impact of boarding inpatients on the ED LOS of discharged patients. METHODS: This retrospective, observational, cohort study investigated the association between ED boarder burden and discharged patient LOS over a 3-year period in an urban, academic tertiary care ED. Median ED LOS of 179,840 discharged patients was calculated for each quartile of the boarder burden at time of arrival, and Spearman correlation coefficients were used to summarize the relationship. Subgroup analyses were conducted, stratified by patient acuity defined by triage designation, and hour of arrival. RESULTS: Overall median discharged patient ED LOS increased by boarder burden quartile (205 [95% confidence interval (CI) 203-207], 215 [95% CI 214-217], 221 [95% CI 219-223], and 221 [95% CI 219-223] min, respectively), with a Spearman correlation of 0.25 between daily total boarder burden hours and median LOS. When stratified by patient acuity and hour of arrival (11:00 a.m.-11:00 p.m.), LOS of medium-acuity patients increased significantly by boarder burden quartile (252 [95% CI 247-255], 271 [95% CI 267-275], 285 [95% CI 95% CI 278-289], and 309 [95% CI 305-315] min, respectively) with a Spearman correlation of 0.18. CONCLUSION: In this retrospective study, increasing boarder burden was associated with increasing LOS of patients discharged from the ED, with the greatest effect between 11:00 a.m. and 11:00 p.m. on medium-acuity patients. This relationship between LOS and ED capacity limitation by inpatient boarders has important implications, as ED and hospital leadership increasingly focus on ED LOS as a measure of efficiency and throughput.
Asunto(s)
Aglomeración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. STUDY OBJECTIVE: We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients. METHODS: We conducted a 2-year before-after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before-after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables. RESULTS: The median time to disposition decision decreased by 6min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors. CONCLUSIONS: Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.
Asunto(s)
Eficiencia Organizacional , Servicio de Urgencia en Hospital/organización & administración , Rol del Médico , Triaje , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Gravedad del Paciente , Admisión del Paciente , Mejoramiento de la Calidad , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. STUDY OBJECTIVE: We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center. METHODS: We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS. RESULTS: During the first year, we estimate the contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%. CONCLUSIONS: In addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.
Asunto(s)
Servicio de Urgencia en Hospital/organización & administración , Médicos , Centros Médicos Académicos/métodos , Centros Médicos Académicos/organización & administración , Centros Médicos Académicos/estadística & datos numéricos , Adulto , Análisis Costo-Beneficio , Economía Hospitalaria/estadística & datos numéricos , Eficiencia Organizacional/estadística & datos numéricos , Servicios Médicos de Urgencia/organización & administración , Servicios Médicos de Urgencia/estadística & datos numéricos , Servicio de Urgencia en Hospital/economía , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Admisión del Paciente/estadística & datos numéricosRESUMEN
BACKGROUND: Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care. STUDY OBJECTIVES: This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients. METHODS: This retrospective before-after study compared performance measures over two 3-month periods (September-November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA). RESULTS: In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001). CONCLUSIONS: In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.