Measuring Sensitivity and Precision of Real-Time Location Systems (RTLS): Definition, Protocol and Demonstration for Clinical Relevance.

The ability of a Real Time Location System (RTLS) to provide correct information in a clinical environment is an important consideration in evaluating the effectiveness of the technology. While past efforts describe how well the technology performed in a lab environment, the performance of such technology has not been specifically defined or evaluated in a practice setting involving workflow and movement. Clinical environments pose complexity owing to various layouts and various movements. Further, RTL systems are not equipped to provide true negative information (where an entity is not located). Hence, this study defined sensitivity and precision in this context, and developed a simulation protocol to serve as a systematic testing framework using actors in a clinical environment. The protocol was used to measure the sensitivity and precision of an RTL system in the emergency department space of a quaternary care medical center. The overall sensitivity and precision were determined to be 84 and 93% respectively. These varied for patient rooms, staff area, hallway and other rooms.

Characterization of emergency department abandonment using a real-time location system.

BACKGROUND: Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting. OBJECTIVE: Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates. METHODS: This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included. RESULTS: Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5). CONCLUSION: Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.

Unnecessary wait hours: a novel ED system-level metric.

BACKGROUND: Emergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the 'Number of Unnecessary Waits (NUW)' and the corresponding 'Unnecessary Wait Hours (UWH)', to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED. METHODS: UWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA. RESULTS: We retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect. CONCLUSIONS: Situational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department's operations.

Consequences of the 48-h rule: A lens into the psychiatric patient flow through an emergency department.

OBJECTIVE: Psychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow. METHODS: A pre- and post- comparison of 2011-2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5days. Changes in patient disposition proportions were assessed using risk ratios. RESULTS: The median ED LOS for patients admitted for psychiatric care increased by 5.22h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3days and ≥15days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively). CONCLUSIONS: The proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care.

Time Motion Analysis: Impact of Scribes on Provider Time Management.

BACKGROUND: Scribes are unlicensed professionals trained in medical data entry. Limited data exist on the impact of scribes on provider time management in the emergency department (ED). Time-motion analysis is a tool utilized in business to capture detailed movements and durations to task completion. It offers a means to categorize how providers allocate their time during a clinical shift. OBJECTIVE: Evaluate the impact of scribes on how ED providers spend their time. METHODS: A prospective observational study was conducted to assess scribe impact on provider time utilization. Four research assistants (RAs) observed attending providers on 24 8-h control shifts (without a scribe), and 24 scribed shifts. RAs observed and categorized provider activity. Providers self-reported after-hours documentation times. Two-sample t-tests were used for normally distributed data, and Wilcoxon rank-sum tests were used for skewed data. All tests were two-sided, and p-values < 0.05 were considered statistically significant. RESULTS: Scribes decreased total documentation time both on shift (mean 55.3 vs. 36.4 min, p < 0.001) and post shift (mean 42.5 vs. 23.3 min, p = 0.038). They did not significantly decrease the amount of time spent reviewing the medical records or placing orders, nor did they have an impact on provider time spent at patients' bedside or time spent discussing patient care with team members. CONCLUSION: The presence of scribes decreased provider documentation time but did not change the amount of time spent at the bedside or communicating with other team members. Scribes may be a potential strategy to decrease the clerical burden.

Impact of scribes on emergency department patient throughput one year after implementation.

OBJECTIVES: Assess the impact of scribes on an academic emergency department's (ED) throughput one year after implementation. METHODS: A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre-defined study hours in a tertiary academic ED with both an adult and pediatric ED. An alternating-day pattern one year following scribe implementation ensured balance between the scribe and non-scribe groups in time of day, day of week, and patient complexity. RESULTS: Adult: Overall length of stay (LOS) was essentially the same in both groups (214 vs. 215min, p=0.34). In area A where staffing includes an attending and residents, scribes made a significant impact in treatment room time in the afternoon (190 vs 179min, p=0.021) with an increase in patients seen per hour on scribed days (2.00 vs. 2.13). There was no statistically significant changes in throughput metrics in area B staffed by an attending and a nurse practitioner/physician assistant, however scribed days did average more patients per hour (2.01 vs. 2.14). Pediatric: All throughput measurements were significantly longer when the treatment team had a scribe; however, patients per hour increased from 2.33 to 2.49 on scribed days. CONCLUSIONS: Overall patient throughput was not enhanced by scribes. Certain areas and staffing combinations yielded improvements in treatment room and door to provider time, however, scribes appear to have enabled attending physicians to see more patients per hour. This effect varied across treatment areas and times of day.

Does gender bias in cardiac stress testing still exist? A videographic analysis nested in a randomized controlled trial.

OBJECTIVES: Despite a high prevalence of coronary heart disease in both genders, studies show a gender disparity in evaluation whereby women are less likely than men to undergo timely or comprehensive cardiac investigation. Using videographic analysis, we sought to quantify gender differences in provider recommendations and patient evaluations. METHODS: We analyzed video recordings from our Chest Pain Choice trial, a single center patient-level randomized trial in which emergency department patients with chest pain being considered for cardiac stress testing were randomized to shared decision-making or usual care. Patient-provider interactions were video recorded. We compared characteristics and outcomes by gender. RESULTS: Of the 204 patients enrolled (101 decision aid; 103 usual care), 120 (58.8%) were female. Of the 75 providers evaluated, 20 (26.7%) were female. The mean (SD) pretest probability of acute coronary syndrome was lower in women [3.7% (2.2) vs 6.7% (4.4), P=.0002]. There was no gender effect on duration of discussion, clinician recommendations, OPTION scores, patient perceptions, or eventual patient dispositions. When the clinician and patient gender matched, OPTION scores were lower (interaction P=.002), and patients were less likely to find the information to be very helpful (interaction P=.10). CONCLUSIONS: Despite a lower pretest probability of acute coronary syndrome in women, we did not observe any significant gender disparity in how patients were managed and evaluated. When the patients' and providers' gender matched, the provider involved them less in the decision making process, and the information provided was less helpful than when the genders did not match.

Impact of Scribes on Billed Relative Value Units in an Academic Emergency Department.

BACKGROUND: Scribe use throughout health care is becoming more common. There is limited peer-reviewed literature supporting this emerging role in health care despite rapid uptake of the role. OBJECTIVES: Our study assesses impact of scribes on relative value units (RVUs) in adult and pediatric emergency departments (EDs). METHODS: A prospective cohort study was developed in a tertiary academic ED. Charts were coded by an external billing and coding company, then returned and mapped by International Classification of Diseases, 9th revision diagnostic codes. After training by a staff member with significant experience in implementing scribe programs, scribes provided 1-to-1 support to a provider as staffing allowed. Comparisons were made between scribed and nonscribed visits. RESULTS: There were 49,389 patient visits during the study period (39,926 adult [80.84%] and 9463 pediatric [19.16%] visits), of which 7865 (15.9%) were scribed. For adults, scribed visits produced 0.20 additional RVUs per patient (p < 0.001). Scribes generated additional RVUs in Emergency Severity Index (ESI) 2 (p < 0.001) and 3 (p < 0.001) patients. There were variable effects of scribes on RVUs by diagnostic codes. For pediatric patients, scribed encounters generated 0.08 fewer RVUs per patient (p = 0.007). ESI score had no effect on RVUs. The impact of scribes on pediatric diagnostic groupings was inconsistent. CONCLUSIONS: Scribes had a positive impact on RVUs in adult but not pediatric patients. Among adults, scribes led to higher RVUs in ESI 2 and 3 but not 4 and 5 patients, perhaps suggesting a limitation to improve revenue capture on lower-acuity patients.

Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department.

BACKGROUND: It is unclear how workflow interruptions impact emergency physicians at the point of care. OBJECTIVES: Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians. METHODS: This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms. RESULTS: A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ2(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ2 [2, n = 2355] = 78.43, p < 0.001). CONCLUSIONS: Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.

Pilot Study of Kano "Attractive Quality" Techniques to Identify Change in Emergency Department Patient Experience.

STUDY OBJECTIVE: We describe the use of the Kano Attractive Quality analytic tool to improve an identified patient experience gap in perceived compassion by emergency department (ED) providers. METHODS: In phase 1, point-of-service surveying assessed baseline patient perception of ED provider compassion. Phase 2 deployed Kano surveys to predict the effect of 4 proposed interventions on patient perception. Finally, phase 3 compared patients receiving standard care versus the Kano-identified intervention to assess the actual effect on patient experience. RESULTS: In phase 1, 193 of 200 surveys (97%) were completed, showing a baseline median score of 4 out of 5 (interquartile range [IQR] 3 to 5), with top box percentage of 33% for patients' perception of receiving compassionate care. In phase 2, 158 of 180 surveys (88%) using Kano-formatted questions were completed, and the data predicted that increasing shared decisionmaking would cause the greatest improvement in the patient experience. Finally, in phase 3, 45 of 49 surveys (92%) were returned and demonstrated a significant improvement in perceived concern and sensitivity, 5 (IQR 5 to 5) versus 4 (IQR 3 to 5) with a difference of 1 (95% CI 0.1-1.9) and a top box rating of 79% versus 35% with a difference of 44% (95% CI 12-66) by patients who received dedicated shared decisionmaking interventions versus those receiving standard of care. CONCLUSION: Kano analysis is likely predictive of change in patient experience. Kano methods may prove as useful in changing management of the health care industry as it has been in other industries.

Impact of scribes on patient throughput in adult and pediatric academic EDs.

OBJECTIVES: Assess the impact of scribes on an academic emergency department's (ED) patient-specific throughput. METHODS: Study design, setting, participants: A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre-defined study hours in a tertiary academic ED with both an adult and pediatric ED. INTERVENTION: Eight scribes were hired and trained on-site by a physician with experience in scribe implementation. Scribes provided 1-to-1 support for a provider's work shift. An alternating-day pattern in months 2 to 5 post implementation ensured balance between the scribe and non-scribe groups in time of day, day of week, and patient complexity. RESULTS: Adult: Overall length of stay (LOS) was significantly longer for scribed patients (265 vs. 255 minutes, P=.028). The remaining throughput measures analyzed (door to provider, provider to disposition, and patient duration in treatment room) had higher summary values, but were not significant. Subgroup analysis revealed that patients seen by postgraduate year (PGY) 3 residents had significantly shorter LOS when seen with a scribe (244 vs. 262 minutes, P=.021). Pediatric: Overall LOS (163 vs. 151 minutes, P=.011), door to provider (21 vs. 16 minutes, P<.001), and treatment room duration (130 vs. 123 minutes, P=.020) were significantly longer when the treatment team had a scribe. CONCLUSIONS: Scribes failed to improve patient-specific throughput metrics in the first few months post implementation. Future work is needed to understand whether throughput efficiencies may eventually be gained after scribe implementation.

Prolonged length of stay in ED psychiatric patients: a multivariable predictive model.

BACKGROUND: We aimed to evaluate factors associated with prolonged emergency department (ED) length of stay (LOS) among psychiatric patients and to develop a multivariable predictive model to guide future interventions to reduce ED LOS. METHODS: Electronic health records of ED patients receiving a psychiatric consultation and providing research authorization were reviewed from September 14, 2010, through September 13, 2013, at an academic hospital with approximately 73000 visits annually. Prolonged LOS was defined as ≥8 hours. RESULTS: We identified 9247 visits among 6335 patients; median LOS was 4.1 hours, with 1424 visits (15%) with prolonged LOS. In the multivariable model, characteristics associated with an increased risk of a prolonged LOS included patient age 12 to 17 years (odds ratio [OR], 2.43; P<.001) or ≥65 years (OR, 1.46; P=.007); male gender (OR, 1.24; P=.002); Medicare insurance coverage (OR, 1.34; P=.008); use of restraints (OR, 2.25; P=.006); diagnoses of cognitive disorder (OR, 4.62; P<.001) or personality disorder (OR, 3.45; P<.001); transfer to an unaffiliated psychiatric hospital (OR, 22.82; P<.001); ED arrival from 11 pm through 6:59 am (OR, 1.53; P<.001) or on a Sunday (OR, 1.76; P<.001); or ED evaluation in February (OR, 1.59; P=.006), April (OR, 1.66; P=.002), and May (OR, 1.54; P=.007). CONCLUSIONS: Many psychiatric patients had a prolonged ED LOS. Understanding the multiple, patient-specific, ED operational, and seasonal factors that predict an increased LOS will help guide allocation of resources to improve overall ED processes and patient care.

Intelligent Emergency Department: Validation of Sociometers to Study Workload.

Sociometers are wearable sensors that continuously measure body movements, interactions, and speech. The purpose of this study is to test sociometers in a smart environment in a live clinical setting, to assess their reliability in capturing and quantifying data. The long-term goal of this work is to create an intelligent emergency department that captures real-time human interactions using sociometers to sense current system dynamics, predict future state, and continuously learn to enable the highest levels of emergency care delivery. Ten actors wore the devices during five simulated scenarios in the emergency care wards at a large non-profit medical institution. For each scenario, actors recited prewritten or structured dialogue while independent variables, e.g., distance, angle, obstructions, speech behavior, were independently controlled. Data streams from the sociometers were compared to gold standard video and audio data captured by two ward and hallway cameras. Sociometers distinguished body movement differences in mean angular velocity between individuals sitting, standing, walking intermittently, and walking continuously. Face-to-face (F2F) interactions were not detected when individuals were offset by 30°, 60°, and 180° angles. Under ideal F2F conditions, interactions were detected 50 % of the time (4/8 actor pairs). Proximity between individuals was detected for 13/15 actor pairs. Devices underestimated the mean duration of speech by 30-44 s, but were effective at distinguishing the dominant speaker. The results inform engineers to refine sociometers and provide health system researchers a tool for quantifying the dynamics and behaviors in complex and unpredictable healthcare environments such as emergency care.

Emergency department rapid medical assessment: overall effect and mechanistic considerations.

BACKGROUND: Although the use of a physician and nurse team at triage has been shown to improve emergency department (ED) throughput, the mechanism(s) by which these improvements occur is less clear. OBJECTIVES: 1) To describe the effect of a Rapid Medical Assessment (RMA) team on ED length of stay (LOS) and rate of left without being seen (LWBS); 2) To estimate the effect of RMA on different groups of patients. METHODS: For Objective 1, we compared LOS and LWBS on dates when we utilized RMA to comparable dates when we did not. For Objective 2, we utilized patient logs to divide patients into groups and estimated the effects of the RMA on each. RESULTS: Objective 1. LOS fell from 297.8 min pre-RMA to 261.7 min during RMA, an improvement of 36.1 (95% confidence interval 21.8-50.4) min; LWBS did not change significantly. Objective 2. Patients seen and dispositioned by the RMA had an estimated decrease in LOS of 117.8 min (estimated decrease in LOS of 45%), but patients seen by the RMA whose care was transitioned to the main ED had an estimated increase in LOS of 25.0 min (estimated increase in LOS of 8%). CONCLUSIONS: On a system level, the addition of an RMA shift at a single facility was associated with an improvement in LOS, but not LWBS. On a mechanistic level, it seems that improvements occurred as a result of the rapid disposition component of the RMA rather than placing advanced orders at triage.

Antihypertensive medication use is associated with increased organ system involvement and hospitalization in emergency department patients with anaphylaxis.

BACKGROUND: Risk factors for increased anaphylaxis severity are poorly understood. Angiotensin-converting enzyme (ACE) inhibitors have been associated with severe anaphylactic reactions in patients with hymenoptera venom allergy. Studies evaluating the association between beta-blockers and severe anaphylaxis have been conflicting. OBJECTIVE: To evaluate the association between antihypertensive medication use and increased anaphylaxis severity. METHODS: We included emergency department anaphylaxis patients aged 18 years and older. Markers of severe anaphylaxis were defined as (1) syncope, hypotension, or hypoxia; (2) signs and symptoms involving 3 or more organ systems; and (3) hospitalization. Antihypertensive medications evaluated included beta-blockers, ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and diuretics. Simple and multiple logistic regression analyses were conducted to estimate the association between antihypertensive medication use and markers of increased anaphylaxis severity. RESULTS: Among 302 patients with anaphylaxis, 55 (18%) had syncope, hypoxia, or hypotension, 57 (19%) required hospitalization, and 139 (46%) had 3 or more organ system involvement. After adjusting for age, gender, suspected trigger, and preexisting lung disease, beta-blocker, ACE-inhibitor, diuretic, or antihypertensive medication use in aggregate remained associated with both 3 or more organ system involvement and need for hospital admission. The adjusted associations between antihypertensive medication use in aggregate and 3 or more organ system involvement yielded an odds ratio of 2.8 (95% CI, 1.5-5.2; P=.0008) and with hospitalization an odds ratio of 4.0 (95% CI, 1.9-8.4; P=.0001). CONCLUSIONS: In emergency department anaphylaxis patients, antihypertensive medication use is associated with increased organ system involvement and increased odds of hospital admission, independent of age, gender, suspected trigger, or preexisting lung disease.

External validation of the Glasgow-Blatchford Bleeding Score and the Rockall Score in the US setting.

BACKGROUND: The Glasgow-Blatchford Bleeding Score (GBS) and Rockall Score (RS) are clinical decision rules that risk stratify emergency department (ED) patients with upper gastrointestinal bleeding (UGIB). We evaluated GBS and RS to determine the extent to which either score identifies patients with UGIB who could be safely discharged from the ED. METHODS: We reviewed and extracted data from the electronic medical records of consecutive adult patients who presented with signs or symptoms of UGIB (hematemesis and/or melena) to an academic ED from April 1, 2004, to April 1, 2009. The primary outcome was need for intervention (blood transfusion and/or endoscopic/surgical intervention) or death within 30 days. RESULTS: We identified 171 patients with the following characteristics: mean age of 69.9 years (SD, 17.0 years ), 52% women, 20% with a history of liver disease, and 22% with history of gastrointestinal bleeding. Ninety (52.6%, 95% confidence interval, 44.9-60.3) patients had the primary outcome. GBS outperformed pre-endoscopy RS [area under the receiver operating characteristic curve (AUC)=0.79 vs 0.62; P=.0001; absolute difference, 0.17]. The prognostic accuracy of GBS and post-endoscopy RS was similarly high (AUC, 0.79 vs 0.72; P=.26; absolute difference, 0.07). The specificity of GBS and RS was suboptimal at all potential decision thresholds. CONCLUSIONS: Although GBS outperformed pre-endoscopy RS, the prognostic accuracy of GBS and post-endoscopy RS was similarly high. The specificity of GBS and RS was insufficient to recommend use of either score in clinical practice.

Assessing the Generalizability of a Clinical Machine Learning Model Across Multiple Emergency Departments.

Objective: To assess the generalizability of a clinical machine learning algorithm across multiple emergency departments (EDs). Patients and Methods: We obtained data on all ED visits at our health care system's largest ED from May 5, 2018, to December 31, 2019. We also obtained data from 3 satellite EDs and 1 distant-hub ED from May 1, 2018, to December 31, 2018. A gradient-boosted machine model was trained on pooled data from the included EDs. To prevent the effect of differing training set sizes, the data were randomly downsampled to match those of our smallest ED. A second model was trained on this downsampled, pooled data. The model's performance was compared using area under the receiver operating characteristic (AUC). Finally, site-specific models were trained and tested across all the sites, and the importance of features was examined to understand the reasons for differing generalizability. Results: The training data sets contained 1918-64,161 ED visits. The AUC for the pooled model ranged from 0.84 to 0.94 across the sites; the performance decreased slightly when Ns were downsampled to match those of our smallest ED site. When site-specific models were trained and tested across all the sites, the AUCs ranged more widely from 0.71 to 0.93. Within a single ED site, the performance of the 5 site-specific models was most variable for our largest and smallest EDs. Finally, when the importance of features was examined, several features were common to all site-specific models; however, the weight of these features differed. Conclusion: A machine learning model for predicting hospital admission from the ED will generalize fairly well within the health care system but will still have significant differences in AUC performance across sites because of site-specific factors.

Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group.

Introduction: Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex-based differences, including metrics such as door-to-room (DTR) and door-to-healthcare practitioner (DTP) times to look for potential signs of systemic bias. Methods: We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min. Results: A total of 106,011 adult visits to the ED were investigated. Female patients had 8-min longer median length-of-stay (LOS) than males (P < 0.01). Females had longer DTR (2-min median difference, P < 0.01), and longer DTP (5-min median difference, P < 0.01). Females had longer median door-to-over-the-counter analgesia time (84 vs. 80, P = 0.58), door-to-advanced analgesia (95 vs. 84, P < 0.01), door-to-PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door-to-intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males. Conclusion: Numerous statistically significant differences were identified in throughput and care measures-mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.