The state of emergency medicine in Greece: at critical momentum.

Greece is a parliamentary republic in southeastern Europe populated by over 10 million permanent residents: 9 million reside on the mainland, with almost 4 million in the greater Athens area. The remaining 1 million populate the over 1200 Greek islands. In addition, more than 160,000 asylum-seekers reached Greece in 2022, and more than 25 million tourists have visited Greece in the last two years. Modern Greek Emergency Medicine (EM) is now in its 4th decade. The Greek government has focused the last few years on enhancing the quality of emergency services provided in public hospitals. Emergency Departments (EDs) are being modernized, undergraduate medical education gradually incorporates EM, and a specialty training program in emergency nursing has been established. However, the late recognition of the critical importance of EM as a specialty in Greece has resulted in the subsequent need to create three alternative pathways to EM, none of which are direct from residency. The first is a 24-month Emergency Medicine fellowship after completing a residency in another specialty and then passing the national exam. The second is for physicians who have worked in a public hospital ED (Gr: Ethniko Systima Ygeias (ESY) ESY for at least three years and successfully passed the national exam. The third, which no longer exists, is a 'grandfather' pathway for those physicians who worked in an ESY ED for five years prior to the creation of the fellowship training program. As a result, there is a critical shortage of EM-trained physicians, resulting in most care being provided by physicians without formal training in EM. This is further confounded by the country's challenging geography, with frequent air transfers from the islands to mainland hospitals. Creating an EM Residency training program is a critical next step to overcoming many of the challenges facing EM provision in Greece today: it would address the shortage of EM-trained providers, decrease the need for costly ground and air transfers, and improve the quality of emergency care throughout Greece.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) RNA and viable virus contamination of hospital emergency department surfaces and association with patient coronavirus disease 2019 (COVID-19) status and aerosol-generating procedures.

Emergency departments are high-risk settings for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) surface contamination. Environmental surface samples were obtained in rooms with patients suspected of having COVID-19 who did or did not undergo aerosol-generating procedures (AGPs). SARS-CoV-2 RNA surface contamination was most frequent in rooms occupied by coronavirus disease 2019 (COVID-19) patients who received no AGPs.

Sociodemographic Disparities in Queue Jumping for Emergency Department Care.

Importance: Emergency department (ED) triage models are intended to queue patients for treatment. In the absence of higher acuity, patients of the same acuity should room in order of arrival. Objective: To characterize disparities in ED care access as unexplained queue jumps (UQJ), or instances in which acuity and first come, first served principles are violated. Design, Setting, and Participants: Retrospective, cross-sectional study between July 2017 and February 2020. Participants were all ED patient arrivals at 2 EDs within a large Northeast health system. Data were analyzed from July to September 2022. Exposure: UQJ was defined as a patient being placed in a treatment space ahead of a patient of higher acuity or of a same acuity patient who arrived earlier. Main Outcomes and Measures: Primary outcomes were odds of a UQJ and association with ED outcomes of hallway placement, leaving before treatment complete, escalation to higher level of care while awaiting inpatient bed placement, and 72-hour ED revisitation. Secondary analysis examined UQJs among high acuity ED arrivals. Regression models (zero-inflated Poisson and logistic regression) adjusted for patient demographics and ED operational variables at time of triage. Results: Of 314 763 included study visits, 170 391 (54.1%) were female, the mean (SD) age was 50.46 (20.5) years, 132 813 (42.2%) patients were non-Hispanic White, 106 401 (33.8%) were non-Hispanic Black, and 66 465 (21.1%) were Hispanic or Latino. Overall, 90 698 (28.8%) patients experienced a queue jump, and 78 127 (24.8%) and 44 551 (14.2%) patients were passed over by a patient of the same acuity or lower acuity, respectively. A total of 52 959 (16.8%) and 23 897 (7.6%) patients received care ahead of a patient of the same acuity or higher acuity, respectively. Patient demographics including Medicaid insurance (incident rate ratio [IRR], 1.11; 95% CI, 1.07-1.14), Black non-Hispanic race (IRR, 1.05; 95% CI, 1.03-1.07), Hispanic or Latino ethnicity (IRR, 1.05; 95% CI, 1.02-1.08), and Spanish as primary language (IRR, 1.06; 95% CI, 1.02-1.10) were independent social factors associated with being passed over. The odds of a patient receiving care ahead of others were lower for ED visits by Medicare insured (odds ratio [OR], 0.92; 95% CI, 0.88-0.96), Medicaid insured (OR, 0.81; 95% CI, 0.77-0.85), Black non-Hispanic (OR, 0.94; 95% CI, 0.91-0.97), and Hispanic or Latino ethnicity (OR, 0.87; 95% CI, 0.83-0.91). Patients who were passed over by someone of the same triage severity level had higher odds of hallway bed placement (OR, 1.01; 95% CI, 1.00-1.02) and leaving before disposition (OR, 1.02; 95% CI, 1.01-1.04). Conclusions and Relevance: In this cross-sectional study of ED patients in triage, there were consistent disparities among marginalized populations being more likely to experience a UQJ, hallway placement, and leaving without receiving treatment despite being assigned the same triage acuity as others. EDs should seek to standardize triage processes to mitigate conscious and unconscious biases that may be associated with timely access to emergency care.

Correlations among common emergency medicine physician performance measures: Mixed messages or balancing forces?

The increasing complexity of ED physician performance measures has resulted in significant challenges, including duplicative and conflicting measures that fail to account for different ED settings. We performed a cross sectional analysis of correlations between measures to characterize their relationships and determine if differences exist between academic versus non-academic ED settings. Pearson correlations were calculated for 12 measures among 220 ED physicians at 11 EDs. Higher admission rate was strongly correlated with higher CT utilization rate (R = 0.7, p < 0.01) and longer room to discharge time (R = 0.7, p < 0.01). Higher patients per hour was strongly correlated with shorter room to doctor time (R = -0.7, p < 0.01). Stronger measure correlations were found in the academic setting compared to the non-academic setting. Strong correlations between ED measures imply opportunities to reduce competing performance demands on clinicians. Differences in correlations at academic versus non-academic settings suggest that it may be inappropriate to apply the same performance standards across settings.

EMS Non-Transport of Low-Risk COVID-19 Patients.

Objectives: COVID-19 infections in the community have the potential to overwhelm both prehospital and in-hospital resources. Transport of well-appearing patients, in the absence of available emergency department treatment capacity, increases strain on the hospital and EMS system. In May of 2020, the Connecticut Office of EMS issued a voluntary, EMS-initiated, non-transport protocol for selected low-risk patients with symptoms consistent with COVID-19. We evaluated the implementation of this non-transport protocol in a mixed urban/suburban EMS system.Methods: We conducted a retrospective review of contemporaneously recorded quality improvement documentation for uses of the Connecticut COVID-19 non-transport protocol by EMS clinicians within our EMS system during two implementations: from 12/14/2020 to 5/1/21, and again from 1/3/22 to 2/18/22, which coincided with large COVID-19 case surges in our region.Results: The vast majority of patients treated under the non-transport protocol were not reevaluated by EMS or in our emergency departments in the subsequent 24 hours. There was reasonable adherence to the protocol, with 83% of cases appropriate for the non-transport protocol. The most common reasons for protocol violations were age outside of protocol scope (pediatric patients), failure of documentation, or vital signs outside of the established protocol parameters. We did not find an increased 24-hour ED visit rate in patients who were inappropriately triaged to the protocol. Of patients who had ED visits within 24 hours, only two were admitted, none to higher levels of care.Conclusion: Within this small study, EMS clinicians in our system were able to safely and accurately apply a non-transport protocol for patients presenting with symptoms consistent with COVID-19. This is consistent with previous literature suggesting that EMS-initiated non-transport is a viable strategy to reduce the burden on health systems.

Patient cost consciousness in the emergency department.

BACKGROUND: 'Surprise billing', or the phenomenon of unexpected coverage gaps in which patients receiving out-of-network medical bills after what they thought was in-network care, has been a major focus of policymakers and advocacy groups recently, particularly in the Emergency Department (ED) setting, where patients' ability to choose a provider is exceedingly limited. The No Surprises Act is the legislative culmination to address "surprise bills," with the aim of promoting price transparency as a solution for billing irregularities. However, the knowledge and perceptions of patients regarding emergency care price transparency, particularly the degree to which ED patients are cost conscious is unknown. Accordingly, we sought to quantify that perception by measuring patients' direct predictions for the cost of their care. METHODS: We conducted an in-person survey of patients in Emergency Departments (EDs) over an 10-month period at two campuses within a large academic hospital system in southern Connecticut. We surveyed a convenience sample of patients at the bedside regarding demographics, care seeking perceptions and their estimates of the total and out-of-pocket costs for their ED care. Survey data was linked to institutional hospital finance datasets including actual charges and payments. We then later obtained the actual costs and billed amounts and compared these to the patients' estimates using a paired t-test. We also analyzed results according to certain patient demographics. RESULTS: A total of 600 patients were approached for survey, and data from 455 were available for the final analysis. On average, patients overestimated the cost of their care by $2484 and overestimated out-of-pocket cost by $144; both of these results met statistical significance (p < .005). Patients were better able to predict both total and out-of-pocket costs if they were: college educated or above; unemployed or retired; aged 65 or older; or had private insurance. Uninsured patients could better predict total cost but not out-of-pocket costs. One in 4 patients reported considering the cost of care prior to visiting the ED. Only 12 patients reported trying to look up that price before coming. CONCLUSIONS: This study is the first to our knowledge that sought to quantify how patients perceive the cost of acute, unscheduled care in the ED. We found that ED patients generally do not consider the price before going to the ED, and subsequently overestimate the negotiated total costs of acute, unscheduled emergency care as well as their out-of-pocket responsibility for care. Certain demographics are less predictive of this association. Notably, patients with Medicare/Medicaid and those with high school education or below were of the furthest off in predicting the actual cost of care. This lends credence to the established trend of patients' limited knowledge of the total cost of healthcare; moreover, that they overestimate the cost of their care could serve as a barrier to accessing that care particularly in more vulnerable groups. We hope that this finding adds useful information to policymakers in sculpting future legislation around surprise billing.

Implementation of an Electronic Health Record Integrated Clinical Pathway Improves Adherence to COVID-19 Hospital Care Guidelines.

BACKGROUND: During the COVID-19 pandemic, frequently changing guidelines presented challenges to emergency department (ED) clinicians. The authors implemented an electronic health record (EHR)-integrated clinical pathway that could be accessed by clinicians within existing workflows when caring for patients under investigation (PUI) for COVID-19. The objective was to examine the association between clinical pathway utilization and adherence to institutional best practice treatment recommendations for COVID-19. METHODS: The authors conducted an observational analysis of all ED patients seen in a health system inclusive of seven EDs between March 18, 2020, and April 20, 2021. They implemented the pathway as an interactive flow chart that allowed clinicians to place orders while viewing the most up-to-date institutional guidance. Primary outcomes were proportion of admitted PUIs receiving dexamethasone and aspirin in the ED, and secondary outcome was time to delivering treatment. RESULTS: A total of 13 269 patients were admitted PUIs. The pathway was used by 40.6% of ED clinicians. When clinicians used the pathway, patients were more likely to be prescribed aspirin (OR, 7.15; 95% CI, 6.2-8.26) and dexamethasone (10.4; 8.85-12.2). For secondary outcomes, clinicians using the pathway had statistically significant ( P < 0.0001) improvement in timeliness of ordering medications and admission to the hospital. Aspirin, dexamethasone, and admission order time were improved by 103.89, 94.34, and 121.94 minutes, respectively. CONCLUSIONS: The use of an EHR-integrated clinical pathway improved clinician adherence to changing COVID-19 treatment guidelines and timeliness to associated medication administration. As pathways continue to be implemented, their effects on improving patient outcomes and decreasing disparities in patient care should be further examined.

Improving Emergency Department Throughput Using Audit-and-Feedback With Peer Comparison Among Emergency Department Physicians.

INTRODUCTION: We sought to determine if audit-and-feedback with peer comparison among emergency physicians is associated with improved emergency department (ED) throughput and decreased variation in physician performance. METHODS: We implemented an audit-and-feedback with peer comparison tool at a single urban academic ED from March 1, 2013, to July 1, 2018. In the first study period, physicians received no reports. In the second period, they received daily reports. In the third period, they received daily, quarterly, and annual reports. Outcomes included patients per hour, admission rate, time to admission, and time to discharge. RESULTS: A total of 272,032 patient visits and 36 ED physicians were included. The mean admission rate decreased 6.8%; the mean time to admission decreased 43.8 minutes; and the mean time to discharge decreased 40.6 minutes. Variation among physicians decreased for admission rate, time to admission, and time to discharge. Low-performing outliers showed disproportionately larger improvements in patients per hour, admission rate, time to admission, and time to discharge. CONCLUSIONS: Automated peer comparison reports for academic emergency physicians was associated with lower admission rates, shorter times to admission, and shorter times to discharge at the departmental level, as well as decreased practice variation at the individual level.

Design and Implementation of an Agitation Code Response Team in the Emergency Department.

STUDY OBJECTIVE: Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. METHODS: This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. RESULTS: Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02). CONCLUSION: With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.

Universal SARS-CoV-2 Testing of Emergency Department Admissions Increases Emergency Department Length of Stay.

STUDY OBJECTIVE: Our institution experienced a change in SARS-CoV-2 testing policy as well as substantial changes in local COVID-19 prevalence, allowing for a unique examination of the relationship between SARS-CoV-2 testing and emergency department (ED) length of stay. METHODS: This was an observational interrupted time series of all patients admitted to an academic health system between March 15, 2020, and September 30, 2020. Given testing limitations from March 15 to April 24, all patients receiving SARS-CoV-2 tests were symptomatic. On April 24, testing was expanded to all ED admissions. The primary and secondary outcomes were ED length of stay and number needed to test to obtain a positive, respectively. RESULTS: A total of 70,856 patients were cared for in the EDs during the 7-month period. The testing change increased admission length of stay by 1.89 hours (95% confidence interval 1.39 to 2.38). The number needed to test was 2.5 patients and was highest yield on April 1, 2020, when the state positivity rate was 39.7%; however, the number needed to test exceeded 170 patients by Sept 1, 2020, at which point the state positivity rate was 0.5%. CONCLUSION: Although universal SARS-CoV-2 testing of ED admissions may meaningfully support mitigation and containment efforts, the clinical cost of testing all admissions amid low community positivity is notable. In our system, universal ED SARS-CoV-2 testing was associated with a 24% increase in admission length of stay alongside the detection of only 1 positive case every other day. Given the known harms and risks of ED boarding and crowding, solutions must be developed to support regular operational flow while balancing infection prevention needs.

Real-world assessment of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nasopharyngeal swab testing in a region with a high burden of coronavirus disease 2019 (COVID-19).

Concerns persist regarding possible false-negative results that may compromise COVID-19 containment. Although obtaining a true false-negative rate is infeasible, using real-life observations, the data suggest a possible false-negative rate of ˜2.3%. Use of a sensitive, amplified RNA platform should reassure healthcare systems.

Disparities in Accessing and Reading Open Notes in the Emergency Department Upon Implementation of the 21st Century CURES Act.

STUDY OBJECTIVE: There is a continued movement toward health data transparency, accelerated by the 21st Century CURES Act, which mandated the automatic and immediate release of clinical notes, often termed "open notes." Differences in utilization among different patient demographics and disproportionately affected populations within the emergency department (ED) are not yet known. METHODS: This was an observational study of 10 EDs and 3 urgent care centers across a single health system over a 13-week period from February 1, 2021 to May 2, 2021. Primary outcomes included the proportion of patients with patient portal access to open notes at the time of encounter, the proportion of patients with access who opened the clinical note, and time from clinical note signing to patient read. RESULTS: Among 98,725 patient visits, less than half (48.9%) had patient portal access, of which 13.7% read an open note. Access was less likely in patients who were under age 18 (odds ratio 0.10, 95% confidence interval 0.08 to 0.11), older than 65 (0.82, 0.73 to 0.93), Black non-Hispanic (0.66, 0.61 to 0.73), non-English speakers, and on public insurance. Patients were less likely to read open notes if they identified as Black non-Hispanic (0.61, 0.57 to 0.66), spoke Spanish (0.70, 0.60 to 0.81), or were on public insurance. CONCLUSION: We identified substantial differences in digital access to clinical notes as well as patient utilization of open notes in a large, diverse sample. Health transparency initiatives must address not only technology adoption broadly but also the unique barriers faced by populations experiencing disadvantage to facilitate equitable access to and awareness about digital health tools without the unintended consequence of expanding disparities.

Simulating approaches to emergency department pandemic physician staffing during COVID-19.

OBJECTIVE: During pandemics, emergency departments (EDs) are challenged by the need to replace quarantined ED staff and avoid staffing EDs with nonemergency medicine (EM) trained physicians. We sought to design and examine three feasible ED staffing models intended to safely schedule EM physicians to staff three EDs within a health system during a prolonged infectious disease outbreak. METHODS: We conducted simulation analyses examining the strengths and limitations of three ED clinician staffing models: two-team and three-team fixed cohort, and three-team unfixed cohort. Each model was assessed with and without immunity, and by varying infection rates. We assumed a 12-week pandemic disaster requiring a 2-week quarantine. MAIN OUTCOME: The outcome, time to staffing shortage, was defined as depletion of available physicians in both 8- and 12-hour shift duration scenarios. RESULTS: All staffing models initially showed linear physician attrition with higher infection rates resulting in faster staffing shortages. The three-team fixed cohort model without immunity was not viable beyond 11 weeks. The three-team unfixed cohort model without immunity avoided staffing shortage for the duration of the pandemic up to an infection rate of 50 percent. The two-team model without immunity also avoided staffing shortage up to 30 percent infection rate. When accounting for immunity, all models behaved similarly initially but returned to adequate staffing during week 5 of the pandemic. CONCLUSIONS: Simulation analyses reveal fundamental tradeoffs that are critical to designing feasible pandemic disaster staffing models. Emergency physicians should test similar models based on local assumptions and capacity to ensure adequate staffing preparedness for prolonged pandemics.

Leadership communication, stress, and burnout among frontline emergency department staff amid the COVID-19 pandemic: A mixed methods approach.

BACKGROUND: Organizations have a key role to play in supporting healthcare workers (HCWs) and mitigating stress during COVID-19. We aimed to understand whether perceptions of support and communication by local leadership were associated with reduced reports of stress and burnout among frontline HCWs. METHODS: We conducted cross-sectional surveys embedded within emergency department (ED) workflow during the first wave of COVID-19 from April 9, 2020 to June 15th, 2020 within three EDs of a multisite health system in the Northeast United States. All ED HCWs were administered electronic surveys during shift via text message. We simultaneously conducted 64 qualitative interviews to better characterize and validate survey responses. Primary survey outcomes were levels of work stress and burnout. RESULTS: Over 10 week study, 327 of 431 (76%) frontline HCWs responded to at least one round of the survey. More useful communication mediated through higher perception of support was significantly associated with lower work stress (B = -0.33, p < 0.001) and burnout (B = -7.84, p < 0.001). A one-point increase on the communication Likert scale was associated with a 9% reduction in stress and a 19% reduction in burnout. Three themes related to effective crisis communication during COVID-19 emerged in interviews: (1) information consolidation prior to dissemination, (2) consistency of communication, and (3) bi-directional communication. CONCLUSION: This work suggests that effective local leadership communication, characterized by information consolidation, consistency, and bi-directionality, leads to higher perceptions of support and lower stress and burnout among ED frontline workers. As the pandemic continues, these results present an evidence-based framework for leaders to support frontline HCWs through effective crisis communication.

A Cross-Sectional Analysis of High-Acuity Professional Services Performed by Urban and Rural Emergency Care Physicians Across the United States.

STUDY OBJECTIVE: We seek to examine differences in the provision of high-acuity professional services between rural and urban physicians receiving reimbursement for emergency care evaluation and management services from Medicare fee-for-service Part B. METHODS: Using the 2017 Medicare Public Use Files, we performed a cross-sectional analysis and defined the primary outcome, the proportion of high-acuity charts (PHAC), at the physician level as the proportion of services provided as 99285 and 99291 emergency care evaluation and management service codes relative to all such codes. After accounting for unique clinician-level characteristics, we categorized individual physicians by PHAC quintiles and conducted ordered logistic regression analyses reporting adjusted marginal probabilities to examine associations with rurality. RESULTS: A total of 34,256 physicians providing emergency care had a median PHAC of 66.8% (interquartile range 55.6% to 75.7%), with 89.2% practicing in an urban setting. Urban and rural physicians had respective median PHACs of 67.6% (interquartile range 57.1% to 76.2%) and 57.9% (interquartile range 42.7% to 69.4%). Urban and rural physicians had respective adjusted marginal probabilities of 15.2% and 11.8% of being in the highest PHAC quintile, and respective adjusted marginal probabilities of 14.3% and 18.2% of being in the lowest PHAC quintile. CONCLUSION: In comparison with rural physicians, urban physicians providing emergency care received reimbursements for a greater PHAC when caring for Medicare fee-for-service beneficiaries. Policymakers must consider these differences in the design and implementation of new emergency care payment policies.

Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions.

BACKGROUND/OBJECTIVE: Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. METHODS: We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement. RESULTS: This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival). CONCLUSIONS: Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.

Clinical impact of rapid influenza PCR in the adult emergency department on patient management, ED length of stay, and nosocomial infection rate.

BACKGROUND: Seasonal influenza causes significant morbidity and mortality and incurs large economic costs. Influenza like illness is a common presenting concern to Emergency Departments (ED), and optimizing the diagnosis of influenza in the ED has the potential to positively affect patient management and outcomes. Therapeutic guidelines have been established to identify which patients most likely will benefit from anti-viral therapy. OBJECTIVES: We assessed the impact of rapid influenza PCR testing of ED patients on laboratory result generation and patient management across two influenza seasons. METHODS: A pre-post study was performed following a multifaceted clinical redesign including the implementation of rapid influenza PCR at three diverse EDs comparing the 2016-2017 and 2017-2018 influenza seasons. Testing parameters including turn-around-time and diagnostic efficiency were measured along with rates of bed transfers, hospital-acquired (HA) influenza, and ED length of stay (LOS). RESULTS: More testing of discharged patients was performed in the post-intervention period, but influenza rates were the same. Identification of influenza-positive patients was significantly faster, and there was faster and more appropriate prescription of anti-influenza medication. There were no differences in bed transfer rates or HA influenza, but ED LOS was reduced by 74 minutes following clinical redesign. CONCLUSIONS: Multifaceted clinical redesign to optimize ED workflow incorporating rapid influenza PCR testing can be successfully deployed across different ED environments. Adoption of rapid influenza PCR can streamline testing and improve antiviral stewardship and ED workflow including reducing LOS. Further study is needed to determine if other outcomes including bed transfers and rates of HA influenza can be affected by improved testing practices.