Transfer boarding delays care more in low-volume rural emergency departments: A cohort study.

PURPOSE: Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals. METHODS: A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas. FINDINGS: A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs. CONCLUSIONS: Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.

High-efficiency Practices of Residents in an Academic Emergency Department: A Mixed-methods Study.

BACKGROUND: Emergency department utilization and crowding is increasing, putting additional pressure on emergency medicine (EM) residency programs to train efficient residents who can meet these demands. Specific practices associated with resident efficiency have yet to be identified. The objective of this study was to identify practices associated with enhanced efficiency in EM residents. METHODS: A mixed-methods study design was utilized to identify behaviors associated with resident efficiency. In Stage 1, eight EM faculty provided 61 efficiency behaviors during semistructured interviews, which were prioritized into eight behaviors by independent ranking. A total of 31 behaviors were tested, including additions from previous literature and the study team. In Stage 2, two 4-hour observations during separate shifts of 27 EM residents were performed to record minute-by-minute timing and frequency of each behavior. In Stage 3, the association between resident efficiency and each of the behaviors was estimated using multivariable regression models adjusted for training year and clustered on resident. The primary efficiency outcome was 6-month average relative value units/hour. A sensitivity analysis was performed using patients/hour. RESULTS: Seven practices were positively associated with efficiency: average patient load, taking initial patient history with nurse present (number/hour, number/new patient), running the board (number/hour), conversations with other care team members (number/hour, % time), dictation use (number/hour, % time), smartphone text communication (number/hour, % time), and nonwork tasks (number/hour). Three practices were negatively associated with efficiency: visits to patient room (number/patient), conversations with attending physicians (% time), and reviewing electronic medical record (number/hour). CONCLUSION: Several discrete behaviors were found to be associated with enhanced resident efficiency. These results can be utilized by EM residency programs to improve resident education and inform evaluations by providing specific, evidence-based practices for residents to develop and improve upon throughout training.

Monocular Vision Loss: A Rare Cause.

A 62-year-old woman with a history of metastatic breast cancer and known meningioma presented with unilateral vision loss associated with anisocoria and an afferent pupillary defect. On magnetic resonance imaging we found the cause to be optic nerve compression by a right frontal meningioma. Monocular vision-loss etiologies are anatomically localized to structures anterior to the optic chiasm. This case serves as a reminder that cerebral structures in this location must not be forgotten in the differential.

Esophageal Perforation After Failed Prehospital Intubation.

Esophageal perforation is a rare condition with high rates of mortality if not recognized quickly. This is a case of a 67-year-old male with a self-inflicted gunshot wound to the head. He had one failed intubation attempt prior to arrival. On postmortem autopsy it was discovered that in addition to significant head trauma he also had an esophageal and gastric rupture.