A rapid admission protocol to reduce emergency department boarding times.

INTRODUCTION: Prolonged emergency department boarding times (EDBT) are associated with adverse clinical outcomes and longer hospital stays. A rapid admission protocol was designed at our institution to reduce both EDBT and time to admission orders (EDTAO) for patients admitted to the internal medicine service. METHODS: The existing admission process was examined by a team of clinical and administrative leaders who focused on developing a change management architecture, narrowing clinical roles, mandating direct communication, establishing clear boundaries for patient responsibility and instituting carefully constructed holding orders. The number of steps in the admission process was reduced from 50 to 10. We collected EDBT and EDTAO for all patients admitted to the internal medicine service before and after intervention using a simple interrupted time-series design. RESULTS: The study involved a total of 9604 admissions to one of three inpatient destinations (general medicine ward, telemetry or intensive care unit). The overall EDBT decreased from 360 min in the preintervention period to 270 min in phase 4 (p<0.001). The overall time to admission orders decreased from 210 min in the preintervention period to 75 min in phase 4 (p<0.001) overall. However, no improvements were noted in EDBT for telemetry or ICU patients. CONCLUSIONS: Institution of a rapid admission protocol successfully reduced overall EDBT at our institution, although few gains were noted for patients with a telemetry or ICU destination. In total, the intervention saved 27 884 h, or 1161 emergency department patient-days, over the course of a single year.

Rapid estimation of carboxyhemoglobin by breath sampling in an emergency setting.

Breath measurement of carbon monoxide (CO) can be rapidly performed in the emergency department setting by a reliable method that closely approximates carboxyhemoglobin. This method is helpful in the immediate determination of CO exposure for individual patients, but could serve as a valuable triage aid when large groups of patients are suspected of CO exposure. Serial CO determinations can be obtained during oxygen treatment to monitor for improvements without painful needle punctures and needless consumption of professional time and expense.

Effects of rapid blood pressure reduction on cerebral blood flow.

The changes that occur in the cerebral circulation with chronic hypertension are important when considering the therapeutic possibilities in treating patients with severe hypertension. Care must be taken not to lower the blood pressure below the lower limit of autoregulation, no matter what drug is used. In patients with severe, chronic hypertension, blood pressure should be lowered carefully. Rapid blood pressure reduction to a level that is below the lower limit of autoregulation may result in central nervous system dysfunction due to cerebral hypoperfusion. This is especially true in patients with increased intracranial pressure and cerebral edema such as those with hypertensive encephalopathy.

Oral clonidine loading in hypertensive urgencies.

The response to oral clonidine hydrochloride loading in 36 severely hypertensive patients is presented. Each patient initially received 0.2 mg of clonidine hydrochloride, followed by 0.1 mg each hour until a dose of 0.7 mg had been given, or the diastolic blood pressure (BP) reached a predetermined goal (110 mm Hg or total fall of at least 20 mm Hg). Only two patients (6%) failed to reach this goal. Supine BP in the group fell from 212 +/- 22 (SD)/139 +/- 11 (SD) mm Hg to 151 +/- 21 (SD) mm Hg at six hours. The average dose of clonidine required was 0.45 mg and control was maximized at five hours. The response to oral clonidine loading in the individual patient was not predictive of the eventual dose of clonidine necessary to achieve acceptable BP control at two weeks. Oral clonidine loading is safe and effective in the management of "hypertensive urgencies" and offers several advantages over parenteral antihypertensive agents in this clinical situation.

Herpetic gastritis.

A case of herpes gastritis is presented. This complication is being described more frequently in the gastrointestinal tract and can be best diagnosed by endoscopic appearance and examination of brush specimens by cytology.

Staged treatment of invasive carcinoma of bladder.

A three-stage approach to carcinoma of the bladder consists of preliminary urinary diversion, radiation therapy, and simple total cystectomy. We have used this method for more than ten years. The survival rates are the same as generally published, and the morbidity and mortality contrast favorably with other reports. To date no patient has died within two months of completion of the course of therapy.