The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time.

STUDY OBJECTIVE: Massachusetts became the first state in the nation to ban ambulance diversion in 2009. It was feared that the diversion ban would lead to increased emergency department (ED) crowding and ambulance turnaround time. We seek to characterize the effect of a statewide ambulance diversion ban on ED length of stay and ambulance turnaround time at Boston-area EDs. METHODS: We conducted a retrospective, pre-post observational analysis of 9 Boston-area hospital EDs before and after the ban. We used ED length of stay as a proxy for ED crowding. We compared hospitals individually and in aggregate to determine any changes in ED length of stay for admitted and discharged patients, ED volume, and turnaround time. RESULTS: No ED experienced an increase in ED length of stay for admitted or discharged patients or ambulance turnaround time despite an increase in volume for several EDs. There was an overall 3.6% increase in ED volume in our sample, a 10.4-minute decrease in length of stay for admitted patients, and a 2.2-minute decrease in turnaround time. When we compared high- and low-diverting EDs separately, neither saw an increase in length of stay, and both saw a decrease in turnaround time. CONCLUSION: After the first statewide ambulance diversion ban, there was no increase in ED length of stay or ambulance turnaround time at 9 Boston-area EDs. Several hospitals actually experienced improvements in these outcome measures. Our results suggest that the ban did not worsen ED crowding or ambulance availability at Boston-area hospitals.

Can an emergency department clinical "triggers" program based on abnormal vital signs improve patient outcomes?

BACKGROUND: Because abnormal vital signs indicate the potential for clinical deterioration, it is logical to make emergency physicians immediately aware of those patients who present with abnormal vital signs. OBJECTIVES: To determine if a clinical triggers program in the emergency department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician-led multidisciplinary team had a measurable effect on inpatient hospital metrics. METHODS: The study design was a retrospective pre and post intervention study. The intervention was the implementation of an ED clinical "triggers" program. Abnormal vital sign criteria that warranted a trigger response included: heart rate 130 beats/minutes, respiratory rate 30 breaths/minute, systolic blood pressure <90 mm Hg, or oxygen saturation <90% on room air. The primary outcome investigated was the median days admitted with secondary outcomes of median days in special care unit, in-hospital 30-day mortality and proportion of patients who required an upgrade in inpatient care level. RESULTS: There was no difference in median days admitted for inpatient care (3.8 v. 4.0 days, p=0.21) or median days spent in a special care unit (5.0 v. 5.6 days, p=0.42) between the groups. There was no difference in the percentage of in-hospital patient deaths (6.0% v. 5.6%, p=0.66) or frequency of upgrade in level of care within 24 hours (4.9% v. 4.0%, p=0.52). CONCLUSIONS: In our study, the implementation of an ED clinical triggers program did not result in a significant change in measured inpatient outcomes.

Pulmonary emergencies in the elderly.

The aging process results in changes in pulmonary physiology that make the elderly population more susceptible to pulmonary disease. These physiologic changes also alter the clinical presentation of such diseases, making the diagnosis and treatment of pulmonary disorders particularly challenging for the clinician. It is important for the clinician to have a high index of suspicion for pulmonary disorders to make the proper diagnosis. It is essential to keep in mind the subtle differences between pulmonary diseases in the elderly compared with younger patients.

Physician in triage improves emergency department patient throughput.

To determine if a physician in triage (PIT) improves Emergency Department (ED) patient flow in a community teaching hospital. This is an interventional study comparing patient flow parameters for the 3-month periods before and after implementation of a PIT model. During the interventional time an additional attending physician was assigned to triage from 1 p.m. to 9 p.m. daily. Outcome measures were median time to attending physician evaluation, median length of stay (LOS), number of patients who left without being seen (LWBS), and total time and number of days on ambulance diversion. Non-normally distributed values were compared with the Wilcoxon rank sum test. Proportions were compared with Chi-square test. Outcome measures were available for 17,631 patients, of whom 8,620 were seen before the initiation of PIT, and 9,011 were seen after PIT was implemented. For all patients, the median time from registration to attending physician evaluation was reduced by 36 min (1:41 to 1:05, p < 0.01) while the median LOS for all patients was reduced by 12 min (3:51 to 3:39, p < 0.01) after the intervention. Both the number of days on diversion (24 vs. 9 days) and total time on diversion (68 h 25 min vs. 26 h 7 min) were decreased, p < 0.01. Finally, there was a slight reduction in the number of patients who LWBS from 1.5 to 1.3 %, but this was not statistically significant (p = 0.36). Patient flow parameters in a community teaching hospital were modestly improved as a result of PIT implementation.

Benign exertional headache.

We describe 4 patients with benign exertional headache presenting to the emergency department. Consideration of this uncommon cause of headache might facilitate an accurate diagnosis of those patients with headache caused by strenuous exercise.