A workshop to improve workflow efficiency in emergency medicine.

OBJECTIVE: The emergency department (ED) environment requires physicians to focus on workflow efficiency (WFE) and manage ED throughput. We sought to determine whether an interactive workshop could be designed and favourably perceived by emergency physicians and residents as a means to improve their self-assessed WFE skills. METHODS: The authors designed a 4-station workshop to simulate key components of ED throughput. These included resource management in 1) acute care, 2) minor care, 3) charting and 4) communication skills and patient sign-overs. Anonymous surveys were completed after each workshop using 5-point Likert scales and qualitative responses. Qualitative data encompassed participants' past WFE training experiences and perspectives on the current workshop. Data were analyzed using descriptive statistics. The workshops were administered on 2 separate occasions to different groups of physicians. The first occasion was primarily for residents and the second session was only for practising physicians. RESULTS: A total of 22 residents and 24 practising physicians participated. Evaluations were completed by 45 of 46 participants. Ratings of "definitely helpful" or "helpful" as noted for each station were received by 37 of 44 respondents for the sign-over and communication station, by 37 of 44 for the minor care station, by 41 of 44 for the acute care station and by 33 of 43 for the effective charting station. Among all participants, 42 of 45 reported that they felt the overall workshop experience was "helpful" or "definitely helpful." CONCLUSION: ED management "flow skills" are valued yet undertaught. A flow workshop designed to improve self-perceived WFE skills yields positive evaluations. Teaching this competency in a workshop setting is both feasible and appreciated by participants. Similar efforts should be considered for inclusion in both graduate and continuing medical education curricula.

Nonurgent emergency department patient characteristics and barriers to primary care.

OBJECTIVE: Nonurgent (NU) emergency department (ED) use is at the forefront of medico-political agendas, and diversion of NU patients has been entertained as a management strategy. Before policy changes are implemented, this population should be better understood with respect to their characteristics and reasons for not presenting to primary care providers (PCPs) instead of EDs. This study compares NU with urgent and semiurgent (USU) patients and describes the NU patients' reasons for not seeking care with a PCP before presenting to the ED. METHODS: This was a secondary analysis from a cross-sectional study with sequential sampling in the EDs of five Quebec tertiary care hospitals (October 19, 1999, to May 26, 2000). Data on medical history, social support, awareness and utilization of health care, ED visits, referrals, activities of daily living, and sociodemographics were obtained. The NU group included patients with triage code 5 and the USU group included patients with triage codes 2, 3, and 4 using the Canadian Triage and Acuity Scale. Patient characteristics were structured into the Andersen behavioral model for health care utilization. RESULTS: Of 2,348 patients approached, 1,783 patients (77%) were eligible and agreed to participate. NU patients (n = 454) were younger than USU patients (n = 1,329) (mean age, 43 [SD +/- 18.1] vs. 49 [SD +/- 20.1] years). Patients in the NU group had better health (number of prior conditions, 3.1 vs. 3.9), were less likely to arrive by ambulance (5% vs. 22%), and were less often admitted from the ED (4% vs. 24%). While 70% of NU compared with 75% of USU patients were followed up by a PCP, only 22% of NU and 27% of USU patients sought PCP care before presenting to the ED. The reasons given by NU patients for not seeking PCP care were accessibility (32%), perception of need (22%), referral/follow-up to the ED (20%), familiarity with the ED (11%), trust of the ED (7%), and no reason (7%). CONCLUSIONS: NU ED patients are different from USU patients and have multiple reasons for not seeking primary care before going to the ED. This may help explain why various diversion strategies have been unsuccessful and indicate that a multifaceted approach may be better suited to this group of patients. The design of new interventions, however, will benefit from further research that clarifies the impact of NU patients on the health care system.

Impact of ambulance transportation on resource use in the emergency department.

OBJECTIVE: To determine how ambulance transportation is associated with resource use in the emergency department (ED). METHODS: A retrospective administrative database review of patient visits to a Montreal tertiary care hospital ED in one year (April 2000-March 2001). Measures of resource use included ED length of stay, admission to the hospital, and whether consultations and radiology/imaging tests (excluding plain-film x-rays) were ordered from the ED. RESULTS: During the study period, 39,674 patients made 59,142 visits to the ED. Ambulance transportation was used for 15.6% of these ED visits. Compared with non-ambulance visits, ambulance visits were more likely to be made by older patients (mean age: 68 vs. 47 years), to be made by females (59% vs. 55%), to have a greater triage urgency score (mean on 1-5 scale, with 1 most urgent: 2.7 vs. 3.9), and to occur after office hours, 5 PM to 9 AM (47% vs. 43%). Ambulance visits were also more likely than non-ambulance visits to result in: a longer length of stay (mean: 13.3 hours [95% CI = 13.0 to 13.6] vs. 5.9 [95% CI = 5.8 to 6.0]), hospital admission (40% vs. 10%) (odds ratio [OR]: 5.94 [95% CI = 5.59 to 6.33]), consultations (56% vs. 20%) (OR: 5.15 [95% = 4.86 to 5.45]), and radiology/imaging tests (20% vs. 12%) (OR: 1.93 [95% CI = 1.81 to 2.07]). In multivariate models that adjusted for the effects of age, gender, triage urgency, and temporal factors, ambulance transportation maintained its association with greater resource use. CONCLUSIONS: This preliminary study indicates that patients arriving at the ED by ambulance use significantly more resources than their walk-in counterparts.