Inpatient boarding definitions and mitigation strategies: A cross-sectional survey of academic emergency departments in the United States.

OBJECTIVE: Conceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management. METHODS: This was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated. RESULTS: Of the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%). CONCLUSIONS: We found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices.

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.

Is the Emergency Department an Inappropriate Venue for Code Status Discussions?

BACKGROUND: Historically, it has been assumed that the Emergency Department (ED) is a place for maximally aggressive care and that Emergency Medicine Providers (EMPs) are biased towards life-prolonging care. However, emphasis on early recognition of code status preferences is increasingly making the ED a venue for code status discussions (CSDs). In 2018, our hospital implemented a policy requiring EMPs to place a code status order (CSO) for all patients admitted through the ED. We hypothesized that if EMPs enter CSDs with a bias toward life-prolonging care, or if the venue of the ED biases CSDs towards life-prolonging care, then we would observe a decrease in the percentage of patients selecting DNR status following our institution's aforementioned CSO mandate. METHODS: We present a retrospective analysis of rates of DNR orders placed for patients admitted through our ED comparing six-month periods before and after the implementation of the above policy. RESULTS: Using quality improvement data, we identified patients admitted through the ED during pre (n=7,858) and post (n=8,069) study periods. We observed the following: after implementation DNR preference identified prior to hospital admission from the ED increased from 0.4% to 5.3% (relative risk (RR) 12.5; 95% CI: 5.2-29.9), defining CS in the ED setting at the time of admission increased from 2.4% to 98.6% (p <0.001), and DNR orders placed during inpatient admission was unchanged (RR=0.97 (95% CI = 0.88-1.07)). DISCUSSION: Our results suggest that the ED can be an appropriate venue for CSDs.

Using sideline concussion tests in the emergency department.

PURPOSE: Traumatic brain injury (TBI) is a significant cause of death and disability in the United States. Many patients with TBI are initially treated in the emergency department (ED), but there is no evidence-based method of detecting or grading TBI in patients who have normal structural neuroimaging. This study aims to evaluate the validity of two common sideline concussion tests. The Concussion Symptom Severity Score (CSSS) and modified Balance Error Scoring System (mBESS) tests are well-validated sideline tests for concussion, but have not been validated in the setting of non-sport-related concussion, in settings other than the sideline or athletic training room or in moderate or severe TBI. PATIENTS AND METHODS: One hundred forty-eight subjects who had sustained a TBI within the previous 72 hours and 53 healthy control subjects were enrolled. CSSS and mBESS were administered. Clinical outcomes were followed up prospectively. RESULTS: The CSSS was collected in 147 TBI subjects but only 51 TBI subjects were able to complete the mBESS. The CSSS was collected for all 53 control subjects, and the mBESS was completed for 51 control subjects. The mean CSSS for TBI and control subjects was 32.25 and 2.70, respectively (P < 0.001). The average mBESS for TBI and control subjects was 7.43 and 7.20, respectively (P = 0.82). CSSS greater than 5.17 was 93.43% sensitive and 69.84% specific for TBI. CONCLUSION: The mBESS is poorly tolerated and, among those who can complete the test, not sensitive to TBI in the ED. The CSSS is both sensitive to TBI and well tolerated.

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions.

BACKGROUND: The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians' (EPs) and nurses' (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A's framework (Ask-Advise-Assess-Assist-Arrange) in the ED. METHODS: We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts. RESULTS: The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients' receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A's in the ED. CONCLUSIONS: There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT00756704.

The emergency department action in smoking cessation (EDASC) trial: impact on cessation outcomes.

INTRODUCTION: The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5A's (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates. METHODS: We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5A's by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5A's composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up). RESULTS: Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5A's composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]). CONCLUSIONS: It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.

Application of lean manufacturing techniques in the Emergency Department.

BACKGROUND: "Lean" is a set of principles and techniques that drive organizations to continually add value to the product they deliver by enhancing process steps that are necessary, relevant, and valuable while eliminating those that fail to add value. Lean has been used in manufacturing for decades and has been associated with enhanced product quality and overall corporate success. OBJECTIVES: To evaluate whether the adoption of Lean principles by an Emergency Department (ED) improves the value of emergency care delivered. METHODS: Beginning in December 2005, we implemented a variety of Lean techniques in an effort to enhance patient and staff satisfaction. The implementation followed a six-step process of Lean education, ED observation, patient flow analysis, process redesign, new process testing, and full implementation. Process redesign focused on generating improvement ideas from frontline workers across all departmental units. Value-based and operational outcome measures, including patient satisfaction, expense per patient, ED length of stay (LOS), and patient volume were compared for calendar year 2005 (pre-Lean) and periodically after 2006 (post-Lean). RESULTS: Patient visits increased by 9.23% in 2006. Despite this increase, LOS decreased slightly and patient satisfaction increased significantly without raising the inflation adjusted cost per patient. CONCLUSIONS: Lean improved the value of the care we delivered to our patients. Generating and instituting ideas from our frontline providers have been the key to the success of our Lean program. Although Lean represents a fundamental change in the way we think of delivering care, the specific process changes we employed tended to be simple, small procedure modifications specific to our unique people, process, and place. We, therefore, believe that institutions or departments aspiring to adopt Lean should focus on the core principles of Lean rather than on emulating specific process changes made at other institutions.

Feasibility of acute clinical trials during aerial interhospital transfer.

BACKGROUND AND PURPOSE: In rural America, patients are often first seen at a small community hospital and then transferred to a tertiary care center by helicopter for further care. If acute clinical research were feasible during the aerial interhospital transport, more patients might be enrolled in trials at a critical earlier stage. METHODS: Prospective data were collected for all aerial transfers of a university-based helicopter service from April 2005 to January 2006. Flight nurses were educated about stroke research and offered certification and participation. Data collected included patient characteristics and the availability of relatives to provide surrogate consent. RESULTS: All 12 flight nurses completed the institutional review board certification requirements and collected data on 215 transfers. Sixty-one patients had acute stroke or myocardial events (MIs). The median time from symptom onset to helicopter arrival at an outside hospital was 213 minutes (range, 90 to 2135) for ischemic stroke (n=12), 186 (45 to 1332) for intracranial hemorrhage (n=28), and 157 (47 to 1044) for MI (n=21). A relative was available in >74% of those transfers. A trial with a 4-hour window would permit enrollment of 67% of the ischemic strokes, 82% of intracranial hemorrhage cases, and 76% of MI patients. CONCLUSIONS: Clinical trials are feasible during aerial interhospital transport of patients. Flight nurses became successful investigators in clinical research and were exposed to potentially eligible patients with the ability to consent either directly or through surrogates. This approach could improve current clinical trial recruitment in rural areas, as well as permit testing of inflight ancillary interventions to improve outcome during patient transport.