Emergency department occupancy is useful as a simple real-time measure of crowding.

INTRODUCTION: Emergency department (ED) crowding compromises patient outcomes. Existing crowding measures are complex and difficult to use in real-time. This study evaluated readily available single flow variables as crowding measures. METHODS: Over 2 weeks in a tertiary Canadian ED, we recorded the following potential crowding measures during 168 consecutive two-hour study intervals: total ED patients (census), patients in beds, patients in waiting rooms, patients in treatment areas awaiting MD assessment; number of inpatients boarding, and ED occupancy. We also calculated four complex crowding scores-NEDOCS, EDWIN, ICMED, and a local modification of NEDOCS. We performed ROC analyses to assess the predictive validity of these measures against a reference standard of physician perception of crowding. RESULTS: We gathered data for 144 (63.9%) of 168 study intervals. ED census correlated strongly with crowding (AUC = 0.82, 95% CI 0.76-0.89), as did ED occupancy (AUC = 0.75, 95% CI 0.66-0.83). Their performance was similar to NEDOCS (AUC = 0.80) and to the local modification of NEDOCS (AUC = 0.83). CONCLUSION: ED occupancy as a single measure has similar predictive accuracy to complex crowding scores and is easily generalizable to diverse emergency departments. Real-time tracking of this simple indicator could be used to prompt investigation and implementation of crowding interventions.

RéSUMé: INTRODUCTION: L'encombrement des services d'urgence (SU) compromet les résultats pour les patients. Les mesures d'encombrement existantes sont complexes et difficiles à utiliser en temps réel. Cette étude a évalué des variables de débit unique facilement disponibles comme mesures d'encombrement. LES MéTHODES: Pendant deux semaines dans un service d'urgence tertiaire canadien, nous avons enregistré les mesures d'encombrement potentiel suivantes au cours de 168 intervalles d'étude consécutifs de deux heures : nombre total de patients dans le service d'urgence (recensement), patients dans les lits, patients dans les salles d'attente, patients dans les zones de traitement en attente d'une évaluation médicale ; nombre de patients hospitalisés en internat et occupation du service d'urgence. Nous avons également calculé quatre scores de surpeuplement complexes : NEDOCS, EDWIN, ICMED et une modification locale de NEDOCS. Nous avons effectué des analyses ROC pour évaluer la validité prédictive de ces mesures par rapport à une norme de référence de perception du surpeuplement par les médecins. RéSULTATS: Nous avons recueilli des données pour 144 (63,9 %) des 168 intervalles d'étude. Le recensement des urgences est fortement corrélé avec le surpeuplement (ASC = 0.82, IC 95 % = 0.76­0.89), tout comme l'occupation des urgences (ASC = 0.75, IC 95 % = 0.66­0.83). Leur performance était similaire à celle des NEDOCS (ASC = 0.80) et à la modification locale des NEDOCS (ASC = 0.83). CONCLUSION: L'occupation des urgences en tant que mesure unique a une précision prédictive similaire aux scores complexes de surpeuplement et est facilement généralisable à divers services d'urgence. Le suivi en temps réel de ce simple indicateur pourrait être utilisé pour accélérer l'enquête et la mise en œuvre des interventions en cas de surpeuplement.

A comparison of work stressors in higher and lower resourced emergency medicine health settings.

OBJECTIVES: The study compares experiences of workplace stressors for emergency medicine trainees and specialists in settings where the specialty is relatively well resourced and established (Canada), and where it is newer and less well resourced (South Africa, (SA)). METHODS: We conducted an online cross-sectional survey of emergency medicine trainees and physicians in both countries for six domains (demands, role, support, change, control, and relationships) using the validated Management Standards Indicator Tool (MSIT, Health, and Safety Executive, United Kingdom). RESULTS: 74 SA and 430 Canadian respondents were included in our analysis. SA trainees (n=38) reported higher stressors (lower MSIT scores) than SA specialists (n=36) for demands (2.2 (95%CI 2.1-2.3) vs. 2.7 (2.5-2.8)), control (2.6 (2.4-2.7) vs. 3.5 (3.3-3.7)) and change (2.4 (2.2-2.6) vs. 3.0 (2.7-3.3)). In Canada, specialists (n=395) had higher demands (2.6 (2.6-2.7) vs. 3.0 (2.8-3.1)) and manager support stressors (3.3 (3.3-3.4) vs. 3.9 (3.6-4.1)) than trainees (n=35). Canadian trainees reported higher role stressors (4.0 (95%CI 3.8-4.1) vs. 4.2 (4.2-4.3)) than Canadian specialists. SA trainees had higher stressors on all domains than Canadian trainees. There was one domain (control) where Canadian specialists scored significantly lower than SA specialists, whereas SA specialists had significantly lower scores on peer support, relationships and role. CONCLUSIONS: Work related stressor domains were different for all four groups. Perceived stressors were higher in all measured domains among SA trainees compared with Canadian trainees. The differences between the SA and Canadian specialists may reflect the developing nature of the specialty in SA, although the Canadian specialists reported less control over their work than SA counterparts.

Do Guidelines Influence Emergency Department Staff Behaviours and Improve Patient Outcomes? Evaluation of a Multifaceted Intervention for the Implementation of Local Acute Exacerbations of Chronic Obstructive Pulmonary Disease Guidelines.

Introduction Published national guidelines on chronic obstructive pulmonary disease (COPD) highlight the importance of oxygen therapy, bronchodilators, corticosteroids, and appropriate antibiotics during acute exacerbations of COPD (AECOPD). We wished to assess how the implementation of local COPD guidelines affects emergency department (ED) staff awareness, knowledge, the use of such guidelines, and patient outcomes, including treatment failure and rates of return to the ED. Methods This study was conducted at a tertiary hospital ED. Local COPD guidelines were developed by a quality improvement group. Guidelines were posted in the department, and educational sessions were provided for staff. We conducted a retrospective chart review and looked at 1849 patient visits before and after COPD guideline implementation. All visits with a diagnosis of COPD or AECOPD were included in the study (for a total of 130 patient visits), and data were collected using a standardized abstraction tool. For non-admitted patients, we recorded 30-day return rates and treatment failures occurring within 30 days of presenting to the ED. Pre- and post-implementation outcomes were analyzed with Fisher's exact tests. We also assessed ED staff awareness, knowledge, and use of COPD guidelines through surveys given out before implementation, and both one and 10 months after the implementation. We calculated proportions and 95% confidence intervals (CI) for our surveys. Pre- and post-implementation survey responses were compared with Fisher's exact tests. Results For ED physicians, the survey response rate was 78%, 79%, and 58% at pre-implementation, one-month follow-up, and 10-month follow-up, respectively. Prior to implementation, 14.3% (95% CI 4.1%-35.5%) were aware and 0% (0%-18.2%) reported using guidelines. One month after implementation, 90.9% (71.0%-98.7%) were aware and 81.8% (60.9%-93.3%) reported using guidelines. At 10 months, 100% (76.1%-100%) were aware and 100% (82%-100%) reported using local guidelines. Similar trends were seen among nurses and respiratory therapists. To assess actual guideline use, 130 visits were evaluated (51 visits prior to implementation and 79 post-implementation). Prior to implementation, 57% (43%-70%) received bronchodilators, systemic steroids, and antibiotics appropriately. Following guideline implementation, 57% (46%-67%) received the respective treatments (p=1.0). For patient-related outcomes, 86 non-admission patient visits were evaluated (35 visits prior to implementation and 51 post-implementation). Prior to guideline implementation, 17% (8%-33%) failed their initial AECOPD treatment, compared to 10% (4%-21%) following guideline implementation (p=0.34). Prior to guideline implementation, 23% (12%-39%) returned to the ED within 30 days in the pre-implementation period while 14% (7%-26%) returned post-implementation (p=0.39). Conclusion Our introduction of local COPD guidelines was successful at increasing self-reported awareness, knowledge, and the use of best practice guidelines among ED staff. At the 10-month follow-up, increased awareness, knowledge, and use of COPD guidelines among ED staff was maintained. However, in practice, guideline adherence, treatment failure, and return rates did not improve significantly after the implementation of local guidelines.