Trends in boarding of admitted patients in US Emergency Departments 2003-2005.

BACKGROUND: Boarding of admitted patients in the Emergency Department (ED) is common and is associated with poor patient outcomes. OBJECTIVES: We sought to estimate the magnitude of and trends for ED boarding in the US. METHODS: We used the 2003-2005 National Hospital Ambulatory Medical Care Survey to estimate the time patients spent boarding in EDs in the US. We used fixed and imputed times required to evaluate, treat, and decide to admit each patient using the number of medications and diagnostic tests received. We calculated the absolute and relative patient-care hours spent boarding in US EDs over the 3-year period. RESULTS: Total patient-hours spent in US EDs increased from 209 million to 217 million between 2003 and 2005. Overall admission rates decreased between 2003 and 2005 (13.9% in 2003, 12.3% in 2005), whereas intensive care unit admission rates increased (1.3% in 2003, 2.0% in 2005). Mean ED length of stay decreased (5.4 h in 2003, 4.6 h in 2005). The proportion of patient-hours accounted for by ED boarding decreased over the study period (11.3-17.1% in 2003, 5.9-15.3% in 2004, and 2.8-12.0% 2005). CONCLUSIONS: Boarding of admitted patients in the ED accounts for a substantial portion of ED patient-care hours. Overall boarding time decreased over the 3 years.

One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome.

OBJECTIVES: Coronary computerized tomographic angiography (CTA) has high correlation with cardiac catheterization and has been shown to be safe and cost-effective when used for rapid evaluation of low-risk chest pain patients from the emergency department (ED). The long-term outcome of patients discharged from the ED with negative coronary CTA has not been well studied. METHODS: The authors prospectively evaluated consecutive low- to intermediate-risk patients who received coronary CTA in the ED for evaluation of a potential acute coronary syndrome (ACS). Patients with cocaine use, known cancer, and significant comorbidity reducing life expectancy and those found to have significant disease (stenosis > or = 50% or ejection fraction < 30%) were excluded. Demographics, medical and cardiac history, labs, and electrocardiogram (ECG) results were collected. Patients were followed by telephone contact and record review for 1 year. The main outcome was 1-year cardiovascular death or nonfatal acute myocardial infarction (AMI). RESULTS: Of 588 patients who received coronary CTA in the ED, 481 met study criteria. They had a mean (+/-SD) age of 46.1 (+/-8.8) years, 63% were black or African American, and 60% were female. There were 53 patients (11%) rehospitalized and 51 patients (11%) who received further diagnostic testing (stress or catheterization) over the subsequent year. There was one death (0.2%; 95% confidence interval [CI] = 0.01% to 1.15%) with unclear etiology, no AMI (0%; 95% CI = 0 to 0.76%), and no revascularization procedures (0%; 95% CI = 0 to 0.76%) during this time period. CONCLUSIONS: Low- to intermediate-risk patients with a Thrombosis In Myocardial Infarction (TIMI) score of 0 to 2 who present to the ED with potential ACS and have a negative coronary CTA have a very low likelihood of cardiovascular events over the ensuing year.

Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes.

STUDY OBJECTIVE: Coronary computed tomographic (CT) angiography has excellent performance characteristics relative to coronary angiography and exercise or pharmacologic stress testing. We hypothesize that coronary CT angiography can identify a cohort of emergency department (ED) patients with a potential acute coronary syndrome who can be safely discharged with a less than 1% risk of 30-day cardiovascular death or nonfatal myocardial infarction. METHODS: We conducted a prospective cohort study at an urban university hospital ED that enrolled consecutive patients with potential acute coronary syndromes and a low TIMI risk score who presented to the ED with symptoms suggestive of a potential acute coronary syndrome and received a coronary CT angiography. Our intervention was either immediate coronary CT angiography in the ED or after a 9- to 12-hour observation period that included cardiac marker determinations, depending on time of day. The main clinical outcome was 30-day cardiovascular death or nonfatal myocardial infarction. RESULTS: Five hundred sixty-eight patients with potential acute coronary syndrome were evaluated: 285 of these received coronary CT angiography immediately in the ED and 283 received coronary CT angiography after a brief observation period. Four hundred seventy-six (84%) were discharged home after coronary CT angiography. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% confidence interval [CI] 0% to 0.8%) or sustained a nonfatal myocardial infarction (0%; 95% CI 0 to 0.8%). CONCLUSION: ED patients with symptoms concerning for a potential acute coronary syndrome with a low TIMI risk score and a nonischemic initial ECG result can be safely discharged home after a negative coronary CT angiography test result.

Actual financial comparison of four strategies to evaluate patients with potential acute coronary syndromes.

OBJECTIVES: Small studies have shown that a negative computed tomography coronary angiogram (CTA) in low-risk chest pain patients predicts a low rate of 30-day adverse events. The authors hypothesized that an immediate CTA strategy would be as effective but less costly than alternative strategies for evaluation of patients with potential acute coronary syndrome (ACS). METHODS: The authors retrospectively compared four strategies for evaluation of patients after initial physician determination that the patient required admission and testing to rule out ACS. Patients were frequency-matched by age, race, gender, thrombolysis in myocardial infarction (TIMI) score, and initial electrocardiogram (ECG). The four groups were immediate CTA in the emergency department (ED) without serial markers (n = 98); clinical decision unit/observation unit (CDU) with biomarkers and CTA (n = 102); CDU evaluation with serial cardiac biomarkers and stress testing (n = 154); and usual care, defined as admission with serial biomarkers and hospitalist-directed evaluation (n = 289). The main outcomes were actual cost of care (facility direct and indirect fixed, facility variable direct labor and supply costs), length of stay (LOS), diagnosis of coronary artery disease (CAD), and safety (30-day death or myocardial infarction [MII). RESULTS: Patients in each group were of similar age (mean +/- standard deviation [SD] 46 +/- 9 years), race (62% African American), and gender (57% female) and had similar TIMI scores (100% between 0-2). Comparing immediate CTA versus CDU CTA versus CDU stress versus usual care, median costs were less ($1,240 vs. 2,318 vs. 4,024 vs. 2,913; p < 0.01), and LOS was shorter (8.1 hr vs. 20.9 hr vs. 26.2 hr vs. 30.2 hr; p < 0.01). Diagnosis of CAD was similar (5.1% vs. 5.9% vs. 5.8% vs. 6.6%; p = 0.95), but fewer patients had 30-day death/MI (0% vs. 0% vs. 0.7% vs. 3.1%; p = 0.04) or 30-day readmission (0% vs. 3.2% vs. 2.3% vs. 12.2%; p < 0.01). CONCLUSIONS: Compared to the other strategies, immediate CTA was as safe, identified as many patients with CAD, had the lowest cost, had the shortest LOS, and allowed discharge for the majority of patients. Larger prospective studies should confirm safety before immediate CTA replaces other strategies to rule out possible ACS.

Gender disparity in analgesic treatment of emergency department patients with acute abdominal pain.

OBJECTIVES: Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain. METHODS: This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used. RESULTS: Of the 981 patients enrolled (mean age +/- standard deviation [SD] 41 +/- 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes). CONCLUSIONS: Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.

Emergency department patient preferences for boarding locations when hospitals are at full capacity.

STUDY OBJECTIVE: Admitted patients are frequently boarded in emergency departments (EDs) when hospitals are at full capacity, which lessens the ED's ability to treat new patients. One alternative is to board admitted patients in inpatient hallways. We assess ED patient preferences for boarding location. METHODS: We surveyed adult ED patients during a 4-week period on preferences for boarding location. Patients were eligible if they were currently being admitted through the ED and had experienced at least 1 previous hospital admission to ensure knowledge of both the ED and inpatient locations. Patients were asked to choose whether they would rather board in an ED hallway or an inpatient hallway or whether they had no preference. Survey responses were hypothetical and did not affect care or bed placement. We tested whether patient demographics, survey location (ED room or ED hallway), admission service, timing to room placement, time to admission request, and time to survey administration were associated with survey responses. RESULTS: A total of 565 patients were approached; 87% consented to be interviewed. Of those consented, 88% of patients had been previously admitted, leaving 431 patients in the study group. A total of 64% (95% confidence interval [CI] 59% to 69%) had a preference for boarding location: 59% (95% CI 52% to 65%) preferred inpatient hallways and 41% (95% CI 35% to 48%) preferred ED hallways. Survey location, admission service, time to room placement, admission request, and survey administration were not associated with survey responses. CONCLUSION: When hospitals are at full capacity, patients would rather board in inpatient hallways than ED hallways.

ED crowding is associated with variable perceptions of care compromise.

OBJECTIVES: The authors measured the association between emergency department (ED) crowding and patient and provider perceptions about whether patient care was compromised. METHODS: This was a cross-sectional study of patients admitted from the ED and their providers. Surveys of patients, nurses, and resident physicians were linked. The primary outcome was agreement or strong agreement on a five-item scale assessing whether ED crowding compromised care. Logistic regression was used to determine the association between the primary outcome and measures of ED crowding. RESULTS: Of 741 patients approached, 644 patients consented (87%); 703 resident physician surveys (95%) and 716 nursing surveys (97%) were completed. A total of 106 patients (16%), 86 residents (12%), and 173 nurses (24%) reported that care was compromised by ED crowding. In 252 cases (35%), one or more respondents reported that care was compromised. There was poor agreement over whose care was compromised. For patients, independent predictors of compromised care were waiting room time (odds ratio [OR], 1.05 for each additional 10-minute wait [95% confidence interval {CI} = 1.02 to 1.09]) and being surveyed in a hallway bed (OR, 2.02 [95% CI = 1.12 to 3.68]). Predictors of compromised care for nurses included waiting room time (OR, 1.05 for each additional 10-minute wait [95% CI = 1.01 to 1.08]), number of patients in the waiting room (OR, 1.05 for each additional patient waiting [95% CI = 1.02 to 1.07]), and number of admitted patients waiting for an inpatient bed (OR, 1.08 for each additional patient [95% CI = 1.03 to 1.12]). For residents, predictors of compromised care were patient/nurse ratio (OR, 1.39 for a one-unit increase [95% CI = 1.09 to 1.20]) and number of admitted patients waiting for an inpatient bed (OR, 1.14 for each additional patient [95% CI = 1.10 to 1.75]). CONCLUSIONS: ED crowding is associated with perceptions of compromised emergency care. There is considerable variability among nurses, patients, and resident physicians over which factors are associated with compromised care, whose care was compromised, and how care was compromised.

The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.

STUDY OBJECTIVE: We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia. METHODS: We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics. RESULTS: In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%). CONCLUSION: ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.

Computed tomography coronary angiography for rapid disposition of low-risk emergency department patients with chest pain syndromes.

BACKGROUND: Patients with recent normal cardiac catheterization are at low risk for complications of ischemic chest pain. Computed tomography (CT) coronary angiography has high correlation with cardiac catheterization for detection of coronary stenosis. Therefore, the investigators' emergency department (ED) incorporated CT coronary angiography into the evaluation of low-risk patients with chest pain. OBJECTIVES: To report on the 30-day cardiovascular event rates of the first 54 patients evaluated by this strategy. METHODS: Low-risk chest pain patients (Thrombolysis In Myocardial Infarction [TIMI] score of 2 or less) without acute ischemia on an electrocardiogram had CT coronary angiography performed in the ED. If the CT coronary angiography was negative, the patient was discharged home. The main outcomes were death and myocardial infarction within 30 days of ED discharge, as determined by telephone follow up and record review. Data are presented as percentage frequency of occurrence with 95% confidence intervals (CIs). RESULTS: Of the 54 patients evaluated, after CT coronary angiography, 46 patients (85%) were immediately released from the ED, and none had cardiovascular complications within 30 days. Eight patients were admitted after CT coronary angiography: one had >70% stenosis, five patients had 50%-69% stenosis, and two had 0-49% stenosis. Three patients had further noninvasive testing; one had reversible ischemia, and catheterization confirmed the results of CT coronary angiography. All patients were followed for 30 days, and none (0; 95% CI = 0 to 6.6%) had an adverse event during index hospitalization or at 30-day follow up. CONCLUSIONS: When used in the clinical setting for the evaluation of ED patients with low-risk chest pain, CT coronary angiography may safely allow rapid discharge of patients with negative studies. Further study to conclusively determine the safety and cost effectiveness of this approach is warranted.

Effects of neural network feedback to physicians on admit/discharge decision for emergency department patients with chest pain.

STUDY OBJECTIVE: Neural networks can risk-stratify emergency department (ED) patients with potential acute coronary syndromes with a high specificity, potentially facilitating ED discharge of patients to home. We hypothesized that the use of "real-time" neural networks would decrease the admission rate for ED chest pain patients. METHODS: We conducted a before-and-after trial. Consecutive ED patients with chest pain were evaluated before and after implementation of a neural network in an urban university ED. Data included 40 variables used in neural networks for acute myocardial infarction and acute coronary syndrome. Data were obtained in real time, and neural network outputs were provided to the treating physician while patients were in the ED. On hospital discharge, attending physicians received feedback, including neural network output, their initial clinical impression, cardiac test results, and final diagnosis. The main outcome was the actual admit/discharge decision made before versus after the implementation of the neural network. RESULTS: Before implementation, 4,492 patients were enrolled; after implementation, 432 patients were enrolled. Implementation of the neural network did not decrease the hospital admission rate (before: 62.7% [95% confidence interval (CI) 61.3% to 64.1%] versus after: 66.6% [95% CI 62.2% to 71.0%]). Additionally, the ICU admission rates were not different (11.4% [95% CI 10.5% to 12.3%] versus 9.3% [95% CI 6.6% to 12.0%]). Physician query found that the neural network changed management in only 2 cases (<1%). CONCLUSION: The use of real-time neural network feedback did not influence the admission decision for ED patients with chest pain, most likely because the neural network output was delayed until the return of cardiac markers, and the disposition decision had already been made by that time.

A neural network aid for the early diagnosis of cardiac ischemia in patients presenting to the emergency department with chest pain.

STUDY OBJECTIVE: Chest pain is the second most common chief complaint presented to the emergency department. Although the causes of chest pain span the clinical spectrum from the trivial to the life threatening, it is often difficult to identify which patients have the most common life-threatening cause, cardiac ischemia. Because of the potential for poor outcome if this diagnosis is missed, physicians have had a low threshold for admitting patients with chest pain to the hospital, the vast majority of whom are found not to have cardiac ischemia. In an earlier study with a large chest pain patient registry, an artificial neural network was shown to be able to identify the subset of patients who present to the ED with chest pain who have sustained acute myocardial infarction. The objective of this study was to use the same registry to determine whether a network could be trained accurately to identify the larger subset of patients who have cardiac ischemia. METHODS: Two thousand two hundred four adult patients presenting to the ED with chest pain who received an ECG were used to train and test an artificial neural network to recognize the presence of cardiac ischemia. Only the data available at the time of initial patient contact were used to replicate the conditions of real-time evaluation. Forty variables from patient history, physical examination, ECG, and the first set of chemical cardiac marker determinations were used to train and subsequently test the network. The network was trained and tested by using the jackknife variance technique to allow for the network to be trained on as many of the features of the small subset of ischemic patients as possible. Network accuracy was compared with 2 existing aids to the diagnosis of cardiac ischemia, as well as a derived regression model. RESULTS: The network had a sensitivity of 88.1% (95% confidence interval [CI] 84.8% to 91.4%) and a specificity of 86.2% (95% CI 84.6% to 87.7%) for cardiac ischemia despite the fact that a mean of 5% of all required network input data and 41% of cardiac chemical marker data were missing. The network also performed more accurately than the 3 other tested approaches. CONCLUSION: These data suggest that an artificial neural network might be able to identify which patients who present to the ED with chest pain have cardiac ischemia with useful sensitivities and specificities.

A neural computational aid to the diagnosis of acute myocardial infarction.

STUDY OBJECTIVE: Accurate identification of the presence of acute myocardial infarction in adult patients who present to the emergency department with anterior chest pain remains elusive. The artificial neural network is a powerful nonlinear statistical paradigm for the recognition of complex patterns, with the ability to maintain accuracy when some data required for network function are missing. Earlier studies revealed that the artificial neural network is able to accurately identify acute myocardial infarction in patients experiencing chest pain. However, these studies did not measure network performance in real time, when a significant amount of data required for network function may not be available. They also did not use chemical cardiac marker data. METHODS: Two thousand two hundred four adult patients presenting to the ED with anterior chest pain were used to train an artificial neural network to recognize the presence of acute myocardial infarction. Only data available at the time of initial patient evaluation were used to replicate the conditions of real-time patient evaluation. Forty variables from patient histories, physical examinations, ECG results, and chemical cardiac marker determinations were used to train and then test the network. RESULTS: The network correctly identified 121 of the 128 patients (sensitivity 94.5%; 95% confidence interval 90.6% to 97.9%) with myocardial infarction at a specificity of 95.9% (95% confidence interval 93.0% to 98.5%), despite the fact that an average of 5% (individual range 0% to 35%) of the input data required by the network were missing on all patients. CONCLUSION: Network accuracy and the maintenance of that accuracy when some data required for function are unavailable suggest that the artificial neural network may be a potential real time aid to the diagnosis of acute myocardial infarction during initial patient evaluation.