Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group.

Introduction: Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex-based differences, including metrics such as door-to-room (DTR) and door-to-healthcare practitioner (DTP) times to look for potential signs of systemic bias. Methods: We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min. Results: A total of 106,011 adult visits to the ED were investigated. Female patients had 8-min longer median length-of-stay (LOS) than males (P < 0.01). Females had longer DTR (2-min median difference, P < 0.01), and longer DTP (5-min median difference, P < 0.01). Females had longer median door-to-over-the-counter analgesia time (84 vs. 80, P = 0.58), door-to-advanced analgesia (95 vs. 84, P < 0.01), door-to-PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door-to-intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males. Conclusion: Numerous statistically significant differences were identified in throughput and care measures-mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.

Assessing the Generalizability of a Clinical Machine Learning Model Across Multiple Emergency Departments.

Objective: To assess the generalizability of a clinical machine learning algorithm across multiple emergency departments (EDs). Patients and Methods: We obtained data on all ED visits at our health care system's largest ED from May 5, 2018, to December 31, 2019. We also obtained data from 3 satellite EDs and 1 distant-hub ED from May 1, 2018, to December 31, 2018. A gradient-boosted machine model was trained on pooled data from the included EDs. To prevent the effect of differing training set sizes, the data were randomly downsampled to match those of our smallest ED. A second model was trained on this downsampled, pooled data. The model's performance was compared using area under the receiver operating characteristic (AUC). Finally, site-specific models were trained and tested across all the sites, and the importance of features was examined to understand the reasons for differing generalizability. Results: The training data sets contained 1918-64,161 ED visits. The AUC for the pooled model ranged from 0.84 to 0.94 across the sites; the performance decreased slightly when Ns were downsampled to match those of our smallest ED site. When site-specific models were trained and tested across all the sites, the AUCs ranged more widely from 0.71 to 0.93. Within a single ED site, the performance of the 5 site-specific models was most variable for our largest and smallest EDs. Finally, when the importance of features was examined, several features were common to all site-specific models; however, the weight of these features differed. Conclusion: A machine learning model for predicting hospital admission from the ED will generalize fairly well within the health care system but will still have significant differences in AUC performance across sites because of site-specific factors.

Incorporating RTLS-Based Spatiotemporal Information in Studying Physical Activities of Clinical Staff.

Clinicians and staff who work in intense hospital settings such as the emergency department (ED) are under an extended amount of mental and physical pressure every day. They may spend hours in active physical pressure to serve patients with severe injuries or stay in front of a computer to review patients' clinical history and update the patients' electronic health records (EHR). Nurses on the other hand may stay for multiple consecutive days of 9-12 working hours. The amount of pressure is so much that they usually end up taking days off to recover the lost energy. Both of these extreme cases of low and high physical activities are shown to affect the physical and mental health of clinicians and may even lead to fatigue and burnout.In this study Real-Time location systems (RTLS) are used for the first time, to study the amount of physical activity exerted by clinicians. RTLS systems have traditionally been used in hospital settings for locating staff and equipment, whereas our proposed method combines both time and location information together to estimate the duration, length, and speed of movements within hospital wards such as the ED. It is also our first step towards utilizing non-wearable devices to measure sedentary behavior inside the ED. This information helps to assess the workload on the care team and identify means to reduce the risk of performance compromise, fatigue, and burnout.We used one year worth of raw RFID data that covers movement records of 38 physicians, 13 residents, 163 nurses, 33 staff in the ED. We defined a walking path as the continuous sequences of movements and stops and identified separate walking paths for each individual on each day. Walking duration, distance, and speed, along with the number of steps and the duration of sedentary behavior, are then estimated for each walking path. We compared our results to the values reported in the literature and showed despite the low spatial resolution of RTLS, our non-invasive estimations are closely comparable to the ones measured by Fitbit or other wearable pedometers.Clinical Relevance- Adequate assessment of workload in a dynamic care delivery space plays an important role in ensuring safe and optimal care delivery [7]. Systems capable of measuring physical activities on a continuous basis during daily work can provide precious information for a variety of purposes including automated assessment of sedentary behaviors and early detection of work pressure. Such systems could help facilitate targeted changes in the number of staff, duration of their working shifts leading to a safer and healthier environment for both clinicians and patients.

A Comprehensive Departmental Care Review Model: Requirements, Structure, and Flow.

BACKGROUND: The Institute of Medicine, the National Patient Safety Foundation, and The Joint Commission have advocated for increased systematic care review to inform future quality improvement. Developing a system to efficiently gather meaningful feedback, review care, and identify areas for improvement can take years to construct. Yet, these systems are vital to reducing future medical error. CONTEXT, HISTORY, AND DEVELOPMENT: In this article, the authors present a refined intradepartmental system of retrospective care review. The team created and iteratively improved this model for more than 10 years. Herein, key aspects and benefits of the system are described. CARE REVIEW SYSTEM: A successful care review system should include a broad catchment for cases to review, direct input from multidisciplinary staff involved in each case, a standardized evaluation and feedback process, a system to translate identified gaps into practice improvement, and development of a psychologically safe space for discussions to occur. Resources required to build this system include a quality specialist, a panel of physician and nurse reviewers, and administrative assistance. Blinding cases and electronic blinded polling technology can enhance participation and reduce bias in case assessment. CONCLUSION: The authors believe that this process for care review can help hospital systems of varying resource levels produce high-quality case review and thereby activate practice improvement to prevent downstream medical errors.

Measuring Sensitivity and Precision of Real-Time Location Systems (RTLS): Definition, Protocol and Demonstration for Clinical Relevance.

The ability of a Real Time Location System (RTLS) to provide correct information in a clinical environment is an important consideration in evaluating the effectiveness of the technology. While past efforts describe how well the technology performed in a lab environment, the performance of such technology has not been specifically defined or evaluated in a practice setting involving workflow and movement. Clinical environments pose complexity owing to various layouts and various movements. Further, RTL systems are not equipped to provide true negative information (where an entity is not located). Hence, this study defined sensitivity and precision in this context, and developed a simulation protocol to serve as a systematic testing framework using actors in a clinical environment. The protocol was used to measure the sensitivity and precision of an RTL system in the emergency department space of a quaternary care medical center. The overall sensitivity and precision were determined to be 84 and 93% respectively. These varied for patient rooms, staff area, hallway and other rooms.

Trauma Activation Responsiveness: An RFID-enabled trauma flowsheet.

Manually documented trauma flow sheets contain critical information regarding trauma resuscitations in the emergency department (ED). The American College of Surgeons (ACS) has enforced certain thresholds on trauma surgeons' arrival time to the trauma bay. Due to the complex and fast-paced ED environment, this information can be easily overlooked or erroneously recorded, affecting compliance with ACS standards. This paper is a retrospective study conducted at a Level I trauma center equipped with an RFID system to investigate an automated solution to evaluate and improve the accuracy of measuring trauma surgeons' response time to the highest level (red) trauma activations.Clinical Relevance- Demonstration of timely response to trauma activations is required for ACS verification. As real-time location systems become more prevalent, they may improve a hospital's ability to report accurate response times for trauma team activations.

Unnecessary wait hours: a novel ED system-level metric.

BACKGROUND: Emergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the 'Number of Unnecessary Waits (NUW)' and the corresponding 'Unnecessary Wait Hours (UWH)', to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED. METHODS: UWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA. RESULTS: We retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect. CONCLUSIONS: Situational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department's operations.

Attitudes and Behavior of Health Care Workers Before, During, and After Implementation of Real-Time Location System Technology.

OBJECTIVE: To assess how staff attitudes before, during, and after implementation of a real-time location system (RTLS) that uses radio-frequency identification tags on staff and patient identification badges and on equipment affected staff's intention to use and actual use of an RTLS. PARTICIPANTS AND METHODS: A series of 3 online surveys were sent to staff at an emergency department with plans to implement an RTLS between June 1, 2015, and November 29, 2016. Each survey corresponded with a different phase of implementation: preimplementation, midimplementation, and postimplementation. Multiple logistic regression with backward elimination was used to assess the relationship between demographic variables, attitudes about RTLSs, and intention to use or actual use of an RTLS. RESULTS: Demographic variables were not associated with intention to use or actual use of the RTLS. Before implementation, poor perceptions about the technology's usefulness and lack of trust in how employers would use tracking data were associated with weaker intentions to use the RTLS. During and after implementation, attitudes about the technology's use, not issues related to autonomy and privacy, were associated with less use of the technology. CONCLUSION: Real-time location systems have the potential to assess patterns of health care delivery that could be modified to reduce costs and improve the quality of care. Successful implementation, however, may hinge on how staff weighs attitudes and concerns about their autonomy and personal privacy with organizational goals. With the large investments required for new technology, serious consideration should be given to address staff attitudes about privacy and technology in order to assure successful implementation.

Characterization of emergency department abandonment using a real-time location system.

BACKGROUND: Patients who present to emergency departments (EDs) for evaluation but are noted to have left without being seen (LWBS) are potentially at great risk. Governmental agencies, such as the Centers for Medicare and Medicaid, as well as hospitals and health organizations, are examining the factors which drive LWBS, including accurately quantifying patient tolerance to wait times and targeting interventions to improve patient tolerance to waiting. OBJECTIVE: Compare traditional methods of estimating time to LWBS with an objective method using a real-time location tracking system (RTLS); examine temporal factors associated with greater LWBS rates. METHODS: This is a retrospective cohort study of all ED visits to a large, suburban, quaternary care hospital in one calendar year. LWBS was calculated as patient registration to nurse recognition and documentation of patient abandonment (traditional method) vs registration to last onsite RTLS timestamp (study method). Descriptives of patterns of patient abandonment rates and patient demographic data were also included. RESULTS: Our study shows that traditional methods of measuring LWBS times significantly overestimate actual patient tolerance to waiting times (median 70, mean 92 min). Patients triaged to resource intensive categories (Emergency Severity Index (ESI) 2, 3) wait longer than patients triaged to less resource intensive categories (ESI 4, 5). CONCLUSION: Compared to traditional methods, RTLS is an efficient and accurate way to measure LWBS rates and helps set the stage for assessing the efficacy of interventions to reduce LWBS and reduce the gap between those seeking evaluation at emergency departments and those ultimately receiving it.

Ongoing and Focused Provider Performance Evaluations in Emergency Medicine: Current Practices and Modified Delphi to Guide Future Practice.

The Joint Commission requires ongoing and focused provider performance evaluations (OPPEs/FPPEs). The authors aim to describe current approaches in emergency medicine (EM) and identify consensus-based best practice recommendations. An online survey was distributed to leaders in EM to gain insight into current practices. A modified Delphi approach was then used to develop consensus to recommend best practice. A variety of strategies are currently in use for OPPE/FPPE. "Peer reviewed cases with opportunity for improvement" was identified as a preferred metric for OPPE. Although the preference was for use of peer review in OPPE, a consistent and standard adoption of robust internal care review processes is needed to establish expected norms. National benchmarking is not available currently. This was a limited survey of self-identified leaders, and there is an opportunity for additional engagement of leaders in EM to identify a unified approach that appropriately relates to patient outcomes.

Progression of Emergency Medicine Resident Patient Experience Scores by Level of Training.

BACKGROUND: Patient satisfaction surveys are vital to measuring a patient's experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known. OBJECTIVES: To evaluate whether EM residents' patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement. METHODS: A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 "physician questions" and the "overall" score. RESULTS: We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [P = .72], courtesy [P = .55], informative about treatment [P = .46], and listening [P = .91]) and overall assessment of emergency department care (P = .51) were not significantly improved over the course of resident. CONCLUSION: We did not observe a difference in EM residents' patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.

A Time-Driven Activity-Based Costing Analysis of Emergency Department Scribes.

OBJECTIVE: To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes. METHODS: This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician-scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department. A tablet-based time recorded was used to obtain estimates for physician documentation time on both control (no scribe) and intervention (scribe) shifts. RESULTS: Control shifts yielded approximately 3 hours of documentation time per 8 hours of clinical time (2 hours during the shift, 1 hour following the shift). When paired with a scribe, attending physician documentation decreased to 1 hour and 45 minutes during a shift and 15 minutes of postshift documentation. The physician cost estimate for documentation without and with a scribe is 644 and 488 dollars, respectively. CONCLUSIONS: When one looks at the time saved by the provider, scribes appear to be a financially sound decision. TDABC methodology demonstrated that scribes afford a cost-effective solution to ED clinical documentation and serves as a tool to develop an accurate costing system, based on actual resources and processes, and allowed for understanding of resource use at a more granular level.

Patient-Care Team Contact Patterns Impact Treatment Length of Stay in the Emergency Department.

Real-time location systems (RTLS) has found extensive application in the healthcare setting, that is shown to improve safety, save cost, and increase patient satisfaction. More specifically, some studies have shown the efficacy of RTLS leading to an improved workflow in the emergency department. However, due to substantial implementation costs of such technologies, hospital administrators show reluctance in RTLS adoption. Our previous preliminary studies with RFID data in the emergency department (ED) demonstrated for the first time the quantification of `patient alone time' and its relationship to outcomes such as 30-day hospitalization. In this study, we use ED RTLS data to analyze patient-care team contact time (PCTCT) and its relationship to the total treatment length of stay (LOS) in ED. An observational cohort study was performed in the ED using RTLS data from Jan 17 - Sep 17, 2017, which included a total of 51,697 patients. PCTCT within the first hour of a patient's placement in a treatment bed was calculated and its relationship to treatment LOS was analyzed while controlling for confounding factors affecting treatment LOS. Results show that treatment LOS is highly correlated with the ED crowding captured by the patient-perprovider ratio, negatively correlated to the physician and resident visit frequency, and positively correlated to nurse visit frequency. The results can inform designing new guidelines for ideal patient-care team interactions and be used to determine optimal ED staffing levels and care team composition for effective care delivery.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes.

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non-ST-elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events? (2) In adult patients with suspected acute non-ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? (3) In adult patients with suspected non-ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events? (4) Should adult patients with acute non-ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.

Time Motion Analysis: Impact of Scribes on Provider Time Management.

BACKGROUND: Scribes are unlicensed professionals trained in medical data entry. Limited data exist on the impact of scribes on provider time management in the emergency department (ED). Time-motion analysis is a tool utilized in business to capture detailed movements and durations to task completion. It offers a means to categorize how providers allocate their time during a clinical shift. OBJECTIVE: Evaluate the impact of scribes on how ED providers spend their time. METHODS: A prospective observational study was conducted to assess scribe impact on provider time utilization. Four research assistants (RAs) observed attending providers on 24 8-h control shifts (without a scribe), and 24 scribed shifts. RAs observed and categorized provider activity. Providers self-reported after-hours documentation times. Two-sample t-tests were used for normally distributed data, and Wilcoxon rank-sum tests were used for skewed data. All tests were two-sided, and p-values < 0.05 were considered statistically significant. RESULTS: Scribes decreased total documentation time both on shift (mean 55.3 vs. 36.4 min, p < 0.001) and post shift (mean 42.5 vs. 23.3 min, p = 0.038). They did not significantly decrease the amount of time spent reviewing the medical records or placing orders, nor did they have an impact on provider time spent at patients' bedside or time spent discussing patient care with team members. CONCLUSION: The presence of scribes decreased provider documentation time but did not change the amount of time spent at the bedside or communicating with other team members. Scribes may be a potential strategy to decrease the clerical burden.

Consequences of the 48-h rule: A lens into the psychiatric patient flow through an emergency department.

OBJECTIVE: Psychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow. METHODS: A pre- and post- comparison of 2011-2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5days. Changes in patient disposition proportions were assessed using risk ratios. RESULTS: The median ED LOS for patients admitted for psychiatric care increased by 5.22h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3days and ≥15days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively). CONCLUSIONS: The proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care.

Clinical care review systems in healthcare: a systematic review.

BACKGROUND: Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review. METHODS: A librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction. RESULTS: We found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review. CONCLUSION: While guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation.

Contact tracing with a real-time location system: A case study of increasing relative effectiveness in an emergency department.

BACKGROUND: Contact tracing is the systematic method of identifying individuals potentially exposed to infectious diseases. Electronic medical record (EMR) use for contact tracing is time-consuming and may miss exposed individuals. Real-time location systems (RTLSs) may improve contact identification. Therefore, the relative effectiveness of these 2 contact tracing methodologies were evaluated. METHODS: During a pertussis outbreak in the United States, a retrospective case study was conducted between June 14 and August 31, 2016, to identify the contacts of confirmed pertussis cases, using EMR and RTLS data in the emergency department of a tertiary care medical center. Descriptive statistics and a paired t test (α = 0.05) were performed to compare contacts identified by EMR versus RTLS, as was correlation between pertussis patient length of stay and the number of potential contacts. RESULTS: Nine cases of pertussis presented to the emergency department during the identified time period. RTLS doubled the potential exposure list (P < .01). Length of stay had significant positive correlation with contacts identified by RTLS (ρ = 0.79; P = .01) but not with EMR (ρ = 0.43; P = .25). CONCLUSIONS: RTLS doubled the potential pertussis exposures beyond EMR-based contact identification. Thus, RTLS may be a valuable addition to the practice of contact tracing and infectious disease monitoring.

Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department.

BACKGROUND: It is unclear how workflow interruptions impact emergency physicians at the point of care. OBJECTIVES: Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians. METHODS: This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms. RESULTS: A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ2(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ2 [2, n = 2355] = 78.43, p < 0.001). CONCLUSIONS: Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.