Predicting severe disease in patients diagnosed with seasonal influenza in the emergency department.

Objectives: We sought to develop an evidence-based tool to risk stratify patients diagnosed with seasonal influenza in the emergency department (ED). Methods: We performed a single-center retrospective cohort study of all adult patients diagnosed with influenza in a large tertiary care ED between 2008 and 2018. We evaluated demographics, triage vital signs, chest x-ray and laboratory results obtained in the ED. We used univariate and multivariate statistics to examine the composite primary outcome of death or need for intubation. We validated our findings in patients diagnosed between 2018 and 2020. Results: We collected data from 3128 subjects; 2196 in the derivation cohort and 932 in the validation cohort. Medical comorbidities, multifocal opacities or pleural effusion on chest radiography, older age, elevated respiratory rate, hypoxia, elevated blood urea nitrogen, blood glucose, blood lactate, and red blood cell distribution width were factors associated with intubation or death. We developed the Predicting Intubation in seasonal Influenza Patients diagnosed in the ED (PIIPED) risk-stratification tool from these factors. The PIIPED tool predicted intubation or death with an area under the receiver operating characteristic curve (AUC) of 0.899 in the derivation cohort and 0.895 in the validation cohort. A version of the tool including only factors available at ED triage, before laboratory or radiographic evaluation, exhibited AUC of 0.852 in the derivation cohort and 0.823 in the validation cohort. Conclusion: Clinical findings during an ED visit predict severe outcomes in patients with seasonal influenza. The PIIPED risk stratification tool shows promise but requires prospective validation.

Shared-Task Worklists Improve Clinical Trial Recruitment Workflow in an Academic Emergency Department.

BACKGROUND: Clinical trials performed in our emergency department at Barnes-Jewish Hospital utilize a centralized infrastructure for alerting, screening, and enrollment with rule-based alerts sent to clinical research coordinators. Previously, all alerts were delivered as text messages via dedicated cellular phones. As the number of ongoing clinical trials increased, the volume of alerts grew to an unmanageable level. Therefore, we have changed our primary notification delivery method to study-specific, shared-task worklists integrated with our pre-existing web-based screening documentation system. OBJECTIVE: To evaluate the effects on screening and recruitment workflow of replacing text-message delivery of clinical trial alerts with study-specific shared-task worklists in a high-volume academic emergency department supporting multiple concurrent clinical trials. METHODS: We analyzed retrospective data on alerting, screening, and enrollment for 10 active clinical trials pre- and postimplementation of shared-task worklists. RESULTS: Notifications signaling the presence of potentially eligible subjects for clinical trials were more likely to result in a screen (p < 0.001) with the implementation of shared-task worklists compared with notifications delivered as text messages for 8/10 clinical trials. The change in workflow did not alter the likelihood of a notification resulting in an enrollment (p = 0.473). The Director of Research reported a substantial reduction in the amount of time spent redirecting clinical research coordinator screening activities. CONCLUSION: Shared-task worklists, with the functionalities we have described, offer a viable alternative to delivery of clinical trial alerts via text message directly to clinical research coordinators recruiting for multiple concurrent clinical trials in a high-volume academic emergency department.

Adding flexible temporal constraints to identify chronic comorbid conditions in ambulatory claims data.

Chronic comorbid conditions are important predictors of primary care outcomes, provide context for clinical decisions, and are potential complications of diseases and treatments. Comorbidity indices and multimorbidity categorization strategies based on administrative claims data enumerate diagnostic codes in easily modifiable lists, but usually have inflexible temporal requirements, such as requiring two claims greater than 30 days apart, or three claims in three quarters. Table structures and claims data search algorithms were developed to support flexible temporal constraints. Tables of disease categories allow subgroups with different numbers of events, different times between similar claims, variable periods of interest, and specified diagnostic code substitutability. The strategy was tested on five years of private insurance claims from 2.2 million working age adults. The contrast between rarely recorded, high prevalence diagnoses (smoking and obesity) and frequently recorded but not necessarily chronic diagnoses (musculoskeletal complaints) demonstrated the advantage of flexible temporal criteria.

Effects of a triage process conversion on the triage of high-risk presentations.

OBJECTIVES: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time-sensitive therapy. METHODS: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time-sensitive care. RESULTS: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. CONCLUSIONS: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time-sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.

Effects of computerized provider order entry and nursing documentation on workflow.

OBJECTIVES: The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). METHODS: The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions. RESULTS: There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and/or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. CONCLUSIONS: The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider-computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected.

The impact of input and output factors on emergency department throughput.

OBJECTIVES: To quantify the impact of input and output factors on emergency department (ED) process outcomes while controlling for patient-level variables. METHODS: Using patient- and system-level data from multiple sources, multivariate linear regression models were constructed with length of stay (LOS), wait time, treatment time, and boarding time as dependent variables. The products of the 20th to 80th percentile ranges of the input and output factor variables and their regression coefficients demonstrate the actual impact (in minutes) of each of these factors on throughput outcomes. RESULTS: An increase from the 20th to the 80th percentile in ED arrivals resulted in increases of 42 minutes in wait time, 49 minutes in LOS (admitted patients), and 24 minutes in ED boarding time (admitted patients). For admit percentage (20th to 80th percentile), the increases were 12 minutes in wait time, 15 minutes in LOS, and 1 minute in boarding time. For inpatient bed utilization as of 7 AM (20th to 80th percentile), the increases were 4 minutes in wait time, 19 minutes in LOS, and 16 minutes in boarding time. For admitted patients boarded in the ED as of 7 AM (20th to 80th percentile), the increases were 35 minutes in wait time, 94 minutes in LOS, and 75 minutes in boarding time. CONCLUSIONS: Achieving significant improvement in ED throughput is unlikely without determining the most important factors on process outcomes and taking measures to address variations in ED input and bottlenecks in the ED output stream.

Emergency department overcrowding: analysis of the factors of renege rate.

BACKGROUND: Reneging (i.e., leaving without being seen) is an important outcome of emergency department (ED) overcrowding. The input-throughput-output conceptualization of ED patient flow is helpful in understanding and measuring the impact of various factors on this outcome. OBJECTIVES: To quantify the impact of input and output factors on ED renege rate. METHODS: The authors used patient-level and system-level data from multiple sources in their institution to build logistic regression models, with reneging as the dependent variable. This approach provides the impact of each input and output factor on renege rate expressed as an odds ratio (OR). RESULTS: The OR for reneging attributable to the difference between the 80th and 20th percentile values for inpatient bed utilization is 1.05. Comparing 80th and 20th percentile values for boarded ED admits as of 7 AM, the OR is 1.73; for daily ED arrivals, the OR is 2.00; and for admission percentage, the OR is 1.12. The OR for evening versus morning patient arrival time is 3.9 and for patient arrival on a Monday versus a Sunday is 2.7. The OR for reneging for a patient presenting on Monday evening versus Sunday morning is 10.5. CONCLUSIONS: The effects of ED input and output factors on renege rate are significant and quantifiable. At least some of the variation in these factors and subsequently their effects are predictable, suggesting that further refinement in the management of ED and inpatient resources could affect improvement in ED renege rate. Continued efforts at quantifying the effects are warranted.

Effects of implementing computerized practitioner order entry and nursing documentation on nursing workflow in an emergency department.

Nurses'perceptions of effective use of their time are critical to the successful implementation of information system changes. We examined the effects of implementing computerized practitioner order entry and nursing documentation in our emergency department with an anonymous survey of nurses and repeated time-motion studies. Emergency care nurses were positive about effects of CPOE, reporting needing less time to complete medication, laboratory, and radiology orders and less time spent clarifying orders. Their perceptions of time spent were congruent with observations from time-motion studies where combined computer-and-paper time and direct-patient-care time did not change significantly. Nurses also reported supplementing template options with free text, and those who were more comfortable using computers reported supplementing template options more often than their counterparts, suggesting that assessments of users' expertise in computer use may influence their ability to maximize their use of the functionality of emergency department information systems.

Embedded guideline information without patient specificity in a commercial emergency department computerized order-entry system.

BACKGROUND: Clinical practice guidelines and computerized provider order entry (CPOE) have potential for improving clinical care. Questions remain about feasibility and effectiveness of CPOE in the emergency department (ED). However, successful implementations in other settings typically incorporate decision support functions that are lacking in many commercially available ED information systems. OBJECTIVES: To compare acute coronary syndrome (ACS) guideline compliance before and after implementation of a locally implemented ACS guideline, first on paper and then in a commercially available ED information system without patient-specific clinical decision support. METHODS: Clinical data were abstracted retrospectively on patients seen before and after introduction of paper and, subsequently, CPOE versions of ACS guideline-based order-sets. Order-set use was determined. Risk category assignments were made retrospectively using guideline criteria and compliance with the guideline regarding beta-blockers, heparin, and aspirin was determined. Association between order-set use and compliance was determined. RESULTS: The authors found increasing use of order-sets over the period of study. However, there was poor association between the order-sets used and risk stratification category. Some association between ED beta-blocker use and use of CPOE order-sets was found, but there was no improvement in overall compliance with any of the guideline recommendations. CONCLUSIONS: Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.

Physician perspective on computerized order-sets with embedded guideline information in a commercial emergency department information system.

Computerized provider order entry (CPOE) is a promising conduit for medical knowledge in support of guideline-consistent decision-making at the point of care. While there are many published examples of successful implementations of CPOE with decision support, there remain questions about the effectiveness of commercially available information system products, particularly in the emergency department (ED). We describe an attempt at using the available CPOE functionality in a commercial ED information system to deliver guideline knowledge and report the results of physician surveys regarding paper-based guideline/order-sets and the corresponding CPOE order-sets that replaced them. Physicians reported that they liked the CPOE order-sets better than the paper version and did use the order-sets, but guide-line compliance did not improve. Cultural and organizational issues as well as limitations in the functionality of the commercial system appear to have limited the effectiveness of this implementation.

Handheld computer application for time-motion studies in the emergency department.

Urban academic emergency departments face significant challenges of increasing patient volumes and sicker patients. Better understanding of the timing and interactions between provider activities may assist in efforts directed toward improving patient-care processes to decrease length of stay. Rapidly chang-ing and overlapping activities in the emergency department make time-motion study difficult. This poster describes a handheld computer application that enables synchronized capture of task description and times across multiple patient care providers in the emergency department.