Emergency Department Operations

Emergency Department Operations

A Novel Approach to Addressing an Unintended Consequence of Direct to Room: The Delay of Initial Vital Signs

Basile, MD, et al.

The concept of “direct to room” (DTR) and “immediate bedding” has been described in the literature as a mechanism to improve front-end, emergency department (ED) processing. The process allows for an expedited clinician-patient encounter. An unintended consequence of DTR was a time delay in obtaining the initial set of vital signs upon patient arrival.

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Emergency Department Operations

Decreasing Emergency Department Walkout Rate and Boarding Hours by Improving Inpatient Length of Stay

Artenstein, MD, et al.

Patient progress, the movement of patients through a hospital system from admission to discharge, is a foundational component of operational effectiveness in healthcare institutions. Optimal patient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate Patient Progress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, was launched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients.

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Emergency Department Operations

Magnetic Resonance Imaging Utilization in an Emergency Department Observation Unit

Sánchez, BA, et al.

Emergency department observation units (EDOUs) are a valuable alternative to inpatient admissions for ED patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU.

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Emergency Department Operations

The Economics of an Admissions Holding Unit

Kraftin E. Schreyer, MD, et al.

With increasing attention to the actual cost of delivering care, return-on-investment calculations take on new significance. Boarded patients in the emergency department (ED) are harmful to clinical care and have significant financial opportunity costs. We hypothesize that investment in an admissions holding unit for admitted ED patients not only captures opportunity cost but also significantly lowers direct cost of care.

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Emergency Department Operations

Cross-Continuum Tool Is Associated with Reduced Utilization and Cost for Frequent High-Need Users

Author Affiliation Lauran Hardin, MSN, RN-BC, CNL Trinity Health-Michigan dba Mercy Health Saint Mary’s, Grand Rapids, Michigan; National Center for Complex Health and Social Needs, Camden, New Jersey Adam Kilian, MD Trinity Health-Michigan dba Mercy Health Saint Mary’s, Grand Rapids, Michigan; University of Utah Health Care, Department of Internal Medicine, Salt Lake City, Utah Leslie […]

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Emergency Department Operations

Mobile COWs (Computer on Wheels): Hamburger or VEAL?

Mobile COWs (Computer on Wheels): Hamburger or VEAL?
Maxwell Jen, MD, et al.

The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 galvanized the universal adoption of electronic health record (EHR) systems to improve the quality, delivery, and coordination of patient care.1 Initial results demonstrated improvement in population health outcomes and increased transparency.2-3 Through the HITECH Act’s Meaningful Use (MU) incentives, EHR adoption also promised shorter hospital stays, reduced costs and improved access to healthcare data.4 These promises, however, never materialized; studies have demonstrated that EHR adoption causes decreased rates of patients seen per hour, highly variable documentation times, and increased order entry times.

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Emergency Department Operations

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?
Michael P. Phelan, MD, et al.

Our goal was to determine if the hemolysis among blood samples obtained in an emergency department and then sent to the laboratory in a pneumatic tube system was different from those in samples that were hand-carried.

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Emergency Department Operations

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality
Guberman, MD, MS, et al.

Attending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality.

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Emergency Department Operations

Emergency Department Length of Stay for Maori and European Patients in New Zealand

Volume 17, Issue 4, July 2016
David Prisk, DO et al.

Emergency department length of stay (ED LOS) is currently used in Australasia as a quality measure. In our ED, Maori, the indigenous people of New Zealand, have a shorter ED LOS than European patients. This is despite Maori having poorer health outcomes overall. This study sought to determine drivers of LOS in our provincial New Zealand ED, particularly looking at ethnicity as a determining factor.

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Emergency Department Operations

Comparison of Result Times Between Urine and Whole Blood Point-of-care Pregnancy Testing

Volume 17, Issue 4, July 2016
Michael Gottlieb, MD, et al.

Point-of-care (POC) pregnancy testing is commonly performed in the emergency department (ED). One prior study demonstrated equivalent accuracy between urine and whole blood for one common brand of POC pregnancy testing. Our study sought to determine the difference in result times when comparing whole blood versus urine for the same brand of POC pregnancy testing.

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Emergency Department Operations

Physician Quality Reporting System Program Updates and the Impact on Emergency Medicine Practice

Volume 17, Issue 2, March 2016.
Jennifer L. Wiler, MD, MBA, et al.

In 2007, the Centers for Medicaid and Medicare Services (CMS) created a novel payment program to
create incentives for physician’s to focus on quality of care measures and report quality performance
for the first time. Initially termed “The Physician Voluntary Reporting Program,” various Congressional
actions, including the Tax Relief and Health Care Act of 2006 (TRHCA) and Medicare Improvements
for Patients and Providers Act of 2008 (MIPPA) further strengthened and ensconced this program,
eventually leading to the quality program termed today as the Physician Quality Reporting System
(PQRS). As a result of passage of the Affordable Care Act of 2010, the PQRS program has expanded
to include both the “traditional PQRS” reporting program and the newer “Value Modifier” program
(VM). For the first time, these programs were designed to include pay-for-performance incentives for
all physicians providing care to Medicare beneficiaries and to measure the cost of care. The recent
passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act
in March of 2015 includes changes to these payment programs that will have an even more profound
impact on emergency care providers. We describe the implications of these important federal policy
changes for emergency physicians.

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Emergency Department Operations

Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice

Volume 16, Issue 5, September 2015.
Jeremy J. Hess, MD, MPH

Introduction: Physicians dedicate substantial time to documentation. Scribes are sometimes used
to improve efficiency by performing documentation tasks, although their impacts have not been
prospectively evaluated. Our objective was to assess a scribe program’s impact on emergency
department (ED) throughput, physician time utilization, and job satisfaction in a large academic
emergency medicine practice.
Methods: We evaluated the intervention using pre- and post-intervention surveys and administrative
data. All site physicians were included. Pre- and post-intervention data were collected in fourmonth
periods one year apart. Primary outcomes included changes in monthly average ED length
of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized
to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent
documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate
tests for paired pre-post differences in continuous, categorical, and ranked variables.
Results: Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded
positively to the intervention, although 9.5% reported negative impressions. There was a 36%
reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in
time spent in direct patient contact. No statistically significant changes were seen in job satisfaction
or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04)
pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped,
and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and
per patient 5.3%; both were statistically significant. No statistically significant changes were seen
in patients seen per hour. There was moderate correlation between changes in ED volume and
changes in productivity metrics.
Conclusion: Scribes were well received in our practice. Documentation time was substantially
reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained,
with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour
and per patient both increased.

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Emergency Department Operations

Identifying Patient Door-to-Room Goals to Minimize Left-Without-Being-Seen Rates

Volume 16, Issue 5, September 2015.
Shea Pielsticker, BS, et al.

Introduction: Emergency department (ED) patients in the leave-without-being-seen (LWBS) group
risk problems of inefficiency, medical risk, and financial loss. The goal at our hospital is to limit LWBS
to <1%. This study’s goal was to assess the influence on LWBS associated with prolonging intervals
between patient presentation and placement in an exam room (DoorRoom time). This study’s major
aim was to identify DoorRoom cutoffs that maximize likelihood of meeting the LWBS goal (i.e. <1%).
Methods: We conducted the study over one year (8/13-8/14) using operations data for an ED with
annual census ~50,000. For each study day, the LWBS endpoint (i.e. was LWBS <1%: “yes or
no”) and the mean DoorRoom time were recorded. We categorized DoorRoom means by intervals
starting with ≤10min and ending at >60min. Multivariate logistic regression was used to assess
for DoorRoom cutoffs predicting high LWBS, while adjusting for patient acuity (triage scores and
admission %) and operations parameters. We used predictive marginal probability to assess utility of
the regression-generated cutoffs. We defined statistical significance at p<0.05 and report odds ratio
(OR) and 95% confidence intervals (CI).
Results: Univariate results suggested a primary DoorRoom cutoff of 20’, to maintain a high
likelihood (>85%) of meeting the LWBS goal. A secondary DoorRoom cutoff was indicated at 35’, to
prevent a precipitous drop-off in likelihood of meeting the LWBS goal, from 61.1% at 35’ to 34.4%
at 40’. Predictive marginal analysis using multivariate techniques to control for operational and
patient-acuity factors confirmed the 20’ and 35’ cutoffs as significant (p<0.001). Days with DoorRoom
between 21-35’ were 74% less likely to meet the LWBS goal than days with DoorRoom ≤20’ (OR
0.26, 95% CI [0.13-0.53]). Days with DoorRoom >35’ were a further 75% less likely to meet the
LWBS goal than days with DoorRoom of 21-35’ (OR 0.25, 95% CI [0.15-0.41]).
Conclusion: Operationally useful DoorRoom cutoffs can be identified, which allow for rational
establishment of performance goals for the ED attempting to minimize LWBS.

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Emergency Department Operations

Demographic, Operational, and Healthcare Utilization Factors Associated with Emergency Department Patient Satisfaction

Volume 16, Issue 4, July 2015.
Matthew W. Morgan, MD, et al.

The primary aim of this study was to determine which objectively-measured patient
demographics, emergency department (ED) operational characteristics, and healthcare utilization
frequencies (care factors) were associated with patient satisfaction ratings obtained from phone
surveys conducted by a third-party vendor for patients discharged from our ED.

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Emergency Department Operations

Waiting for Triage: Unmeasured Time in Patient Flow

Volume 16, Issue 1, January 2015
Christopher Houston, MD et al.

The Centers for Medicare and Medicaid Services (CMS) requires reporting of multiple time-sensitive metrics. Most facilities use triage time as the time of arrival. Little is known about how long patients wait prior to triage. As reimbursement to the hospital may be tied to these metrics, it is essential to accurately record the time of arrival.

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Emergency Department Operations

Using Lean-Based Systems Engineering to Increase Capacity in the Emergency Department

Volume 15, Issue 7, November 2014
Benjamin A. White, MD et al.

While emergency department (ED) crowding has myriad causes and negative downstream effects, applying systems engineering science and targeting throughput remains a potential solution to increase functional capacity. However, the most effective techniques for broad application in the ED remain unclear.

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Emergency Department Operations

Implementation of a Team-based Physician Staffing Model at an Academic Emergency Department

Volume 15, Issue 6, September 2014
Jose V. Nable, MD et al.

There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model.

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Emergency Department Operations

Reducing Patient Placement Errors in Emergency Department Admissions: Right Patient, Right Bed

Volume 15, Issue 6, September 2014
Niels K. Rathlev, MD et al.

Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement.

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Emergency Department Operations

Adherence to Head Computed Tomography Guidelines for Mild Traumatic Brain Injury

Volume 15, Issue 4, July 2014
Landon A. Jones, MD et al.

Traumatic brain injury (TBI) is a significant health concern. While 70–90% of TBI cases are considered mild, decision-making regarding imaging can be difficult. This survey aimed to assess whether clinicians’ decision-making was consistent with the most recent American College of Emergency Physicians (ACEP) clinical recommendations regarding indications for a non-contrast head computed tomography (CT) in patients with mild TBI.

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Emergency Department Operations

Application of a Proactive Risk Analysis to Emergency Department Sickle Cell Care

Volume 15, Issue 4, July 2014
Victoria L. Thornton, MD, MBA et al.

Patients with sickle cell disease (SCD) often seek care in emergency departments (EDs) for severe pain. However, there is evidence that they experience inaccurate assessment, suboptimal care, and inadequate follow-up referrals. The aim of this project was to 1) explore the feasibility of applying a failure modes, effects and criticality analysis (FMECA) in two EDs examining four processes of care (triage, analgesic management, high risk/high users, and referrals made) for patients with SCD, and 2) report the failures of these care processes in each ED.

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: westjem@gmail.com


ISSN: 1936-900X
e-ISSN: 1936-9018

ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.