scholarly journals MP12: Emergency department boarding: predictors and outcomes

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S44-S44
Author(s):  
L. Salehi ◽  
V. Jegatheeswaran ◽  
J. Herman ◽  
P. Phalpher ◽  
R. Valani ◽  
...  
Keyword(s):  
Critical Care ◽  
Patient Care ◽  
High Volume ◽  
Patient Characteristics ◽  
Patient Specific ◽  
Medicine Service ◽  
Comorbidity Burden ◽  
Ed Overcrowding ◽  
Ed Visits ◽  
The Impact

Introduction: Delays in transfer to an in-patient bed of admitted patients boarded in the ED has been identified as one of the chief drivers of ED overcrowding. Our study aims to replicate findings from a previous study in identifying patient characteristics associated with increased boarding time, and the impact of increased boarding time on in-patient length of stay (IPLOS). Methods: We conducted a retrospective single-centre observational study during the period between January 1, 2015 December 31, 2015 at a very high volume community hospital (~ 75,000 ED visits/year). All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean time to in-patient bed (TTB), as well as patient-specific and institutional factors that were associated with prolonged boarding times ( 12 hours) were identified. Mean IP LOS was calculated for those with prolonged boarding times and compared to those without prolonged boarding times. Results: There were 8,096 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher boarding times than those admitted to other services, with a mean boarding time of 17.4 hrs, as compared to 4.2 hrs, 5.7 hrs, and 4.0 hrs for those admitted to Surgery, Critical Care and Pediatrics respectively. Within Medicine patients, there was a statistically significant greater odds of prolonged boarding time for patients who were older, had a greater comorbidity burden, and required more specialized in-patient care (i.e. an isolation bed or telemetry bed). Medicine patients with prolonged boarding times also experienced 0.7 days longer IP LOS, even after correcting for age and comorbidity (mean adjusted IP LOS 10.6 days versus 11.3 days). Conclusion: Within our study period, older, sicker patients and those patients requiring more resource-intensive in-patient care have the longest ED boarding times. These prolonged ‘boarding’ times are associated with significantly increased IP LOS.

scholarly journals Implementation, Evolution and Impact of ICU Telepharmacy Services Across a Health care System

2019 ◽  
Vol 54 (4) ◽  
pp. 232-240 ◽  
Author(s):  
Desiree E. Kosmisky ◽  
Sonia S. Everhart ◽  
Carrie L. Griffiths
Keyword(s):  
Critical Care ◽  
Patient Care ◽  
Healthcare System ◽  
Improve Patient Care ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Use Of Technology ◽  
American Society ◽  
The Impact

Purpose: A review of the implementation and development of telepharmacy services that ensure access to a critical care-trained pharmacist across a healthcare system. Summary: Teleintensive care unit (tele-ICU) services use audio, video, and electronic databases to assist bedside caregivers. Telepharmacy, as defined by the American Society of Health-System Pharmacists, is a method in which a pharmacist uses telecommunication technology to oversee aspects of pharmacy operations or provide patient care services. Telepharmacists can ensure accurate and timely order verification, recommend interventions to improve patient care, provide drug information to clinicians, assist in standardization of care, and promote medication safety. This tele-ICU pharmacy team is one of the only entirely clinical-based tele-ICU pharmacy models among the tele-ICU programs across the United States. The use of technology for customized alert generation and intervention proposal with medication orders and chart notation are unique. In a 34-month period from September 2015 to July 2018, more than 110 000 alerts were generated and 13 000 interventions were performed by telepharmacists. Conclusions: Tele-ICU pharmacists employ limited resources to provide critical care pharmacy expertise to multiple sites within a healthcare system during nontraditional hours with documented clinical and financial benefits. Further study is needed to determine the impact of tele-ICU pharmacists on ICU and hospital length of stay, morbidity, and mortality.

scholarly journals Modern family: Texas critical care clinicians need to know about informal marriage

2020 ◽  
Vol 8 (34) ◽  
pp. 73-76
Author(s):  
Jamie Crist
Keyword(s):  
Critical Care ◽  
Patient Care ◽  
Interpersonal Relationships ◽  
Family Relationship ◽  
Improve Patient Care ◽  
Medical Decision ◽  
Modern Family ◽  
Surrogate Decision Makers ◽  
Surrogate Decision ◽  
The Impact

Critical care clinicians are legally and ethically obligated to identify the appropriate surrogate decision-makers for patients who lack capacity and cannot make medical decisions for themselves. When the identification of the appropriate surrogate is streamlined, patient care is improved due to an uninterrupted and consistent plan of care that adheres to patient preferences. However, the process of identifying this “appropriate” person can be complex, especially as interpersonal relationships have evolved over time. One such modern family relationship is informal marriage, a Texas-specific relationship formerly known as “common-law” marriage. Though crucially important, this relationship is can difficult to recognize and frequently misunderstood. Utilizing a case study that illustrates the impact the existence of an informal marriage has on medical decision-making, this paper seeks to demystify informal marriage by outlining what makes a relationship an informal marriage and provide tools to assist clinicians with identifying it.  In an age where non-traditional relationships are more common, Texas critical care clinicians should be familiar enough with informal marriage to recognize it in their patients in order to efficiently identify surrogates and therefore improve patient care.

scholarly journals Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study

2015 ◽  
Vol 2015 ◽  
pp. 1-11 ◽  
Author(s):  
Hao Wang ◽  
Richard D. Robinson ◽  
John S. Garrett ◽  
Kellie Bunch ◽  
Charles A. Huggins ◽  
...  
Keyword(s):  
Emergency Department ◽  
Patient Care ◽  
Care Delivery ◽  
Average Length ◽  
High Volume ◽  
Patient Acuity ◽  
Factors Affecting ◽  
Left Without Being Seen ◽  
Ed Overcrowding ◽  
Care Outcomes

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes.Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses.Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns.Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

scholarly journals Development and validation of a machine learning model predicting illness trajectory and hospital utilization of COVID-19 patients—a nationwide study

2021 ◽  
Author(s):  
Michael Roimi ◽  
Rom Gutman ◽  
Jonathan Somer ◽  
Asaf Ben Arie ◽  
Ido Calman ◽  
...  
Keyword(s):  
Critical Care ◽  
Clinical Status ◽  
Patient Characteristics ◽  
Hospitalized Patients ◽  
Hospital Utilization ◽  
Clinical State ◽  
Care Hospital ◽  
System Utilization ◽  
The Impact ◽  
Day By Day

Abstract Objective The spread of COVID-19 has led to severe strain on hospital capacity in many countries. We aim to develop a model helping planners assess expected COVID-19 hospital resource utilization based on individual patient characteristics. Materials and Methods We develop a model of patient clinical course based on an advanced multistate survival model. The model predicts the patient's disease course in terms of clinical states—critical, severe, or moderate. The model also predicts hospital utilization on the level of entire hospitals or healthcare systems. We cross-validated the model using a nationwide registry following the day-by-day clinical status of all hospitalized COVID-19 patients in Israel from March 1st to May 2nd, 2020 (n = 2,703). Results Per-day mean absolute errors for predicted total and critical-care hospital-bed utilization were 4.72 ± 1.07 and 1.68 ± 0.40 respectively, over cohorts of 330 hospitalized patients; AUCs for prediction of critical illness and in-hospital mortality were 0.88 ± 0.04 and 0.96 ± 0.04, respectively. We further present the impact of patient influx scenarios on day-by-day healthcare system utilization. We provide an accompanying R software package. Discussion The proposed model accurately predicts total and critical-care hospital utilization. The model enables evaluating impacts of patient influx scenarios on utilization, accounting for the state of currently hospitalized patients and characteristics of incoming patients. We show that accurate hospital-load predictions were possible using only a patient’s age, sex, and day-by-day clinical state (critical, severe or moderate). Conclusion The multistate model we develop is a powerful tool for predicting individual-level patient outcomes and hospital-level utilization.

Consensus Guidelines for Coordinated Outpatient Oral Anticoagulation Therapy Management

1997 ◽  
Vol 31 (5) ◽  
pp. 604-615 ◽  
Author(s):  
Jack E Ansell ◽  
Marissa L Buttaro ◽  
Orsula Voltis Thomas ◽  
Calvin H Knowlton ◽  
Keyword(s):  
Patient Care ◽  
Patient Outcomes ◽  
Current Practice ◽  
Systems Of Care ◽  
Anticoagulation Therapy ◽  
Anticoagulation Clinic ◽  
Third Party ◽  
Patient Specific ◽  
Anticoagulation Management ◽  
The Impact

OBJECTIVE: TO provide primary and referring healthcare practitioners with guidelines for the provision of safe and effective anticoagulation management in any venue to standardize and improve quality of care and to permit negotiation for reimbursement from third-party payers. DATA EXTRACTION AND SYNTHESIS: Data on the current practice of anticoagulation providers and outcomes related to anticoagulation clinic care were obtained through the literature, interviews with anticoagulation providers, and a focus group meeting of anticoagulation clinic stakeholders. This information collation process revealed that an anticoagulation service consists of three separate areas for which guidelines should be developed. Based on the consensus opinions of the committee members, the literature review, and the current practice of anticoagulation services providers, a draft guideline was developed and reviewed by an independent multidisciplinary panel of anticoagulation services providers whose comments were incorporated into the final guideline. CONCLUSIONS: Systematic outpatient anticoagulation services are systems of care designed to coordinate and optimize the delivery of anticoagulation therapy by (1) evaluating patient-specific risks and benefits to determine the appropriateness of therapy; (2) facilitating the management of anticoagulation dosages and prescription pick up or delivery; (3) providing ongoing education of the patient and other caregivers about warfarin and the importance of self-care behavior leading to optimal outcomes; (4) providing continuous systematic monitoring of patients, international normalized ratio results, diet, concomitant drug therapy, and disease states; and (5) communicating with other healthcare practitioners involved in the care of the patient. To create a reproducible framework for the provision of these services, guidelines for structure, process, and outcomes of coordinated outpatient anticoagulation management services were developed. Guidelines for organization and management include (1) qualifications for personnel, (2) supervision, (3) care management and coordination, (4) communication and documentation, and (5) laboratory monitoring. Guidelines for the process of patient care include (6) patient selection and assessment, (7) initiation of therapy, (8) maintenance and management of therapy, (9) patient education, and (10) management and triage of therapy-related and unrelated problems. Guidelines for the evaluation of patient outcomes include (11) organizational components and (12) patient outcomes. The impact of these 12 guidelines on patient care and reimbursement procurement will depend on their implementation and the perceived value of their use.

scholarly journals Conditional Transformation Models for Survivor Function Estimation

2015 ◽  
Vol 11 (1) ◽  
Author(s):  
Lisa Möst ◽  
Torsten Hothorn
Keyword(s):  
Survival Data ◽  
Proportional Hazards ◽  
Patient Characteristics ◽  
Patient Specific ◽  
Survival Times ◽  
Transformation Models ◽  
Survivor Function ◽  
Conditional Transformation ◽  
The Impact ◽  
Survivor Functions

AbstractIn survival analysis, the estimation of patient-specific survivor functions that are conditional on a set of patient characteristics is of special interest. In general, knowledge of the conditional survival probabilities of a patient at all relevant time points allows better assessment of the patient’s risk than summary statistics, such as median survival time. Nevertheless, standard methods for analysing survival data seldom estimate the survivor function directly. Therefore, we propose the application of conditional transformation models (CTMs) for the estimation of the conditional distribution function of survival times given a set of patient characteristics. We used the inverse probability of censoring weighting approach to account for right-censored observations. Our proposed modelling approach allows the prediction of patient-specific survivor functions. In addition, CTMs constitute a flexible model class that is able to deal with proportional as well as non-proportional hazards. The well-known Cox model is included in the class of CTMs as a special case. We investigated the performance of CTMs in survival data analysis in a simulation that included proportional and non-proportional hazard settings and different scenarios of explanatory variables. Furthermore, we re-analysed the survival times of patients suffering from chronic myelogenous leukaemia and studied the impact of the proportional hazards assumption on previously published results.

The Pulmonary Artery (Swan-Ganz) Catheter: Evaluation of A Hemodynamic Monitoring Device in Critical Care Medicine

1993 ◽  
Vol 9 (2) ◽  
pp. 202-209 ◽  
Author(s):  
Giuseppe Pagliarello
Keyword(s):  
Critical Care ◽  
Pulmonary Artery ◽  
Patient Care ◽  
Hemodynamic Monitoring ◽  
Scientific Evidence ◽  
Care Physician ◽  
Monitoring Device ◽  
Medical Monitoring ◽  
Critical Care Units ◽  
The Impact

AbstractThe pulmonary artery catheter (PAC) is an invasive hemodynamic monitoring device that is used extensively in critical care units. This technological advance allows the critical care physician and nurse to closely monitor physiological functions at the bedside. There have been no formal evaluations of the impact of this device on patient care. Reviews and observational studies have yielded different conclusions regarding risks and benefits to patients. This has resulted in much editorial comment expressing divergent opinions on the value of the PAC, but there has been no scientific evidence to guide practice and no apparent effect on the use of these devices. The PAC and other medical monitoring devices must be evaluated with respect to their impact on patient care.

scholarly journals Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians

CJEM ◽  
2015 ◽  
Vol 17 (2) ◽  
pp. 123-130 ◽  
Author(s):  
Cheryl Hunchak ◽  
David Tannenbaum ◽  
Michael Roberts ◽  
Thrushar Shah ◽  
Predrag Tisma ◽  
...  
Keyword(s):  
Emergency Department ◽  
Patient Care ◽  
Family Physician ◽  
Family Physicians ◽  
Communication Tool ◽  
Web Based ◽  
Absolute Increase ◽  
Baseline Rate ◽  
Ed Visits ◽  
The Impact

AbstractObjective: Postdischarge emergency department (ED) communication with family physicians is often suboptimal and negatively impacts patient care. We designed and piloted an online notification system that electronically alerts family physicians of patient ED visits and provides access to visitspecific laboratory and diagnostic information.Methods: Nine (of 10 invited) high-referring family physicians participated in this single ED pilot. A prepilot chart audit (30 patients from each family physician) determined the baseline rate of paper-based record transmission. A webbased communication portal was designed and piloted by the nine family physicians over 1 year. Participants provided usability feedback via focus groups and written surveys.Results: Review of 270 patient charts in the prepilot phase revealed a 13% baseline rate of handwritten chart and a 44% rate of any information transfer between the ED and family physician offices following discharge. During the pilot, participant family physicians accrued 880 patient visits. Seven and two family physicians accessed online records for 74% and 12% of visits, respectively, an overall 60.7% of visits, corresponding to an overall absolute increase in receipt of patient ED visit information of 17%. The postpilot survey found that 100% of family physicians reported that they were ‘‘often’’ or ‘‘always’’ aware of patient ED visits, used the portal ‘‘always’’ or ‘‘regularly’’ to access patients’ health records online, and felt that the web portal contributed to improved actual and perceived continuity of patient care.Conclusion: Introduction of a web-based ED visit communication tool improved ED–family physician communication. The impact of this system on improved continuity of care, timeliness of follow-up, and reduced duplication of investigations and referrals requires additional study.

scholarly journals Characteristics of patients presenting, and not presenting, to the emergency department during the early days of COVID-19

2020 ◽  
Author(s):  
Bjorn C. Westgard ◽  
Matthew W. Morgan ◽  
Gabriela Vazquez-Benitez ◽  
Lauren O. Erickson ◽  
Michael D. Zwank
Keyword(s):  
Initial Step ◽  
Patient Characteristics ◽  
Substantial Effect ◽  
The State ◽  
Care Seeking ◽  
Demographic Groups ◽  
Number Of Patients ◽  
Before And After ◽  
Ed Visits ◽  
The Impact

AbstractObjectiveSocietal responses to the COVID-19 pandemic have had a substantial effect upon the number of patients seeking healthcare. An initial step in estimating the impact of these changes is characterizing the patients, visits, and diagnoses for whom care is being delayed or deferred.MethodsWe conducted an observational study, examining demographics and diagnoses for all patient visits to the ED of an urban Level-1 trauma center before and after the state declaration and compared them to visits from a similar period in 2019. We estimated the ratios of the before and after periods using Poisson regression, calculated the percent change with respect to 2019 for total ED visits, patient characteristics, and diagnoses, and then evaluated the interactions between each factor and the overall change in ED visits.ResultsThere was a significant 35.2% drop in overall ED visits after the state declaration. Disproportionate declines were seen in visits by pediatric and older patients, women, and Medicare recipients as well as for presentations of syncope, cerebrovascular accidents, urolithiasis, abdominal and back pain. Significantly disproportionate increases were seen in ED visits for potential symptoms of COVID-19, including URIs, shortness of breath, and chest pain.ConclusionsPatient concerns about health care settings and public health have significantly altered care-seeking during the COVID-19 pandemic. Overall and differential declines in ED visits for certain demographic groups and disease processes should prompt efforts to encourage care-seeking and research to monitor for the morbidity and mortality that is likely to result from delayed or deferred care.

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