scholarly journals MP23: A collaborative quality improvement initiative to improve the time to electrocardiogram in patients with chest pain presenting to the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S48-S49
Author(s):  
H. C. Lindsay ◽  
J. Gallaher ◽  
C. Wright ◽  
L. Korchinski ◽  
C. Kim Sing
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Data Extraction ◽  
Physical Space ◽  
Extraction Process ◽  
Vancouver General Hospital ◽  
Adverse Outcomes ◽  
Quality Improvement Initiative ◽  
Target Time ◽  
Risk Of Death

Introduction: For patients with chest pain, the target time from first medical contact to obtaining an electrocardiogram (ECG) is 10 minutes, as reperfusion within 120 minutes can reduce the risk of death and adverse outcomes in patients with ST elevation myocardial infarction (STEMI). In 2007, Vancouver Coastal Health (VCH) began tracking key indicators including time to first ECG. The Vancouver General Hospital (VGH) Emergency Department (ED) has been troubled with the longest door to ECG times in the region since 2014. In 2016, the VGH ED Quality Council developed a strategy to address this issue, with an aim of obtaining ECGs on 95% of patients presenting to the VGH ED with active chest pain within 10 minutes of presentation within a 6 month period. Methods: The VGH ED Quality Council brought together frontline clinicians, ECG technicians, and other stakeholders and completed a process map. We obtained baseline data regarding the median time to ECG in both patients with STEMI and all patients presenting with chest pain. Root cause analysis determined two main barriers: access to designated space to obtain ECGs, and the need for patients to be registered in the computer system before an ECG could be ordered. The team identified strategies to eliminate these barriers, identifying a dedicated space and undergoing multiple PDSA cycles to change the workflow to stream patients to this space before registration. Results: Our median times in patients with STEMI have gone from 33 minutes to 8 minutes as of June 2017. In all patients presenting with chest pain, we improved from a median of 36 to 17 minutes. As of April 2017 we are obtaining an ECG within 10 minutes in 27% of our patients, compared to 3% in 2016. Given the limitations in our data extraction process, we were not able to differentiate between patients with active chest pain versus those whose chest pain had resolved. Conclusion: By involving frontline staff, and having frontline champions providing real time support, we were able to make significant changes to the culture at triage. We cultivated sustainability by changing the workflow and physical space, and not relying on education only. While we have improved the times for our walk-in patients, we have not perfected the process when a patient moves immediately to a bed or presents via ambulance. Implementing small changes and incorporating feedback has allowed us to identify these new challenges early.

scholarly journals The impact of the Emergency Department target upon the discharge decision for people who self-harm

2019 ◽  
Vol 19 (2) ◽  
pp. 89-97
Author(s):  
Michael Brian Haslam ◽  
Emma S. Jones
Keyword(s):  
Mental Health ◽  
Emergency Department ◽  
Wait Time ◽  
Adverse Outcomes ◽  
Patient Journey ◽  
Content Type ◽  
Target Time ◽  
Starting Point ◽  
Self Harm ◽  
The Impact

Purpose The purpose of this paper is to consider the influence of the Emergency Department (ED) target wait time upon the discharge decision in ED, specifically for patients who have self-harmed. Pressures to discharge patients to avoid breaching the 4-h target wait time, potentially increase the risk of adverse responses from clinicians. For the patient who has self-harmed, such interactions may be experienced as invalidating and may result in adverse outcomes. Design/methodology/approach Secondary data analysis was applied to the retrospective referral data of a Mental Health Liaison Team (MHLT), collected over a period of 11 months from a single hospital in the North of England. In total, 734 episodes of care were referred to the team from ED, where the primary presentation was recorded as self-harm. Findings Over half of patients referred to the MHLT from ED having self-harmed were seen after already breaching the target and the potential for a more restrictive outcome reduced. Of those patients seen within 4 h, the potential for a more restrictive treatment option was increased. Practical implications Recommendations to improve the patient journey for those who have self-harmed include mental health triage and treatment in clinical areas outside of the target. Social implications This study challenges the concept of the target as being realistic and attainable for patients who have self-harmed. Originality/value This exploratory study provides a starting point from which to explore the impact of the target time upon discharge decisions and clinical outcomes specifically for those who have self-harmed.

The utility of copeptin in the emergency department as a predictor of adverse outcomes in non-ST-elevation acute coronary syndrome: the COPED-PAO study

2013 ◽  
Vol 31 (4) ◽  
pp. 286-291 ◽  
Author(s):  
Miquel Sánchez ◽  
Pere Llorens ◽  
Pablo Herrero ◽  
F Javier Martín-Sanchez ◽  
Pascual Piñera ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Adverse Events ◽  
Adverse Outcomes ◽  
Troponin Level ◽  
Prognostic Information ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
St Elevation ◽  
Elevation Acute Coronary Syndrome

AimsTo test the utility of a single copeptin determination at presentation to the emergency department (ED) as a short-term prognosis marker in patients with non-ST-elevation acute coronary syndrome (NSTEACS). To compare the results with those achieved with conventional troponin.MethodsA multicentric, prospective, observational, longitudinal, cohort study involving 15 Spanish EDs. Inclusion: consecutive patients with chest pain (<12 h) finally diagnosed of NSTEACS. Measurements: copeptin and troponin at arrival. Cut-off point for copeptin: 25.9 pmol/l. Follow-up: within 2 months after ED attendance to identify 30-day adverse events. Discriminatory capacity of copeptin and troponin was compared by receiver operating characteristic (ROC) curves.ResultsWe included 377 patients with NSTEACS. Adverse events: 11 (2.9%) patients died, 27 (7.2%) had an adverse coronary event, 14 (3.7%) had a stroke, and 48 (12.7%) a composite endpoint. The initial copeptine value was over 25.9 pmol/l in 114 patients, and they presented a higher mortality rate (OR: 4.2, (95% CI 1.2 to 14.8); p=0.03). This association disappeared after adjusting by clinical variables or troponin level. No significant differences were found for the remaining endpoints. The area under the curve  of the ROC curve of 30-day mortality was 0.73 (95% CI 0.58 to 0.87) for copeptin, and 0.80 (95% CI 0.73 to 0.87) for troponin.ConclusionsIn patients with NSTEACS, determination of copeptin at presentation to the ED is associated with risk of death during the subsequent month. This association, however, disappears after adjusting by baseline features or troponin level, so copeptin does not add complementary prognostic information over that provided by troponin.

scholarly journals Recommendations and practices for holistic chronic obstructive pulmonary disease (COPD) assessment and optimal referral patterns in emergency department presentations: a scoping review protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e030358 ◽  
Author(s):  
Clint Moloney ◽  
Emily Sneath ◽  
Tania Phillips ◽  
Hancy Issac ◽  
Gavin Beccaria ◽  
...  
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Emergency Department ◽  
Pulmonary Disease ◽  
Scoping Review ◽  
Data Extraction ◽  
Extraction Process ◽  
Current Evidence ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Holistic Management

IntroductionChronic obstructive pulmonary disease (COPD) is a common respiratory condition that causes persistent respiratory symptoms and decline in lung function over many years. This chronic disease significantly affects health-related quality of life and is known to contribute to frequent emergency department (ED) presentations. Multidimensional management of these patients, including interconnecting health disciplinarians will allow holistic care provision in the ED. The purpose of this scoping review is to synthesise current evidence on holistic management and assessment, and referral practices stemming from acute COPD presentation in the ED. Specifically, to determine: (1) What are the known causal factors associated with COPD ED presentations and (2) Is there an identified connection with appropriate healthcare professional assessment within ED presentations and reported referral pathways?Methods and analysisThe iterative stages of the Arskey and O’Malley, and Levac advanced scoping review framework informs this review. Using published and unpublished studies in English, a three-tiered search strategy will be applied. After duplicates are removed, screen 1 (title and abstract) and screen 2 (full-text) will be conducted by two independent reviewers to determine eligibility of articles. Disputes will be settled through discussion or by using a third reviewer. A data collection tool developed by the authors will inform the data extraction process. Schematic tabular format of results with a narrative summary will depict how the results link with the scoping review objectives. Categorisation of results will be narrowed down as key conceptual findings and will align with the strategic intent of this review.Ethics and disseminationEthics approval was not required for this study. A multidisciplinary team of authors will participate in dissemination activities (publications, reports, conference presentations, framework development).

Abstract P117: Frailty and Outcomes among Heart Failure Patients in the Community

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Sheila M McNallan ◽  
Shannon M Dunlay ◽  
Mandeep Singh ◽  
Alanna M Chamberlain ◽  
Margaret M Redfield ◽  
...  
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Adverse Outcomes ◽  
Emergency Department Visits ◽  
Physical Component Score ◽  
Risk Of Death ◽  
Increased Risk ◽  
Ed Visits

Objective: To determine among community heart failure (HF) patients whether frailty is associated with an increased risk of hospitalization, emergency department (ED) visits and death, independently of comorbidities. Background: Frailty is associated with adverse outcomes in some populations; however the prognostic value of frailty among HF patients is not fully documented, particularly for healthcare utilization. Methods: Olmsted, Dodge and Fillmore County residents with HF between 10/2007 and 12/2010 were prospectively recruited to undergo frailty assessment. Frailty was defined as 3 or more of the following: unintentional weight loss >10 lbs. in 1 year, physical exhaustion, weak grip strength, and slowness and low activity measured by the SF-12 physical component score. Intermediate frailty was defined as having 1-2 components. To account for repeated events, Anderson-Gill modeling was used to determine if frailty predicted hospitalization or ED visits. Cox proportional hazards regression examined associations between frailty and death. Results: Among 409 patients (mean age 73±13, 58% male), 19% were frail and 55% had intermediate frailty. Within one year, 449 hospitalizations, 523 ED visits and 34 deaths occurred. There was a positive graded association between frailty and hospitalization and ED visits (Table). After adjustment for age, sex, ejection fraction and comorbidity, frailty was associated with an 80% increased risk of hospitalization and a 60% increased risk of ED visits. Frailty was also associated with more than a 2-fold increased risk of death after adjustment. Conclusion: In the community, frailty is prevalent and is a strong and independent predictor of hospitalizations, ED visits and death among HF patients. As it is independent from coexisting comorbidities, frailty defines new avenues for intervention and should be formally assessed clinically. Hazard Ratios (95% CI) for Hospitalizations, Emergency Department Visits and Death by Frailty Status Not Frail Intermediate Frail Frail P for trend Hospitalization Crude 1.00 1.46 (1.05-2.02) 2.15 (1.45-3.19) <0.001 Fully-adjusted 1.00 1.29 (0.94-1.77) 1.82 (1.22-2.73) 0.005 Emergency Department Visits Crude 1.00 1.59 (1.14-2.21) 1.88 (1.22-2.90) 0.002 Fully-adjusted 1.00 1.46 (1.05-2.05) 1.58 (1.01-2.48) 0.034 Death Crude 1.00 1.40 (0.73-2.69) 3.98 (2.01-7.90) <0.001 Fully-adjusted 1.00 0.87 (0.44-1.73) 2.42 (1.19-4.95) 0.003

scholarly journals Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

CJEM ◽  
2015 ◽  
Vol 17 (3) ◽  
pp. 253-262 ◽  
Author(s):  
Michael Schull ◽  
Marian Vermeulen ◽  
Astrid Guttmann ◽  
Therese Stukel
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Length Of Stay ◽  
Population Based ◽  
Adverse Outcomes ◽  
Relative Reduction ◽  
Patient Acuity ◽  
Risk Of Death ◽  
High Acuity ◽  
Reduced Risk

AbstractIntroductionEmergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.MethodsA retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.ResultsFrom 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.ConclusionsBetter performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.

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