Pharmacy-based medication reconciliation leads to a substantial reduction in medication discrepancies in acutely admitted elderly adults.

BackgroundIn The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding.MethodsA survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow.ResultsSurveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners.ConclusionsDespite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.

BackgroundOvercrowding in the emergency department (ED) is an increasing problem worldwide. In The Netherlands overcrowding is not a major issue, although some urban hospitals struggle with increased throughput. In 2004, Weiss et al. created the NEDOCS tool (National Emergency Department Over Crowding Study), a web-based instrument to measure objective overcrowding with scores between 0 (not busy at all) to above 181 (disaster). In this study we tried to validate the accuracy of the NEDOCS tool by comparing this with the subjective feelings of the ED nurse and emergency physician (EP) in an inner city hospital in The Netherlands.MethodsIn a 4-week period, data of a total of 147 time samplings were collected. The subjective feelings of being overcrowded and feeling rushed by the ED nurse and EP were scored on a survey using a 6-point Likert scale on answering the question of how busy they would say the ED is right now. NEDOCS tool scores were calculated, and these were compared with the subjective feelings using the kappa statistic assessing linear weights according to Cohen’s method.ResultsOf all the time samplings, approximately 80% of the surveys were completed. The ED was rated as overcrowded 9% of the time by the ED nurses and 11% of the time by the EPs. The median NEDOCS score was 37 (0 to 120) and scored as overcrowded in 3%. There was a good intrarater agreement for the ED nurse and EP for the feeling of overcrowding and feeling of being rushed (κ = 0.79 and 0.73, respectively); the interrater agreement was moderate (κ = 0.53 and 0.43, respectively). The agreement between the NEDOCS and the subjective variables was moderate (κ = 0.50 and 0.53, respectively). A composite variable was created as the average of both the scores of feeling overcrowded of the nurse and the EP and the score of the EP of feeling rushed. The agreement between this and the NEDOCS was κ = 0.53.ConclusionsThe NEDOCS tool is a reasonably good tool to quantify the subjective feelings of overcrowding. When overcrowding is encountered and immediately recognised, specific measures can be taken to guarantee the timely provision of necessary medical care to the patients in the ED at that time. However, possibly more accurate agreements could be obtained as approximately 20% of the surveys were not completed because of perceived crowdedness. An important limitation is that only 3% of the NEDOCS is scored as overcrowded, so no conclusions can be drawn about the agreement for higher categories of overcrowding. It is suggested to repeat the study in a busier period. As the triage category was not taken into account in the formula, a high workload with only a few patients giving high scores in subjective overcrowding in spite of a low NEDOCS score could have led to lower agreements. Incorporating the triage category in the NEDOCS tool possibly will lead to better agreement, but further research is needed to assess this idea.

PurposeEmergency care delivery is a process requiring input from various healthcare professionals within the hospital. To deliver efficient and effective emergency care, professionals must integrate rapidly at multiple interfaces, working across functional, spatial and professional boundaries. Yet, the interdisciplinary nature of emergency care presents a challenge to the optimization of patient flow, as specialization and functional differentiation restrict integration efforts. This study aims to question what boundaries exist at the level of professionals and explores how these boundaries may come to influence integration and operational performance.Design/methodology/approachTo provide a more holistic understanding of the inherent challenges to integration at the level of professionals and in contexts where professionals play a key role in determining operational performance, the authors carried out an in-depth case study at a busy, Level 1 trauma center in The Netherlands. In total, 28 interviews were conducted over an 18-month period.FindingsThe authors reveal the existence of structural, relational and cultural barriers between (medical) professionals from different disciplines. The study findings demonstrate how relational and cultural boundaries between professionals interrupt flows and delay service processes.Originality/valueThis study highlights the importance of interpersonal and cultural dynamics for internal integration and operational performance in emergency care processes. The authors unveil how the presence of professional boundaries creates opportunity for conflict and delays at important interfaces within the emergency care process, and can ultimately accumulate, disrupting patient flow and increasing lead times.

Emergency departments (ED) worldwide have experienced dramatic increases in crowding over the past 20 years that now have reached critical levels. One consequence of ED crowding has been the routine use of ED hallways for patient care. This includes ED patients who are awaiting care but are considered unstable to remain in the waiting room, patients who are undergoing active medical and trauma treatment, and patients who have been stabilized but await transfer to an inpatient bed (boarding) or another institution. Compared with licensed hospital or standard ED beds, care in ED hallways results in increased patient morbidity and mortality, as well as patient and staff dissatisfaction. Complications experienced by hallway patients include unrecognized sudden respiratory arrest or unstable cardiac arrhythmias, delay in time-sensitive procedures and laboratory testing, delay in receiving important medications, excessive or unrelieved pain, overall increased length of stay, increased disability, and exposure to traumatic psychological events. While much has been published on the general problems of ED crowding, only recently have studies focused exclusively on the issues of providing care in ED hallways. This review summarizes the current issues, challenges, and solutions for hallway care.