Objectives Overcapacity issues plague emergency departments (EDs). Studies suggest triage liaison providers (TLPs) may shorten patient length of stay (LOS) and reduce the proportion of patients who leave without being seen (LWBS), but these results are not universal. Previous studies used physicians as TLPs. We evaluated whether a physician assistant (PA), acting as a TLP, would shorten LOS and decrease LWBS rates. Methods The authors used an observational cohort controlled before-and-after study design with predefined outcome measures, comparing eight pilot days to eight control days. The TLP evaluated all Emergency Severity Index (ESI) level 3, 4, and 5 patients, excluding pediatric and behavioral health patients. Results Three hundred fifty-three patients were included on pilot days, and 371 on control days. LOS was shorter on pilot days than control days (median 229 minutes [IQR 168 to 303 minutes] vs. 270 minutes [IQR 187 to 372 minutes], p < 0.001). Waiting room times were similar between pilot and control days (median 69 minutes [IQR 20 to 119 minutes] vs. 70 minutes [IQR 19 to 137 minutes], p = 0.408), but treatment room times were shorter (median 151 minutes [IQR 92 to 223 minutes] vs. 187 minutes [IQR 110 to 254 minutes], p < 0.001). Finally, a lower proportion of patients LWBS on pilot days (1.4% vs. 9.7%, p < 0.001). Conclusions The addition of a PA as a TLP was associated with a 41 minute decrease in median total LOS, and a lower proportion of patients who LWBS. The decrease in total LOS is likely attributable to the addition of the TLP, with patients having shorter duration in treatment rooms on pilot days compared to control days.

Background Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. Objective To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine auto-injectors and to measure the effect on anaphylaxis guideline adherence. Methods A cohort study was conducted from April 29, 2008-August 9, 2012. Adult ED patients diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up and incidence of biphasic reactions were evaluated. Results The study included 202 patients. Median age of patients was 45.3 years (IQR 31.3 – 56.4); 139 (69%) were female. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs. 33%, OR 2.05, 95%CI 1.04- 4.04) and admitted to ED observation unit (EDOU) (65% vs. 44%, OR 2.38, 95%CI 1.23-4.60) and less likely to be dismissed home directly from ED (16% vs. 29%, OR: 0.47, 95%CI 0.22- 1.00). Eleven patients (5%) had a biphasic reaction. Of these, five (46%) had the biphasic reaction in EDOU; one patient was admitted to intensive care unit (ICU). Six patients (55%) had reactions within 6 hours of initial symptom resolution of whom two were admitted to ICU. Conclusion Significantly greater proportions of anaphylaxis patients received epinephrine and were admitted to EDOU after introduction of epinephrine auto-injectors and order set implementation. Slightly over half of the biphasic reactions occurred within recommended observation time of 4-6 hours. These data suggest that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

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Background-American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) Ͻ90 minutes for nontransferred patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention. Systems of care to achieve and sustain this DTB performance over several years have not been previously reported.

Rationale, aims, and objectives: Waist circumference (WC) and waist-to-height ratio (WHtR) are superior surrogate markers of central obesity than body mass index.However, WC is not measured routinely in paediatric clinics. The objective of this study was to implement measurement of WC during routine assessment of children in an ambulatory outpatient clinic setting and subsequent dissemination of cardiometabolic risk counselling in children with central obesity (defined as WHtR ≥0.5). Method: Prospective cohort of patients aged 6 to 20 years. Study period was divided into three phases: baseline (3 months), process improvement (2 months), and implementation (6 months). Define-Measure-Analyse-Improve-Control (DMAIC) strategy was applied. Measurement of WC was implemented as a component of the physical examination in patients. Outcome measures were (1) improvement in frequency of WC measurement and (2) utilization of WHtR in cardiometabolic risk counselling.Results: Waist circumference was not measured in any patient during baseline phase (n = 551). During process improvement phase, of the total 347 patients, WC was measured in 35% vs target of 30%. In the implementation phase, WC was measured in 37% patients (365 out of 964). Of these 365 patients, 175 (48%) had elevated WHtR, and 73% of them (n = 128) were counselled about their increased cardiometabolic risk. Conclusions:Application of an evidence-based DMAIC protocol led to significant improvement in assessment for central obesity in an ambulatory clinic practice and appropriate counselling regarding cardiometabolic risk reduction in children and adolescents with central obesity over an 8-month period. Meticulous planning and execution, frequent reinforcement, and integrating feedback from the involved multi-disciplinary team were important factors in successful implementation of this quality improvement project.