Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine: a health records review

Charbonneau, Valerie; Kwok, Edmund; Boyle, Loree; Stiell, Ian G.

doi:10.1136/emermed-2017-207149

Cited by 4 publications

(6 citation statements)

References 20 publications

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“…This result suggests that, while the system is undergoing strain, priority is appropriately provided to those who are the sickest through the triage process. This finding corroborates results from a previous Canadian study that showed ED surge levels did not impact the extent of investigations and treatments provided for ED patients with COPD who required referral to internal medicine [11]. The low acuity group was most prominently impacted by crowding as increased in the metrics of time to physician initial assessment and length of stay resulted in the highest increases in individual time to physician initial assessment and length of stay for this group.…”

Section: Previous Literaturesupporting

confidence: 88%

“…Respiratory conditions, such as pneumonia [7], asthma [8,9], and chronic obstructive pulmonary disease (COPD) [10], are common ED presentations and these patients are especially vulnerable to crowding-related delays in treatment [11]. Exacerbations of these respiratory conditions are often severe enough to require hospitalization [12], and can lead to adverse outcomes including cardiac complications, pneumothorax, intubation, and death [13].…”

Section: Introductionmentioning

confidence: 99%

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Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

et al. 2023

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Objectives Emergency department (ED) crowding leads to poor outcomes. Patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) are especially vulnerable to crowding-related delays in care. We aimed to assess the associations of ED crowding metrics with outcomes for patients presenting with COPD. Methods We conducted a population-based cohort study of adult patients presenting with a diagnosis of COPD to 18 highvolume EDs between 2014 and 2019 in Alberta, Canada. Administrative databases provided date and time data on key stages of the presentation including physician initial assessment and disposition decision. Crowding metrics were calculated using facility-specific median physician initial assessment and length of stay. Patient presentations were grouped by acuity and mixed-effects regression models were fit to adjust for the clustering at the facility level. Results There were 49,085 presentations for COPD made by 25,734 patients (median age = 73 years). A 1-h increase in the physician initial assessment metric was associated with an increase in physician initial assessment for COPD patients by 23, 53, and 59 min for the high, moderate, and low acuity groups, respectively, adjusted for other predictors. For the low acuity group, this metric was associated with an increased length of stay of 73 min for admitted individuals. Similarly, an increase in the length of stay metric was also associated with an increased likelihood of being admitted for all acuity groups. Conclusions For patients with COPD, ED crowding results in delays in assessment increased length of stay, and increased proportion of patients admitted. These results suggest that ED crowding mitigation efforts to provide timely care for patients with COPD are urgently needed. Trial registration N/A. Keywords Administrative health data • Chronic obstructive pulmonary disease • Crowding metrics • Emergency department RésuméObjectifs L'encombrement des services d'urgence entraîne de mauvais résultats. Les patients souffrant de maladies respiratoires telles que la maladie pulmonaire obstructive chronique (MPOC) sont particulièrement vulnérables aux retards de soins liés à l'encombrement. Notre avons cherché à évaluer les associations entre les paramètres d'encombrement des services d'urgence et les résultats pour les patients présentant une MPOC. Méthodes Nous avons mené une étude de cohorte basée sur la population de patients adultes se présentant avec un diagnostic de MPOC dans dix-huit services d'urgence à haut volume entre 2014 et 2019 en Alberta, au Canada. Les bases de données administratives ont fourni des données sur la date et l'heure des principales étapes de la présentation, y compris l'évaluation

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Section: Previous Literaturesupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

et al. 2023

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“…Other studies ascribed inefficiencies within the handover process itself as the main driving force for conflict 25–27 . The focus of three other articles was conflict arising from ED crowding (i.e., excessive patient volume overwhelming ED capacity) and high workload 28–30 . Conflict is also portrayed as a contributing factor to occupational burnout and stress 31,32 .…”

Section: Resultsmentioning

confidence: 99%

“…[25][26][27] The focus of three other articles was conflict arising from ED crowding (i.e., excessive patient volume overwhelming ED capacity) and high workload. [28][29][30] Conflict is also portrayed as a contributing factor to occupational burnout and stress. 31,32 Avelino-Silva and Steinman 33 presented conflict as diagnostic discrepancy, i.e., disparities between initial ED diagnoses on admission and final diagnoses on discharge.…”

Section: What Constitutes Conflict In the Ed?mentioning

confidence: 99%

Conflict in emergency medicine: A systematic review

Tjan,

Wong,

Rixon

2024

Academic Emergency Medicine

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BackgroundThe emergency department (ED) is a demanding and time‐pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual‐, team‐, and systemic‐level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research.MethodsOnline databases PubMed and Web of Science were systematically searched for relevant peer‐reviewed journal articles in English with keywords relating to “conflict” and “emergency department,” yielding a total of 29 articles.ResultsNarrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual‐level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team‐level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems‐level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships.ConclusionsIn emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.

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“… 16 According to Charbonneau et al, there was no evidence to suggest that the levels of ED crowding and the timing at the end of a shift had any impact on the decision-making of EPs regarding the ordering of investigations or the provision of treatment to patients. 17 , 18 …”

Section: Discussionmentioning

confidence: 99%

Impact of Fatigue on Emergency Physicians’ Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Centre of the Sultanate of Oman

Hazra,

Al-Arimi,

Al-Alawi

2023

Indian Journal of Critical Care Medicine

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A bstract Objective Multiple factors contribute to decision fatigue experienced by emergency physicians (EPs). This study examines the association between decision fatigue and the frequency of computed tomographic (CT) scan requests and inpatient referrals among EPs. Methods This retrospective database analysis was done for 3 months. Scans and inpatient referral requests were coded and analyzed to assess the impact of physician fatigue on decision-making. Subsequently, the outcomes were evaluated. Results The majority of patients ( n = 481; 51.1%) had a CT brain request. Among these requests, the morning shift (8:00 a.m.–3:00 p.m.) accounted for the highest number ( n = 400; 42.5%), followed by the evening shift (3:00–11:00 p.m.) ( n = 345; 36.7%). Approximately one-third of the patients ( n = 301; 31.9%) had positive CT scan findings. Statistical analysis comparing the first and the second halves of each shift did not reveal significant variations in the percentage of negative CT results ( p -value: 0.093). Inpatient referral was necessary for over half of the patients ( n = 1,048; 52.7%), and the majority of these referrals ( n = 778; 74.2%) were deemed necessary for treatment under various surgical or medical specialties. There was a statistically significant difference in the proportion of negative inpatient referrals between the first and the second halves of the afternoon shift ( p -value < 0.001). Conclusions Fatigue among EPs was observed, leading to more frequent consultations without inpatient admission during the latter half of the afternoon shift. However, the study found no significant impact of decision fatigue on CT scan decision-making. How to cite this article Al-Arimi AH, Hazra D, Al-Alawi AKA. Impact of Fatigue on Emergency Physicians’ Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman. Indian J Crit Care Med 2023;27(9):620–624.

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Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine: a health records review

Abstract: We found no evidence that surge levels and end of shift impact the extent of investigations and treatments provided to patients diagnosed in the ED with heart failure, COPD or sepsis and referred to internal medicine.

Cited by 4 publications

References 20 publications

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

Conflict in emergency medicine: A systematic review

Impact of Fatigue on Emergency Physicians’ Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Centre of the Sultanate of Oman

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