“Not So Fast!” The Complexity of Attempting to Decrease Door-to-Floor Time for Emergency Department Admissions

Quinn, Gene R.; Le, Elizabeth; Soni, Krishan; Berger, Gabrielle N.; Mak, Y. Erica; Pierce, Read

doi:10.1016/s1553-7250(14)40004-7

Cited by 6 publications

(5 citation statements)

References 17 publications

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“…Furthermore, absence of feedback on clinical performance and patient outcomes, and an inability to unite staff behind a common goal of providing expeditious patient-centred care, all impede smooth patient transfers. [16][17][18][19] However, there are currently no universally agreed criterion measures of patient flow through EDs, despite the existence of 71 different indices. 20 Most hospitals use traditional proxy measures of ED flow, such as hospital bed occupancy (midnight occupancy as measured by bed census, a measure of ED exit block) matched against ED demand (numbers of ED attendances over the previous 24 h).…”

Section: How To Measure Overcrowding In the Ed And Its Contributory Cmentioning

confidence: 99%

Deconstructing the 4-h rule for access to emergency care and putting patients first

Scott¹,

Sullivan²,

Staib³

et al. 2018

Aust. Health Review

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Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED-in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED-in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care.

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Section: How To Measure Overcrowding In the Ed And Its Contributory Cmentioning

confidence: 99%

Deconstructing the 4-h rule for access to emergency care and putting patients first

Scott¹,

Sullivan²,

Staib³

et al. 2018

Aust. Health Review

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show abstract

“…A patient is subject to the EDii from the ED decision to admit until they are under the care of the inpatient team and located in their destination ward. The EDii involves the transition between ED and inpatient care and has been identified as a period when errors in communication and confused accountability may lead to missed care or clinical errors . In addition, the EDii is physically indistinct as patients at the interface may often be located in transitory spaces such as corridors or waiting areas that may be less well serviced with clinical equipment and facilities …”

Section: Introductionmentioning

confidence: 99%

“…Inpatient teams may be understandably disengaged from ED time pressures and place greater emphasis on comprehensive formulation of a definitive diagnosis and management plan. These differing goals can create tension across the EDii and distract from patient care …”

Section: Introductionmentioning

confidence: 99%

“…Partial definitions of the EDii have been published as listed in Table . Most of these definitions have transit or handover as their core principles and do not fully encapsulate the process of emergency admission to hospital as an example of a complex adaptive system . The term ‘ED–inpatient interface’ (EDii) attempts to take account of the inherent complexity of the system.…”

Section: Introductionmentioning

confidence: 99%

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Uniting emergency and inpatient clinicians across the ED–inpatient interface: The last frontier?

Staib

Sullivan

Prins

et al. 2017

Emerg Medicine Australasia

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Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes.

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“…The ED-ACE being implemented and evaluated in this study is paper-based. STS also allows us to explore the team level interactions and the trust between team members as this is essential to ED functioning [37]. Finally, STS analysis allows us to focus on the process at the level at which it is relevant to the proposed implementation of ED-ACE.…”

Section: Introductionmentioning

confidence: 99%

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach

Ward

McAuliffe

Wakai

et al. 2017

BMC Health Serv Res

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BackgroundEarly detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED).MethodsA novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of ‘Plan Do Study Act’ (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed.DiscussionOver 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

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“Not So Fast!” The Complexity of Attempting to Decrease Door-to-Floor Time for Emergency Department Admissions

Cited by 6 publications

References 17 publications

Deconstructing the 4-h rule for access to emergency care and putting patients first

Deconstructing the 4-h rule for access to emergency care and putting patients first

Uniting emergency and inpatient clinicians across the ED–inpatient interface: The last frontier?

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach

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