The Opportunity Loss of Boarding Admitted Patients in the Emergency Department

Falvo, Thomas; Grove, Lance; Stachura, Ruth; Vega, David; Stike, Rose; Schlenker, Melissa; Zirkin, William

doi:10.1111/j.1553-2712.2007.tb02017.x

Cited by 66 publications

(30 citation statements)

References 38 publications

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“…3 Downstream effects include ED crowding and compromised capability to provide quality and timely care to other patients. 13,21 …”

Section: Discussionmentioning

confidence: 99%

“…“Boarding time” in the ED was defined as the timebetween when the ED physician noted the decision to admit the patient (bed control had called the admitting team) and the time of the patient’s departure from the ED. While some ED literature suggests that a two hour delay has negative clinical implications 13 , based on critical care clinical experience, boarding time was dichotomized at 4 hours. For each ICU admission from the ED, we computed whether the ED boarding time exceeded four hours.…”

Section: Methodsmentioning

confidence: 99%

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The Opportunity Cost of Futile Treatment in the ICU*

Huynh

Kleerup

Raj

et al. 2014

Critical Care Medicine

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Objective When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered “futile.” While futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided. Design For 3 months, we surveyed critical care physicians in 5 intensive care units (ICUs) to identify patients that clinicians identified as receiving futile treatment. We identified days when an ICU was full and containedat least one patient who was receiving futile treatment. For those days, we evaluated the number of patients waiting for ICU admission more than 4 hours in the emergency department (ED) or more than 1 day at an outside hospital. Setting One health system that included a quaternary care medical center and an affiliated community hospital. Patients Critically ill patients Interventions none Measurements Boarding time in the ED and waiting time on the transfer list Main Results 36 critical care specialists made 6916 assessments on 1136 patients of whom 123 were assessed to receive futile treatment. A full ICU was less likely to contain a patient receiving futile treatment compared to an ICU with available beds (38% v 68%, p<0.001). On 72 (16%) days, an ICU was full and contained at least one patient receiving futile treatment. During these days, 33 patients boarded in the ED for >4 hours after admitted to the ICU team, 9patients waited >1 day to be transferred from an outside hospital, and 15 patients cancelled the transfer request after waiting >1 day. Two patients died while waiting to be transferred. Conclusions Futile critical care was associated with delays in care to other patients.

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“…3 Downstream effects include ED crowding and compromised capability to provide quality and timely care to other patients. 13,21 …”

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

The Opportunity Cost of Futile Treatment in the ICU*

Huynh

Kleerup

Raj

et al. 2014

Critical Care Medicine

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“…The ability to safely discharge patients following a single troponin below the LOD may shorten ED length of stay for these patients, ease overall ED crowding, and save costs for hospitals. 20,21 In our dataset, 17% (148/888; 95% CI 14–19%) of patients with a low-risk HEART score and initial troponin below the LOD were discharged from the ED, suggesting that 17% of our ED population that currently undergoes evaluation with serial troponin testing might be safely discharged after a single troponin.…”

Section: Discussionmentioning

confidence: 84%

Troponin Limit of Detection Plus Cardiac Risk Stratification Scores to Rule Out Acute Myocardial Infarction and 30-Day Major Adverse Cardiac Events in ED Patients

Datlow

Gray

Watts

et al. 2017

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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When screening for acute myocardial infarction (AMI), troponin levels below the 99th percentile, including those below the limit of detection (LOD), are considered normal. We hypothesized that a low-risk HEART Score (0–3) or ACS Pretest Probability Assessment <2% plus a single troponin below the LOD would rule out both AMI and 30-day major adverse cardiac events (MACE). We studied all patients who presented to a single academic ED and received a troponin I (Siemens Ultra Troponin I) from 9/1/13 to 11/13/13 (n=888). Demographic and clinical data were abstracted from the electronic medical record. Primary outcome was a final encounter diagnosis of MI. Secondary outcome was 30-day MACE, defined as composite of MI, revascularization, or death from a cardiac or uncertain etiology. Sensitivities of low-risk HEART score and ACS Pretest Probability <2% alone were 98% (95%CI 89–100%) and 96% (95%CI 86–100%) for AMI and 94% (95%CI 86–98%) and 95% (95%CI 88–99%), respectively, for 30-day MACE. When combined with troponin below the LOD, sensitivity for AMI was 100% (95%CI 93–100%; difference 2%, 95%CI −2% to 6%) for low-risk HEART Score and 100% (95%CI 93–100%; difference 4%, 95% CI −1.5 to 10%) for ACS Pretest Probability <2%. When combined with troponin below the LOD, sensitivity for 30-day MACE was 100% (95%CI 95–100%; difference 6%; 95%CI 1–12%) for low-risk HEART Score and 100% (95%CI 95–100%; difference 5%; 95%CI 0.2–10%) for ACS Pretest Probability <2%. Addition of a single troponin below the LOD to these scores improves sensitivity for 30-day MACE.

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“…Occupying ED staff in the provision of care to admitted patients for prolonged periods compromises their ability to deliver emergency care 1 7 9–12. Sprivulis et al have shown that hospital and ED overcrowding is associated with a 30% increase in mortality by Day 2 and Day 7 for patients requiring admission via the ED to an inpatient bed 15.…”

Section: The Problem With Overcrowdingmentioning

confidence: 99%