Adoption of High-sensitivity Troponin Testing and Emergency Physician Ordering Behavior.

Introduction: Emergency departments (ED) are rapidly replacing conventional troponin assays with high-sensitivity troponin tests. We sought to evaluate emergency physician utilization of troponin tests before and after high-sensitivity troponin introduction in our ED.

Methods: We retrospectively examined 9,477 ED encounters, identifying the percentage in which physicians ordered a serum troponin both before and after our institution adopted a high-sensitivity troponin test.

Are Smaller Emergency Departments More Prone to Volume Variability?

Introduction: Daily patient volume in emergency departments (ED) varies considerably between days and sites. Although studies have attempted to define "high-volume" days, no standard definition exists. Furthermore, it is not clear whether the frequency of high-volume days, by any definition, is related to the size of an ED.

Not All Testers are Admitters: An Analysis of Emergency Physician Resource Utilization and Consultation Rates.

Background: Variability exists in emergency physician (EP) resource utilization as measured by ordering practices, rate of consultation, and propensity to admit patients.

Objective: To validate and expand upon previous data showing that resource utilization as measured by EP ordering patterns is positively correlated with admission rates.

Methods: This is a retrospective study of routinely gathered operational data from the ED of an urban academic tertiary care hospital.

Physician Workflow in Two Distinctive Emergency Departments: An Observational Study.

Objectives: We characterize physician workflow in two distinctive emergency departments (ED). Physician practices mediated by electronic health records (EHR) are explored within the context of organizational complexity for the delivery of care.

Methods: Two urban clinical sites, including an academic teaching ED, were selected.

Patient Assignment Models in the Emergency Department.

Early assignment of patients to specific treatment teams improves length of stay, rate of patients leaving without being seen, patient satisfaction, and resident education. Multiple variations of patient assignment systems exist, including provider-in-triage/team triage, fast-tracks/vertical pathways, and rotational patient assignment. The authors discuss the theory behind patient assignment systems and review potential benefits of specific models of patient assignment found in the current literature.

Increased Inpatient Length of Stay After Early Unplanned Transfer to Higher Levels of Care.

Unlabelled: Patients admitted to a medical-surgical unit infrequently require early transfer to higher level care, although how their inpatient length of stay compares to untransferred patients, or those directly admitted to intermediate care, is unknown. We sought to compare the inpatient length of stay of these groups.

Design: Single-site retrospective analysis.

"Rainbow Draws" in the Emergency Department: Clinical Utility and Staff Perceptions.

Background: Collecting a predefined set of blood tubes (the "rainbow draw") is a common but controversial practice in many emergency departments (EDs), with limited data to support it. We determined the actual utilization of rainbow draw tubes at a single facility and evaluated the perceptions of ED staff regarding the utility of rainbow draws.

Methods: We analyzed 2 weeks of ED visits (1326 visits by 1240 unique patients) to determine blood tube utilization for initial and add-on testing, as well as the incidence of additional venipunctures.

Association of Vital Signs and Process Outcomes in Emergency Department Patients.

Introduction: We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients.

Methods: We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed.

Emergency Physicians' Perceived Influence of EHR Use on Clinical Workflow and Performance Metrics.

Objective: Over the last decade, electronic health records (EHRs) have shaped clinical practice. In this article, we investigated the perceived effects of EHR use on clinical workflow and meaningful use (MU) performance metrics.

Materials And Methods: Semistructured interviews were conducted with 20 (= 20) physicians at two urban emergency departments.

Serum Lactate and Mortality in Emergency Department Patients with Cancer.

Introduction: Patients with malignancy represent a particular challenge for the emergency department (ED) given their higher acuity, longer ED length of stay, and higher admission rate. It is unknown if patients with malignancies and hyperlactatemia are at increased risk of mortality. If serum lactic acid could improve detection of at-risk patients with cancer, it would be useful in risk stratification.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices.

Objective: To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician.

Methods: Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate.

Modelling attending physician productivity in the emergency department: a multicentre study.

Objectives: Emergency physician productivity, often defined as new patients evaluated per hour, is essential to planning clinical operations. Prior research in this area considered this a static quantity; however, our group's study of resident physicians demonstrated significant decreases in hourly productivity throughout shifts. We now examine attending physicians' productivity to determine if it is also dynamic.

Interphysician Differences in Emergency Department Length of Stay.

Background: Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS).

Objective: To describe how ED LOS differs among physicians.

The durability of operational improvements with rotational patient assignment.

Introduction: Previous work has suggested that Emergency Department rotational patient assignment (a system in which patients are algorithmically assigned to physicians) is associated with immediate (first-year) improvements in operational metrics. We sought to determine if these improvements persisted over a longer follow-up period.

Methods: Single-site, retrospective analysis focused on years 2-4 post-implementation (follow-up) of a rotational patient assignment system.

Resource Utilization in Emergency Department Patients with Known or Suspected Poisoning.

Introduction: Previous work has shown poisoning-related emergency department (ED) visits are increasing, and these visits are resource-intensive. Little is known, however, about how resource utilization for patients with known or suspected poisoning differs from that of general ED patients.

Methods: We reviewed 4 years of operational data at a single ED.

Emergency Department Holding Orders.

Background: Holding orders help transition admitted emergency department (ED) patients to hospital beds.

Objective: To describe the effect of ED holding orders.

Methods: We conducted a single-site retrospective study of ward admissions from the ED to the hospital internal medicine (HIM) service over 2 years.

Initial Diagnosis and Management of Coma.

Coma represents a true medical emergency. Drug intoxications are a leading cause of coma; however, other metabolic disturbances and traumatic brain injury are also common causes. The general emergency department approach begins with stabilization of airway, breathing, and circulation, followed by a thorough physical examination to generate a limited differential diagnosis that is then refined by focused testing.

Physician in Triage Versus Rotational Patient Assignment.

Background: Physician in triage and rotational patient assignment are different front-end processes that are designed to improve patient flow, but there are little or no data comparing them.

Objective: To compare physician in triage with rotational patient assignment with respect to multiple emergency department (ED) operational metrics.

Methods: Design-Retrospective cohort review.

Emergency Department Rotational Patient Assignment.

Study Objective: We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion).

Methods: This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio.

Risk of Venous Thromboembolism After Receiving Prothrombin Complex Concentrate for Warfarin-associated Intracranial Hemorrhage.

Background: Prothrombin complex concentrates (PCCs) are commonly used to rapidly reverse warfarin-associated coagulopathy; however, venous thromboembolism (VTE) is an established adverse event.

Objective: To determine risk factors for VTE AFTER administration of a three-factor prothrombin complex concentrate (3F-PCC) for warfarin-associated intracranial hemorrhage (ICH).

Methods: Retrospective chart review of all patients with a warfarin-associated ICH who received a 3F-PCC at a single tertiary care hospital between 2008 and 2013.

Emergency department rapid medical assessment: overall effect and mechanistic considerations.

Background: Although the use of a physician and nurse team at triage has been shown to improve emergency department (ED) throughput, the mechanism(s) by which these improvements occur is less clear.

Objectives: 1) To describe the effect of a Rapid Medical Assessment (RMA) team on ED length of stay (LOS) and rate of left without being seen (LWBS); 2) To estimate the effect of RMA on different groups of patients.

Methods: For Objective 1, we compared LOS and LWBS on dates when we utilized RMA to comparable dates when we did not.

Flashback phenomenon and residual neurological deficits after the use of "bath salt" 3, 4- methylenedioxypyrovalerone.

Background: The use and abuse of designer drugs has been recognized for decades; however there are many derivatives of compounds that make their way into the community. Abuse of compound(s) known on the street as "bath salt" is on the rise.

Methods: We report the case of a 33-year-old man who complained of "flashbacks" and right arm shaking that followed a night of "bath salt" snorting.

Diagnosis of reversible causes of coma.

Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders.

Emergency department physician telemedical triage.

Background: Telemedical physician triage (TPT) is a potential application of telemedicine in the emergency department (ED). We report the technical success, patient satisfaction, and effect on ED throughput metrics (length of stay [LOS] and time to physician evaluation [TPE]) of TPT performed on a mobile platform.

Materials And Methods: Patients underwent standard nursing triage with or without TPT.