Measures of crowding in the emergency department: a systematic review.

Objectives: Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity.

Methods: This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED).

Intravenous opioid dosing and outcomes in emergency patients: a prospective cohort analysis.

Objectives: Pain management in emergency department (ED) patients is variable and often inadequate. This study sought to (1) describe the variability in intravenous opioid dosing and (2) compare the outcomes that result from the most commonly prescribed opioid doses.

Methods: This prospective cohort study enrolled emergency patients who were prescribed intravenous morphine or hydromorphone as their initial analgesic.

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals.

Outcomes after intravenous opioids in emergency patients: a prospective cohort analysis.

Objectives: Pain management continues to be suboptimal in emergency departments (EDs). Several studies have documented failures in the processes of care, such as whether opioid analgesics were given. The objectives of this study were to measure the outcomes following administration of intravenous (IV) opioids and to identify clinical factors that may predict poor analgesic outcomes in these patients.

Addition of levalbuterol to a pediatric emergency department automated medication management system does not increase its use.

Background: Although adding a drug to an emergency department-based automated medication management system is known to increase how frequently it is ordered, little is known about this effect when the added drug does not offer substantial benefit over a substitute drug that was already available.

Aims: We studied the effect of adding nebulized levalbuterol to a pediatric emergency department-based automated medication management system that already included albuterol.

Methods: All completed orders for nebulized levalbuterol or nebulized albuterol from our academic pediatric emergency department were retrospectively identified using a computerized pharmacy database.

The effect of emergency department crowding on clinically oriented outcomes.

Background: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.

Objectives: The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).

Unique sexual assault examiner program utilizing mid-level providers.

Background: We implemented a unique sexual assault examiner (SAE) program utilizing Emergency Department (ED)-based mid-level providers. Sexual assault forensic evidence collection processes and training are not uniform in all EDs, with varying models in place.

Methods: Our study evaluated the quality of SAE evidentiary collection in standardized evidence kits (Kits), compared to Kits from other EDs without the SAE program.

Care without coverage: is there a relationship between insurance and ED care?

The Institute of Medicine (IOM) has concluded that differences in care exist for hospitalized patients on the basis of insurance; we attempted to determine if these differences begin in the emergency department (ED). We retrospectively studied high-acuity adult visits to one ED over 6 months, utilizing electronic databases. Uninsured patients were more often younger, male, and non-white (n = 3899 visits; 468 uninsured, 3431 insured).

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs.

Emergency department digital radiology: moving from photos to pixels.

Emergency department (ED) patient care relies heavily on radiologic imaging. As advances in technologic innovation continue to present opportunities to streamline and simplify the delivery of care, emergency medicine (EM) practitioners face the challenge of transitioning from a system of primarily film-based radiography to one that utilizes digitized images. The move to digital radiology can result in enhanced quality of patient care, reduction of errors, and increased ED efficiency; however, making this transition will necessarily involve changes in EM practice.

Where's the beef? The promise and the reality of clinical documentation.

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.

Point of care pregnancy testing provides staff satisfaction but does not change ED length of stay.

Point of care testing (POCT) is widely viewed as possibly improving ED care and reducing length of stay (LOS). However reports are mixed, and regulatory barriers complicate considerations. We studied a simple urine pregnancy assay (human chorionic gonadotropin-HCG).

The demands of 24/7 coverage: using faculty perceptions to measure fairness of the schedule.

Objectives: Ensuring fair, equitable scheduling of faculty who work 24-hour, 7-day-per-week (24/7) clinical coverage is a challenge for academic emergency medicine (EM). Because most emergency department care is at personally valuable times (evenings, weekends, nights), optimizing clinical work is essential for the academic mission. To evaluate schedule fairness, the authors developed objective criteria for stress of the schedule, modified the schedule to improve equality, and evaluated faculty perceptions.

Emergency department crowding: a point in time.

Study Objective: This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the degree of physical crowding and personnel shortage in our sample.

Methods: A mail survey was sent to a random sample of 250 EDs chosen from a database compiled by the American College of Emergency Physicians of 5,064 EDs in the United States.

Clinical operations in academic emergency medicine.

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession.

Coping with a crowded ED: an expanded unique role for midlevel providers.

Crowding in the emergency department (ED) has multiple causes, including space and staffing in both inpatient areas and the ED. Waiting for inpatient beds is the primary issue in our ED. Waiting inpatients require continuing care and attention from emergency-medicine (EM) physicians.

Fatalities associated with therapeutic use and overdose of atypical antipsychotics.

Since 1989, several novel antipsychotic drugs have become available for use including clozapine, risperidone, olanzapine, quetiapine and ziprasidone. These agents represent a substantial improvement in the treatment of schizophrenia and related disorders and are considered to have a favourable adverse effect profile relative to traditional antipsychotics. Nonetheless, in rare cases, people have died as a result of taking atypical antipsychotic drugs at therapeutic and supratherapeutic doses.

An inexpensive modification of the laboratory computer display changes emergency physicians' work habits and perceptions.

Study Objective: Little is known about how the availability of laboratory data affects emergency physicians' practice habits and satisfaction. We modified our clinical information system to display laboratory test status with continuous updates, similar to an airport arrival display. The objective of this study was to determine whether the laboratory test status display altered emergency physicians' work habits and increased satisfaction compared with the time period before implementation of laboratory test status.

The effects of the absence of emergency medicine residents in an academic emergency department.

Objective: What are the quality effects of an emergency medicine (EM) residency, and the associated 24/7 supervision of residents by faculty, in an academic emergency department (ED)? The authors evaluated activity and quality indicators when there were no EM residents present. The hypothesis of the study was that there was no difference between the patient care provided by faculty supervising EM residents and that with an alternative model without EM residents (AbsenceEMResident).

Methods: To support the weekly residency educational program (Thursday), EM residents are not scheduled clinically for a 24-hour period (ConfDay).

CT in detecting urinary tract calculi: influence on patient imaging and clinical outcomes.

Purpose: To determine changes in examination patterns and effectiveness of care since the introduction of unenhanced helical computed tomography (CT) for examination of patients presenting to the emergency department (ED) with symptoms of urinary tract calculi (UTC).

Materials And Methods: Hospital clinical and radiology information systems were used to retrospectively identify patients presenting with UTC symptoms from January to December 1997 (before introduction of unenhanced CT) and from January to December 1999 (after introduction of unenhanced CT). Chart abstraction was used to confirm the identification of patients with presenting symptoms suggestive of UTC and assess patient outcomes.

Recently discharged inpatients as a source of emergency department overcrowding.

Objective: To assess the impact on the emergency department (ED) of recently discharged inpatients and how they contribute to and worsen the current situation of ED overcrowding.

Methods: Retrospective, observational study of medical records and billing data of all patients presenting to the ED within seven days of inpatient discharge from the hospital ("returns") in September 2000. The data were collected from electronic logs.

Rochester, New York: a decade of emergency department overcrowding.

Unlabelled: Overcrowding is common in emergency departments (EDs) throughout the United States. The history of ED overcrowding in Rochester, New York, is notable due to its unique health care system that introduced the concepts of managed care as early as the 1950s. An effect of this system was to intentionally restrict resources and allow the issue of access to limit utilization.

Use of lumbosacral spine radiographs in a level II emergency department.

Objective: We studied indications for lumbosacral spine radiographs in an emergency department setting.

Subjects And Methods: Clinicians completed a lumbosacral spine request form before obtaining lumbosacral radiographs on 482 patients who were examined in a level II emergency department. The clinicians detailed the indications for the examination, their suspected clinical diagnoses, and the expected effect of the lumbosacral spine study on management.