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Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician

Published:January 24, 2013DOI:https://doi.org/10.1016/j.ajem.2012.10.012

      Abstract

      Objectives

      The aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention.

      Methods

      A before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a “team norm” imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011–September 30, 2011) and after (October 1, 2011–January 30, 2012) intervention were compared.

      Results

      Patients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention.

      Conclusions

      The intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly.
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      References

        • Asplin B.R.
        • Magid D.J.
        • Rhodes K.V.
        • et al.
        A conceptual model of emergency department crowding.
        Ann Emerg Med. 2003; 42: 173-180
        • Moskop J.C.
        • Sklar D.P.
        • Geiderman J.M.
        • et al.
        Emergency department crowding, part 1—concept, causes, and moral consequences.
        Ann Emerg Med. 2009; 53: 605-611
        • Bernstein S.L.
        • Aronsky D.
        • Duseja R.
        • et al.
        The effect of emergency department crowding on clinically oriented outcomes.
        Acad Emerg Med. 2009; 16: 1-10
        • Rondeau K.V.
        • Francescutti L.H.
        Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction.
        J Healthc Manag. 2005; 50: 327-340
        • Kelen G.D.
        • Kraus C.K.
        • McCarthy M.L.
        • et al.
        Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study.
        Lancet. 2006; 368: 1984-1990
        • Weiner S.G.
        • Brown S.F.
        • Goetz J.D.
        • et al.
        Weekly e-mail reminders influence emergency physician behavior: a case study using the Joint Commission and Centers for Medicare and Medicaid Services Pneumonia Guidelines.
        Acad Emerg Med. 2009; 16: 626-631
        • Hoot N.R.
        • Zhou C.
        • Jones I.
        • et al.
        Measuring and forecasting emergency department crowding in real time.
        Ann Emerg Med. 2007; 49: 747-755
        • Hoot N.R.
        • Aronsky D.
        Systematic review of emergency department crowding: causes, effects, and solutions.
        Ann Emerg Med. 2008; 52: 126-136
        • Moskop J.C.
        • Sklar D.P.
        • Geiderman J.M.
        • et al.
        Emergency department crowding, part 2: barriers to reform and strategies to overcome them.
        Ann Emerg Med. 2009; 53: 612-617
        • Boyle A.
        • Beniuk K.
        • Higginson I.
        • et al.
        Emergency department crowding: time for interventions and policy evaluations.
        Emerg Med Int. 2012; ([Article ID 838610, 8 pages]. http://dx.doi.org/10.1155/2012/838610.)
      1. Clark JJ. Unlocking hospital gridlock. Healthc Financ Manage. 2005;59:94–96, 98, 100–102.

        • Greene J.
        Emergency department flow and the boarded patient: how to get admitted patients upstairs.
        Ann Emerg Med. 2007; 49: 68-70
        • Kelen G.D.
        • Scheulen J.J.
        • Hill P.M.
        Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion.
        Acad Emerg Med. 2001; 8: 1095-1100
        • Moloney E.D.
        • Bennett K.
        • O'Riordan D.
        • et al.
        Emergency department census of patients awaiting admission following reorganisation of an admissions process.
        Emerg Med J. 2006; 23: 363-367
        • McConnell K.J.
        • Richards C.F.
        • Daya M.
        • et al.
        Effect of increased ICU capacity on emergency department length of stay and ambulance diversion.
        Ann Emerg Med. 2005; 45: 471-478
        • Jamtvedt G.
        • Young J.M.
        • Kristoffersen D.T.
        • et al.
        Audit and feedback: effects on professional practice and health care outcomes.
        Cochrane Database Syst Rev. 2006; : CD000259
        • Ghrooda E.
        • Alcock S.
        • Jackson A.C.
        Improvement in thrombolytic therapy administration in acute stroke with feedback.
        Can J Neurol Sci. 2012 Nov; 39: 789-792
        • Lai C.L.
        • Fan C.M.
        • Liao P.C.
        • et al.
        Impact of an audit program and other factors on door-to-balloon times in acute ST-elevation myocardial infarction patients destined for primary coronary intervention.
        Acad Emerg Med. 2009 Apr; 16: 333-342
        • Hardin L.V.
        • Nguyen S.A.
        • Ravenel J.G.
        Is e-mail communication effective in changing ordering patterns in the emergency department? A case study of computed tomography for pulmonary embolus.
        Acad Radiol. 2008; 15: 433-437
        • Falk A.
        • Ichino A.
        Clean evidence on peer effects.
        J Labor Econ. 2006; 24: 39-57
        • Mas A.
        • Moretti E.
        Peers at work.
        Am Econ Rev. 2009; 99: 112-145
        • Scott A.
        • Sivey P.
        • Ait Q.D.
        • et al.
        The effect of financial incentives on the quality of health care provided by primary care physicians.
        Cochrane Database Syst Rev. 2011; 9: CD008451
        • Glaser W.F.
        The effects of bonus payments on emergency service performance in Victoria.
        Med J Aust. 2000; 172: 92-93
        • Roski J.
        • Jeddeloh R.
        • An L.
        • et al.
        The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines.
        Prev Med. 2003; 36: 291-299
        • Epstein A.M.
        • Lee T.H.
        • Hamel M.B.
        Paying physicians for high quality care.
        N Engl J Med. 2004; 350: 406-410
        • Sikka R.
        Pay for performance in emergency medicine.
        Ann Emerg Med. 2007; 49: 756-761