Advertisement

Increased door to admission time is associated with prolonged throughput for ED patients discharged home

      Abstract

      Background

      Emergency Department (ED) service evaluations are typically based on surveys of discharged patients. Physicians/administrators benefit from data that quantifies system-based factors that adversely impact the experience of those who represent the survey cohort.

      Objective

      While investigators have established that admitted patient boarding impacts overall ED throughput times, we sought to specifically quantify the relationship between throughput times for patients admitted (EDLOS) versus discharged home from the ED (DCLOS).

      Methods

      We performed a prospective analysis of consecutive patient encounters at an inner-city ED. Variables collected: median daily DCLOS for ED patients, ED daily census, left without being seen (LWBS), median door to doctor, median room to doctor, and daily number admitted. Admitted patients divided into 2 groups based on daily median EDLOS for admits (<6 hours, ≥6 hours). Continuous variables analyzed by t-tests. Multivariate regression utilized to identify independent effects of the co-variants on median daily DCLOS.

      Results

      We analyzed 24,127 patient visits. ED patient DCLOS was longer for patients seen on days with prolonged EDLOS (193.7 minutes, 95%CI 186.7–200.7 vs. 152.8, 144.9–160.5, P< .0001). Variables that were associated with increased daily median EDLOS for admits included: daily admits (P= 0.01), room to doctor time (P< .01), number of patients that left without being seen (P< .01). When controlling for the covariate daily census, differences in DCLOS remained significant for the ≥6 hours group (189.4 minutes, 95%CI 184.1–194.7 vs. 164.8, 155.7–173.9 (P< .0001).

      Conclusion

      Prolonged ED stays for admitted patients were associated with prolonged throughput times for patients discharged home from the ED.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • McCusker J
        • Vadeboncoeur A
        • Levesque JF
        • Ciampi A
        • Belzile E
        Increases in emergency department occupancy are associated with adverse 30-day outcomes.
        Acad Emerg Med. 2014; 21: 1092-1100
        • Sprivulis PC
        • Da Silva JA
        • Jacobs IG
        • Frazer AR
        • Jelinek GA
        The association between hospital over- crowding and mortality among patients admitted via western Australian emergency departments.
        Med J Aust. 2006; 184: 208-212
        • Richardson DB
        Increase in patient mortality at 10 days associated with emergency department over- crowding.
        Med J Aust. 2006; 184: 213-216
        • Fee C
        • Weber EJ
        • Maak CA
        • Bacchetti P
        Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia.
        Ann Emerg Med. 2007; 50: 501-505
        • Schull MJ
        • Vermeulen M
        • Slaughter G
        • Morrison L
        • Daly P
        Emergency department crowding and thrombolysis delays in acute myocardial infarction.
        Ann Emerg Med. 2004; 44: 577-585
        • Pines JM
        • Hollander JE
        Emergency department crowding is associated with poor care for patients with severe pain.
        Ann Emerg Med. 2008; 51: 1-5
        • Mills AM
        • Shofer FS
        • Chen EH
        • Hollander JE
        • Pines JM
        The association between emergency department crowding and analgesia administration in acute abdominal pain patients.
        Acad Emerg Med. 2009; 16: 603-608
        • Hwang U
        • Richardson L
        • Livote E
        • Harris B
        • Spencer N
        Sean Morrison R emergency department crowding and decreased quality of pain care.
        Acad Emerg Med. 2008; 15: 1248-1255
        • Bernstein SL
        • Aronsky D
        • Duseja R
        • et al.
        The effect of emergency department crowding on clinically oriented outcomes.
        Acad Emerg Med. 2009; 16: 1-10
        • Pines JM
        • Pollack Jr., CV
        • Diercks DB
        • Chang AM
        • Shofer FS
        • Hollander JE
        The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain.
        Acad Emerg Med. 2009; 16: 617-625
      1. Institute of Medicine Hospital-Based Emergency Care: at the breaking point.
        2006 ([released June 13, 2006])
        • Centers for Medicare and Medicaid Services and The Joint Commission
        (The revisions include enhancements and additions to “Leadership” (LD) Standard LD.04.03.11, known as “the patient flow standard,” and “Provision of Care, Treatment, and Services” (PC) Standard PC.01.01.01).
        2012
        • Hoffenberg S
        • Hill BH
        • Houry D
        Does sharing process differences reduce patient length of stay in the emergency department?.
        Acad Emerg Med. 2001; 8: 578
        • Kyriacou DN
        • Ricketts V
        • Dyne PL
        • et al.
        A 5-year time study analysis of emergency department patient care efficiency.
        Ann Emerg Med. 1999; 34: 326-335
        • Schneider S
        • Zwemer F
        • Doniger A
        • et al.
        Rochester, New York: a decade of Emergency department overcrowding.
        Acad Emerg Med. 2001; 8: 1044-1050
        • Krall SP
        • O'Connor R
        • Maerks L
        • Reese C
        Hospital admission volume effect on emergency department length of stay intervals.
        Ann Emerg Med. 2002; 40: S17
        • Forster AJ
        • Stiell I
        • Wells G
        • Lee AJ
        • van Walraven C
        The effect of hospital occupancy on emergency department length of stay and patient disposition.
        Acad Emerg Med. 2003; 10: 127-133
        • Krall SP
        • Cornelius A
        • Addison JB
        Hospital factors more heavily impact the variation in Total length of stay for emergency department patients than physician controlled factors.
        West J Emerg Med. 2014; 15 ([PUBMED 24672604]): 158-164
        • Herring A
        • Wilper A
        • Himmelstein DU
        • Woolhandler S
        • Espinola JA
        • Brown DF
        • et al.
        Increasing length of stay among adult visits to U.S. emergency departments, 2001–2005.
        Acad Emerg Med. 2009; : 609-616
        • Krall SP
        • O'Connor RE
        • Maercks L
        Higher inpatient medical surgical bed occupancy extends admitted patients stay.
        West J Emerg Med. 2009; 10: 93-96
        • Arya R
        Wei g, McCoy JV, crane J, Ohman-Strickland P, Eisenstein RM, Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model.
        Acad Emerg Med. 2013; 20: 1171-1179
        • Krall SP
        • Addison B
        • Cornelius A
        • Richman P
        Significant improvement in door-to-room time following redesign of emergency department workflow and infrastructure to accommodate triage surge and vertical patient care.
        Acad Emerg Med. 2014; 21: s293
        • Russ S
        • Jones I
        • Aronsky D
        • Dittus RS
        • Slovis C
        Placing physician orders at triage: the effect of length of stay.
        Ann Emerg Med. 2010; 56: 27-33
        • Considine J
        • Kropman M
        • Kelly E
        Winter C; The effect of emergency department fast track on emergency department length of stay: a case control study.
        Emerg Med J. 2008; 25: 815-819
        • Krall SP
        • Cornelius A
        • Addison JB
        12 hour physician at triage results in a decrease in the left not seen patients by 2.4 patients daily, however it also increased throughput times.
        Ann Emerg Med. 2011; 58: p9A
        • Rogg J
        • White BA
        • Biddinger PD
        • Chang Y
        • Brown DF
        A long-term analysis of physician triage screening in the emergency department.
        Acad Emerg Med. 2013; 20: 374-380
        • Han JH
        • France DJ
        • Levin SR
        • Jones ID
        • Storrow AB
        • Aronsky D
        The effect of physician triage on emergency department length of stay.
        J Emerg Med. 2012; 2: 227-233
        • Holroyd BR
        • Bullard MJ
        • Latoszek K
        • Gordon D
        • Allen S
        • et al.
        Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial.
        Acad Emerg Med. 2007; 14: 702-708
        • Kocher KE
        • Meurer WJ
        • Desmond JS
        • Nailamonthu BK
        Effect of testing and treatment on emergency department length of stay using a National Database.
        Acad Emerg Med. 2012; 5: 525-534
        • Retezar R
        • Bessman E
        • Ding R
        • Zeger SL
        • McCarthy ML
        The effect of triage diagnostics standing orders on emergency department treatment time.
        Ann Emerg Med. 2010;
        • Holland LL
        • Smith LL
        • Blick KE
        Reducing laboratory turnaround time outliers can reduce emergency department patient length of stay.
        Am J Clin Pathol. 2005; 124: 672-674
        • Steindel SJ
        • Howanitz PJ
        Physician satisfaction and emergency department laboratory test turnaround time: observations based on College of American Pathologists Q-probes studies.
        Arch Pathol Lab Med. 2001; 125: 863-871
        • Murray RP
        • Leroux M
        • Sabga E
        • Palatnich W
        • Ludwig L
        Effect of point-of-care testing on length of stay in an adult emergency department.
        J Emerg Med. 1999; 17: 811-814
        • Fernandes CM
        • Worster A
        • Eva K
        • Hill S
        • McCallum C
        Pneumatic tube delivery system for blood samples reduces turnaround times without affecting sample quality.
        J Emerg Nurs. 2006; 32: 139-143
        • Lucas R
        • Farley H
        • Twanmoh J
        • Urumov A
        Olsen N, et al; Emergency department patient flow: the influence of hospital census variables on emergency department length of stay.
        Acad Emerg Med. 2009; 16: 597-602
        • Hoot NR
        • LeBlanc LJ
        • Jones ID
        • Levin SR
        • Zhou C
        Forecasting emergency department crowding: a discrete event stimulation.
        Ann Emerg Med. 2008; 52: 116-125
        • Asaro PV
        • Lewis LM
        • Boxerman SB
        The impact of input and output factors on emergency department throughput.
        Acad Emerg Med. 2007; 14: 235-242
        • Viccellio A
        • Santora C
        • Singer AJ
        • Thode Jr., HC
        • Henry MC
        The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.
        Ann Emerg Med. 2009; 54: 487-491
        • White BA
        • Biddinger PD
        • Chang Y
        • Grabowski B
        • Carignan S
        • Brown DFM
        Boarding inpatients in the emergency department increases discharged patient length of stay.
        J Emerg Med. 2013; 44: 230-235
        • Wuerz RC
        • Milne LW
        • Eitel DR
        • Traverst D
        Gilboy N; Reliability and validity of a new five-level triage instrument.
        Acad Emerg Med. 2000; 7: 236-242
        • Welch SJ
        • Stone-Griffith S
        • Brent Asplin B
        • Davidson SJ
        • Augustine J
        • et al.
        Emergency department operations dictionary: results of the second performance measures and benchmarking summit.
        Acad Emerg Med. 2011; 18: 539-544
        • Weiss SJ
        • Derlet R
        • Arndahl J
        • et al.
        Estimating the degree of emergency department overcrowding in academic medical centers: results of the national ED overcrowding study (NEDOCS).
        Acad Emerg Med. 2004; 11: 38-50
        • Saunders CE
        • Makens PK
        • LeBlanc LJ
        Modeling emergency department operations using advanced computer simulation systems.
        Ann Emerg Med. 1989; 18: 134-140
        • Patel PB
        • Combs MA
        • Vinson DR
        Reduction of admit wait times: the effect of a leadership-based program.
        Acad Emerg Med. 2014; 21: 266-273
        • Schull MJ
        • Szalia JP
        • Schwartz B
        • Redelmeier DA
        Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years.
        Acad Emerg Med. 2001; 8: 1037-1043
        • Trout A
        • Magnusson AR
        • Hedges JR
        Patient satisfaction investigations and the emergency department: what does the literature say?.
        Acad Emerg Med. 2000; 7: 695-709
        • Bleustein C
        • Rothschild DB
        • Valen A
        • Valaitis E
        • Schweitzer L
        • Jones R
        • et al.
        Wait times, patient satisfaction scores, and the perception of care. Manag Care. 2014; 20: 393-400