Abstract
Background
The diagnostic cascade in the emergency department (ED) has not been fully elucidated.
Aim
To inspect whether the usage of consulting medicine and imaging contributes to hospital
outcomes. We also propose a theoretical model for better understanding the diagnostic
cascade of needless medical testing.
Methods
A two-level study was conducted. The first local phase was a retrospective archive
study that was conducted between 2014 and 2017 in a tertiary hospital. We extracted
the number of requested imaging and consultations for each patient, and main time
lags were calculated. The second-phase (January–April 2018) was conducted on a national
level. We examined 22 hospitals with the emphasis on five hospital outcomes: recurrent
ED visits (within 24 h), median waiting time at the ED, rate of early discharge at
the same day and day after and percentage of patients spending >4 h in the ED.
Results
A 5% upsurge in CT scans was observed (p = .032), and a significant increase was found in the number of consultations (14%,
p = .002). On a national level, a linear regression model found that the proportion
of patients discharged from the hospital on the same day and on the day after and
the proportion of patients staying in the ED > 4 h predict ED recurrence visits within
24 h (p = .025; R2 = 46.3%).
Conclusions
Upsurge in resource usage in the ED leads to a diagnostic cascade of health consumption.
Further study is necessary to examine the proposed model in a global scale.
Keywords
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 MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The effect of emergency department crowding on clinically oriented outcomes.Acad Emerg Med. 2009; 16: 1-10https://doi.org/10.1111/j.1553-2712.2008.00295.x
- Reduced access block causes shorter emergency department waiting times: an historical control observational study.Emerg Med Australas. 2003; 15: 232-238https://doi.org/10.1046/j.1442-2026.2003.00441.x
- Strategies and solutions to alleviate access block and overcrowding in emergency departments.Hong Kong Med J. June 2015; https://doi.org/10.12809/hkmj144399
- Initiatives to reduce overcrowding and access block in Australian emergency departments: a literature review.Collegian. 2014; 21: 359-366https://doi.org/10.1016/J.COLEGN.2013.09.005
- Emergency department overcrowding in the United States: an emerging threat to patient safety and public health.Emerg Med J. 2003; 20: 402-405https://doi.org/10.1136/EMJ.20.5.402
- Access block causes emergency department overcrowding and ambulance diversion in Perth.Western Australia Emerg Med J. 2005; 22: 351-354https://doi.org/10.1136/emj.2004.018002
- The effect of prolonged ED stay on outcome in patients with necrotizing fasciitis.Am J Emerg Med. 2009; 27: 385-390https://doi.org/10.1016/J.AJEM.2008.03.010
- Patients using the internet to obtain health information: how this affects the patient–health professional relationship.Patient Educ Couns. 2006; 63: 24-28https://doi.org/10.1016/J.PEC.2005.10.006
- Toward a theory of patient and consumer activation.Patient Educ Couns. 2010; 78: 377-381https://doi.org/10.1016/J.PEC.2009.12.015
- A novel approach to improving emergency department consultant response times.BMJ Qual Saf. 2013; 22: 299-305https://doi.org/10.1136/bmjqs-2012-001503
- Avoiding prolonged waiting time during busy periods in the emergency department: Is there a role for the senior emergency physician in triage?.vol. 13. Lippincott Williams & Wilkins, 2006 ([Accessed October 8, 2018])
- Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage.Emerg Med J. 2004; 21: 537-541https://doi.org/10.1136/emj.2002.003913
- Emergency department visits for nonurgent conditions: systematic literature review.Am J Manag Care. 2013; 19 ([Accessed October 8, 2018]): 47-59
- Urgent care needs among nonurgent visits to the emergency department.JAMA Intern Med. 2016; 176: 852https://doi.org/10.1001/jamainternmed.2016.0878
- National Study of non-urgent emergency department visits and associated resource utilization.West J Emerg Med. 2013; 14: 609-616https://doi.org/10.5811/westjem.2013.5.16112
- One hundred tasks an hour: an observational study of emergency department consultant activities.Emerg Med Australas. 2012; 24: 294-302https://doi.org/10.1111/j.1742-6723.2012.01540.x
- Analysis of factors influencing length of stay in the emergency department.CJEM. 2003; 5: 155-161https://doi.org/10.1017/S1481803500006539
- Consultations in the emergency department: a systematic review of the literature.Emerg Med J. 2008; 25: 4-9https://doi.org/10.1136/emj.2007.051631
- Computed tomography in the emergency department.Polish J Radiol. 2014; 79: 23-27https://doi.org/10.12659/PJR.890550
- Trends in utilization rates of the various imaging modalities in emergency departments: Nationwide Medicare data from 2000 to 2008.J Am Coll Radiol. 2011; 8: 706-709https://doi.org/10.1016/J.JACR.2011.04.004
- Increasing utilization of computed tomography in the adult emergency department, 2000–2005.Emerg Radiol. 2006; 13: 25-30https://doi.org/10.1007/s10140-006-0493-9
- The overuse of diagnostic imaging and the choosing wisely initiative.Ann Intern Med. 2012; 157: 574https://doi.org/10.7326/0003-4819-157-8-201210160-00535
- The frequency of unnecessary testing in hospitalized patients.Am J Med. 2018; 131: 500-503https://doi.org/10.1016/j.amjmed.2017.11.025
- The diagnostic Cascade of incidental findings.JAMA Intern Med. 2015; 175: 1089https://doi.org/10.1001/jamainternmed.2015.1520
- Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada.BMJ. 2011; 342: d2983https://doi.org/10.1136/BMJ.D2983
- The relationship between emergency department crowding and patient outcomes: a systematic review.J Nurs Scholarsh. 2014; 46: 106-115https://doi.org/10.1111/jnu.12055
- Emergency physician perceptions of medically unnecessary advanced.Diagn Imaging. 2014; https://doi.org/10.1111/acem.12625
- Regional variation of computed tomographic imaging in the United States and the risk of nephrectomy.JAMA Intern Med. 2018; 178: 221https://doi.org/10.1001/jamainternmed.2017.7508
- Radiological imaging of patients with suspected urinary tract stones: National Trends, diagnoses, and predictors.Acad Emerg Med. 2011; 18: 699-707https://doi.org/10.1111/j.1553-2712.2011.01103.x
- Does diagnosis change as a result of repeat renal colic computed tomography scan in patients with a history of kidney stones?.Am J Emerg Med. 2010; 28: 291-295https://doi.org/10.1016/J.AJEM.2008.11.024
- Trends in the rates of radiography use and important diagnoses in emergency department patients with abdominal pain.Med Care. 2009; 47: 782-786https://doi.org/10.1097/MLR.0b013e31819748e9
- Analysis of factors influencing length of stay in the emergency department.CJEM. 2003; 5: 155-161https://doi.org/10.1017/S1481803500006539
- Predictors of prolonged length of stay and adverse events among older adults with behavioral health−related emergency department visits: a systematic medical record review.J Emerg Med. 2016; 50: 143-152https://doi.org/10.1016/J.JEMERMED.2015.06.073
- Consultations in the emergency department: a systematic review of the literature.Emerg Med J. 2008; 25: 4-9https://doi.org/10.1136/emj.2007.051631
- Emergency department boarding: a descriptive analysis and measurement of impact on outcomes.CJEM. April 2018; : 1-9https://doi.org/10.1017/cem.2018.18
- The impact of consultation on length of stay in tertiary care emergency departments.Emerg Med J. 2014; 31: 134-138https://doi.org/10.1136/emermed-2012-201908
- Computed tomography use in the adult emergency Department of an Academic Urban Hospital from 2001 to 2007.Ann Emerg Med. 2010; 56: 591-596.e1https://doi.org/10.1016/J.ANNEMERGMED.2010.05.027
- Consultant volume, as an outcome determinant, in emergency medical admissions.QJM. 2013; 106: 831-837https://doi.org/10.1093/qjmed/hct119
- Decline in consultant availability in Massachusetts emergency departments: 2005 to 2014.Ann Emerg Med. 2016; 68: 461-466https://doi.org/10.1016/j.annemergmed.2016.06.013
Article Info
Publication History
Published online: December 28, 2018
Accepted:
December 11,
2018
Received in revised form:
December 10,
2018
Received:
October 23,
2018
Footnotes
☆The research has not been presented.
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
