(October 2016 to April 2017)
WTC, wait time to consultation.
The median WTC improved to 21 min, compared with a baseline timing of 24 min ( table 1 ). The effect on median WTC was seen with implementation of PDSA cycle 1 and maintained through the study period. The implementation of PDSA cycles 2 and 3 resulted in further marginal improvement in median WTC.
The improvements in wait times occurred during the period with an average P2 patient load of 4317 patients per month, which was greater than the baseline monthly average of 4053 patients ( table 1 ). Department manpower remained stable. After the implementation of all three PDSA cycles, improvement was observed in several process outcome and measures. There was a 15% decrease in inpatient admissions from ED of P2 patients compared with the prior period (66% pre-intervention to 52% post-intervention; P<0.05), thereby relieving the daily requirement of an average of 20 beds.
The flow of patients through the consultation stage has improved. Time to review by a doctor in critical care area has improved by 14 min (60 min pre-intervention to 46 min post-intervention; P<0.05). There is also a 0.6% decrease in the cancellations of orders for patients’ management plan (7.3% pre-implementation to 6.7% post-implementation; P<0.05).
There was a 1.6% decrease for patient admissions from the ED compared with the prior period (56.0% post-intervention and 57.6% pre-intervention; P=0.004). The total time duration to ED disposition also saw a decrease of 17 min during the study period, compared with the prior period (145 min post-intervention and 162 min pre-intervention; P<0.001).
Feedback from doctors and nurses within the department was uniformly positive. Commonly cited reasons included increased efficiencies, greater clarity and a transparent yet equitable workload. Feedback was markedly positive for the group of junior doctors who experienced the pre-intervention phase and post-intervention phase within the same posting period. As the study was focused on quantitative outcomes, no formal pre-intervention and post-intervention comparison on feedback was carried out.
To ensure patient safety and outcomes were not compromised, reattendances to SGH ED within 72 hours were tracked as a balancing measure to make sure the quality of care for all ED patients would not be compromised for pursuing a faster process time. This indicator was measured with patients who were discharged home and subsequently returned to SGH ED within 72 hours. Comparing with the rates of reattendances 6 months prior to implementation, the rates during post-implementation have remained steady at an average of 3.4% (P>0.1).
Data analytics played a significant role in the successful implementation of PDSA cycles. The team could identify significant areas for improvement with in-depth analysis of baseline data, and results were corroborated with root cause analysis findings. The ability to identify patterns in patient arrivals allowed us to match department manpower to periods of surge. Expected work output, based on frequently refreshed data, was communicated to staff, enabling clarity and equitable workload.
To gain constant buy-in from staff on the ground and ensure sustainability of the interventions, results and findings were shared with doctors and nurses regularly through the study period. We identified best practices and encouraged staff to share positive actions that contributed to better team-based care for the patient. Feedback was also constantly received from staff during the study period and has helped to further adjust interventions.
Numbers and data gleaned were distilled into easy-to-understand charts and tables, and disseminated to the department, to keep everyone updated on the progress of the quality improvement effort. Having regular feedback to stakeholders and department staff helped to allay concerns early and allowed a visual translation of the hard work performed on the ground. This helped improve acceptance and compliance to the interventions. Senior clinicians were extremely supportive of interventions and enabled the smooth implementation of measures taken.
Using a simple board that highlighted everyone’s workload contribution for the day was effective, as the transparency it offered allowed juniors on shift to keep pace with one another, allowed fairer sharing of load and gave them the psychological effect of wanting to keep up with their peers’ output. There was clarity into the distribution of work done within the area by individual, and allowed seniors on shift to visualise the tempo of their shift and easy identification of junior doctors in need of assistance.
Although the median WTC target was achieved, we were not able to meet the 95th centile target of 76 min, and thus did not attain the stated goal of this study. WTC starts from the time the patient is registered. Subsequent analysis postintervention has identified the wait time to triage now as a significant contributor to both median and 95th centile WTC. We are currently conducting a separate quality improvement effort to decrease the wait time for triage.
During periods of prolonged wait for inpatient beds for patients admitted from ED, the increased workload due to boarded patients places strains on the team-based care model, as teams need to care for both incoming and boarded patients at the same time. This manifests in increased WTC during days with higher proportion of boarded patients.
Despite initiatives on the ground to improve processes within the ED, wait times also depend on the smooth flow of admitted patients out of the ED into the inpatient wards. Studies have shown that boarded patients at the ED contribute to overcrowding, affect the delivery of care and may lead to increased costs and length of stay. 11 12
Currently, data on daily WTC and individual work output are retrospectively collated every 2–4 weeks for feedback and analysis. To have to manually paste patient stickers on the board also contributes to time spent by doctors, which may be better used on actual patient care. We are looking to develop an intelligent electronic version of the board, which removes the need for use of stickers, and that also allows for real-time capability for feedback and automated reporting.
Implementing the package of changes to improve the P2 WTC was a major effort that required a data-driven approach, catalysed by the staffs’ conviction to improve patient outcomes. We demonstrated how implementation of low-cost interventions, enabling equitable workload and how breaking down work silos with the use of a team-based care model can help to bring down wait times for patients.
The insights gleaned from the analysed data allowed the team to make quick and informed decisions, while teamwork and staff buy-in ensured the sustainability of the project. The team is currently looking to further decrease the total time duration to ED disposition for patients by implementation of further quality improvement initiatives targeting other aspects of the patient’s journey at the ED.
The authors would like to acknowledge the following: Dr Evelyn Wong, Head DEM; Tan Puay Hwang, Nurse Clinician, DEM; Muqtasidatum Binte Mustaffa, Nurse Clinician, DEM; and Ryan Koh Zhao Yuan, Hospital Executive, OPM.
Contributors: All authors contributed to the design and writing, data collection and interpretation of the results of this study.
Competing interests: None declared.
Ethics approval: The SingHealth Centralised Institutional Review Board exempted the study from ethical approval as the work was deemed a quality improvement study and not a study on human subjects.
Provenance and peer review: Not commissioned; externally peer reviewed.
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1. Introduction. The Emergency Department (ED) is one of the most crowded hospital units, where many patients with various medical conditions, including high-risk patients, are admitted [].The main purpose of the ED is to treat emergency and urgent cases that need immediate assistance through a rapid diagnosis and the administration of a medical or surgical treatment in a very short time.
The emergency department is the first critical link in the clinical diagnosis and treatment of critical illnesses and infectious diseases, and individualized accurate assessment and prevention of disease susceptibility is a valuable research direction for precision emergency medicine. [14] Acute infectious diseases are among the most common ...
Y.G. Bodien and OthersN Engl J Med 2024;391:598-608. Among 241 persons with disorders of consciousness who had no observable response to commands, 25% had a verifiable response to commands on EEG ...
Previous research highlighted the importance of bed occupancy 4-7 and the proportion of patients attending the ED who were admitted into the hospital (the 'admissions conversion rate') 7 8 on patient waits for emergency care in England. However, this research was limited by use of a short time period, or less often, aggregated data.
The initial keywords used were "patient flow", "emergency department," "emergency care," and "systematic review." ... The classification criteria categorised a paper as "low quality" if its results were below 50%, "moderate quality" if they ranged between 50 and 69%, and "high quality" if the results were above 69%. ... Obs observational ...
Introduction. Overcrowding in the emergency department (ED) is a serious public health issue worldwide. Overcrowding in the ED is defined as a situation in which the demand for emergency services exceeds the ability of a department to provide quality care within acceptable time frames [].In 2018, the number of patients who were treated in EDs in Korea was 10,609,107, which was an increase of 1 ...
Brian Freeze is an assistant medical director for the Emergency Department at Cooper University Hospital, and a member of the Department of Clinical Informatics and Innovative Care delivery. His passion in medicine lies in the cross section between clinical practice and leveraging technology to make myself and others better clinicians, by ...
Patient experience with emergency department (ED) care is a rapidly expanding area of research and focus for health-care leaders, and recent literature has demonstrated a strong correlation between high overall patient experience and improved patient outcomes, profitability, and other health-care system goals (1-3).An ED visit often represents the patient's initial experience with a ...
Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA. Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York, USA. Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA. Search for more papers by this author
Ingestion of magnets carries risks for significant morbidity. We propose a new protocol designed to reduce the need for surgery, shorten length of stay, and decrease morbidity. Ortal Schaffer, Adi Kenoshi and Osnat Zmora. International Journal of Emergency Medicine 2024 17:88. Research Published on: 15 July 2024.
The number of emergency department (ED) visits in the United States has increased by 14.2% in the past decade . Inadequate inpatient capacity in hospitals, the growing number of nonurgent ED visits, and an imbalance between the capacity of EDs and the number of patients lead to congestion in EDs (Chow et al., 2017; Raven et al., 2013
DOI 10.3386/w30608. Issue Date October 2022. Revision Date July 2024. This paper studies the productivity of nurse practitioners (NPs) and physicians, two professions performing overlapping tasks but with starkly different backgrounds, training, and pay. Using quasi-experimental variation in patient assignment to NPs versus physicians in ...
Background In recent years, the flow of patients to the Emergency Departments (ED) of Western countries has steadily increased, thus generating overcrowding and extended waiting times. Scholars have identified four main causes for this phenomenon, related to: continuity of primary care services; availability of specific clinical pathways for chronic patients; ED's personnel endowment ...
Research education is an important component of emergency medicine training, with many programs encouraging formalized exposure to research for students, residents, and junior faculty.1, 2 Regardless of whether directly involved with research or not, a basic understanding of research methodology aids emergency clinicians in the assessment of scientific evidence and its potential relevance to ...
Overcrowding in Emergency Departments (EDs) is a phenomenon that is now widespread globally and causes a significant negative impact that goes on to affect the entire hospital. This contributes to a number of consequences that can affect both the number of resources available and the quality of care. Overcrowding is due to a number of factors that in most cases lead to an increase in the ...
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Telemedicine in the emergency department: an overview of systematic reviews Z Gesundh Wiss. 2022 Jan 27:1-15. doi: 10.1007/s10389-021-01684-x. Online ahead of print. Authors ... Form these 18 studies, 12 papers yielded a high risk of bias in their investigation. Nine papers concluded that real-time video conferencing was the best method of ...
It is often difficult to keep up with all of the highest impact papers in emergency medicine. The EMRA Research Committee has compiled a quick review of some of the most practice-affirming or practice-changing papers published from September 2020 to September 2021. This is by no means a definitive list, but all of these papers will likely be ...
Quality emergency medical care is critical to reducing the burden of disease in low-income and middle-income countries (LMICs) and protecting the health of populations during disasters and epidemics. However, conducting research in emergency care settings in LMIC settings entails unique methodological and operational challenges. Therefore, new approaches and strategies that address these ...
3 Robert Wood Johnson Medical School, Department of Emergency Medicine, Piscataway, NJ, USA. Electronic address: [email protected]. PMID: 35339973 DOI: 10.1016/j.ajem.2022.03.020 No abstract available. Publication types Randomized Controlled Trial MeSH terms ...
Emergency Department Throughput, Definitions, and ED Times. Our ED throughput and waiting times are measured using our Electronic health Record, Epic. Patients entering the ED through the walk-in entrance are preregistered, then undergo a "quick look" triage where the patient is assigned an Emergency Severity Index with levels 1 to 5 by the ...
Objective This study describes recency of suicide attempt (SA) and suicidal ideation (SI) at index emergency department (ED) visit and post‐ED‐discharge reattempt among pediatric patients. Methods Secondary analysis from the ED Screen for Teens at Risk for Suicide study included patients ages 12-17 who reported a past SA during screening and received a phone call 3‐month post‐ED ...
Presenter. Mary Acri, Ph.D. Division of Services and Intervention Research . Goal. The purpose of this concept is to support research examining the effectiveness, implementation, adoption and scale-up of patient navigation emergency department (ED) diversion models for youth with non-urgent mental health concerns and their caregivers.
Emergency Department Screening More Than Doubles Detection of Syphilis Cases. Providing optional syphilis tests to most people seeking care at a large emergency department led to a dramatic increase in syphilis screening and diagnosis, according to an NIH-supported study of nearly 300,000 emergency department encounters in Chicago.
Abstract. Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements ...
On September 6, the USGS released the U.S. Geological Survey Climate Science Plan—Future Research Directions, the culmination of a two-year effort by the Climate Science Plan Writing Team.The team was charged with identifying the major climate science topics of future concern and developing an integrated approach to conducting climate science in support of the USGS, Department of the ...
Problem. Timeliness and efficiency form two of the six domains of healthcare quality as defined by the Institute of Medicine. 1 At the emergency department (ED), prolonged wait times have been found to be associated with increased morbidity and mortality, and decreased patient satisfaction. 2 3 Increasing attendances to the ED, an ageing population and greater disease complexity, coupled with ...