STUDY OBJECTIVE:To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED.DATA SOURCES:All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits.STUDY DESIGN:Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least-squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures.PRINCIPAL FINDINGS:A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit.CONCLUSION:EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.

Objective Emergency Department (ED) patient volumes are unpredictable, which can result in service delays and patients leaving without care. We initiated a programme of emergency physician (EP) telepresence in the ED with the objectives of assessing feasibility, safety, patient and provider acceptance, and throughput time. Methods This was a prospective convenience study. Patients presenting to the ED during operation of the study who were planned for placement in the waiting room were considered for enrolment. A faculty EP conducted patient evaluations via telepresence with confirmatory evaluation by the onsite faculty EP prior to disposition. Patient care was either taken to completion by the telemedicine EP or initiated and handed off to the onsite team. Measures included patient demographics, triage class (ESI 1–5), throughput time and a single question satisfaction survey (rating 1–5, 5 most favourable) completed by patients, registered nurses and EPs. Patients were called within 3 days and the electronic health record reviewed at 7 days looking for unscheduled visits and adverse events. Results In total, 130 patients were enrolled. Mean triage class was 3.9 with a median throughput of 150 minutes (IQR = 116.5, 206). Non-telemedicine patients during the same time period with similar triage classes had a median throughput of 287 minutes (IQR = 199, 408). Mean satisfaction scores were: patient 4.91, nurse 4.75, onsite EP 4.47 and telemedicine EP 4.79. There was one potential misdiagnosis and no adverse events. Conclusion Patient evaluation by EP via telepresence is feasible, safe, readily accepted by patients and providers and associated with reduced throughput time.

Healthcare delivery is becoming a significant proportion of the service economy around the world. Within healthcare, the emergency department ED constitutes one of the most challenging areas of service delivery. Patient customer arrival is highly unpredictable, job scope is variable and uncertain, and timely service response is essential to save lives. In addition, emergency physicians and hospitals may soon be monitored and compensated based on patient satisfaction measured after service delivery. In this paper, we seek to understand how a process design piloted at two academic EDs-involving the addition of a new process step that uses health provider follow-up patient calls after discharge from the ED-influences patient assessment of the service. We examine the overall impact of this process redesign on patient satisfaction as measured by the "likelihood to recommend" question on patient surveys and develop an identification strategy to uncover the mechanism by which callbacks influence patient satisfaction. Our findings indicate that the follow-up callback design improves patient appraisals across the board, and not just as a service recovery tool where it moderates the assessment of select patient groups. These findings can help hospitals implement a redesign of the ED service process for callback in an effective manner. Underlying fundamental implications and future work possibilities are discussed.

Providing health care to inmates in county jails and state prisons is very challenging. Beyond the diverse medical issues encountered, there is often limited access to high quality practitioners, serious security concerns and costs related both to provision of care onsite and transfer to community medical facilities.

BACKGROUND:Patient satisfaction is a common parameter tracked by health care systems, and likely influences patient provider choice and may impact insurer payment. Achieving high satisfaction in an academic emergency department (ED) can be a daunting task due to variable volumes, acuity, and overcrowding. OBJECTIVE:The objective of this study was to assess the impact of a postdischarge telephone call by a staff member after discharge from the ED on patient satisfaction. METHODS:This was a prospective cohort study conducted in the two University of California San Diego Health System EDs. Press Ganey patient satisfaction surveys are mailed to a random sample of 50% of all discharged patients. In August 2010 a program of MD and RN telephone call back 1 to 5 days after the ED visit was initiated. In conjunction with this program, a custom question was added to the standard survey, "Called back after discharge, Yes/No?" All surveys returned between September 22, 2010 and December 7, 2010 were reviewed, and those that chose to self-identify were selected to allow for ED chart review. The key outcome variable "likelihood to recommend score" was dichotomized into the highest category, 5 (very good) and remaining levels, 1-4 (very poor, poor, fair, good). ED records were abstracted for data on waiting time (WT), length of stay (LOS), and triage class (TC). These variables were selected because they have been shown to impact patient satisfaction in prior studies. Likelihood to recommend ratings for those reporting "Yes" to call back were compared to those reporting "No" to call back. Summary statistics were generated for patient characteristics in the "Yes" and "No" groups. Ninety-five percent confidence intervals (CIs) for all counts and proportions were calculated with the "exact" method. A logistic regression model was constructed assessing odds ratio (OR) for likelihood-to-recommend score 5 while controlling for the variables of WT, LOS, and TC. RESULTS:In the study period, about 5000 surveys were mailed, 507 were returned, and 368 self-identified. Of those that self-identified, 136 patients answered "Yes" to the callback question and 232 answered "No." The mean age for those indicating "Yes" was 55.8 years (CI 52.9-58.7), and for those indicating "No," 50.7 years (CI 47.9-53.5). Gender and triage code were similar between the two groups. Among those answering "Yes," 89.0% (CI 82.5-93.7) provided a "5" rating for "likelihood to recommend," compared to 55.6% (CI 49.0-62.1) who replied "No" for call back. The logistic regression model generated an OR of 6.35 (CI 3.4-11.7) for providing a level 5 rating for "likelihood to recommend" for patients reporting "Yes" for call back after controlling for WT, LOS, and TC. CONCLUSION:In the study institution, patients that are called back are much more likely to have a favorable impression of the visit as assessed by likelihood to recommend regardless of WT, LOS, or TC. These data support "call back" as an effective strategy to improve ED patient satisfaction.

Healthcare delivery is becoming a significant proportion of the service economy around the world. Within healthcare, the Emergency Department (ED) constitutes one of the most challenging areas of service delivery. Patient (customer) arrival is highly unpredictable, job scope is variable and uncertain, and timely service response is essential to save lives. In addition, emergency physicians and hospitals may soon be monitored and compensated with a new set of metrics including patient satisfaction measured after service delivery. In this paper, we report data and results from a study that involved a service process innovation at two academic EDs – the proposed redesign involves utilizing the addition of a new process step that uses health provider capacity when available for follow-up patient calls after discharge from the emergency department. We examine the overall impact of this process redesign on patient satisfaction as measured by the “likelihood to recommend” question on patient surveys. We also examine how follow-up caller identity (nurse vs. medical doctor) and patient characteristics influence customer/patient satisfaction. Our findings first confirm that the addition of a follow-up call back step to the service process has a significant impact on reported patient satisfaction. We focus on identifying ways to improve the efficiency of the call back step in the service design. Specifically, we find that patients over age 65 are more likely to respond positively to call back than those under 65 and the impact of call back is strongly associated for certain healthcare insurance (Medicare and MediCal). These findings can help hospitals redesign the ED service process and segment patients for call back in an effective manner. Underlying fundamental implications and future work possibilities are discussed.

Emergency department (ED) crowding is a major obstacle to safe, time-effective care. Implementation of the affordable care act is expected to increase ED use which may exacerbate crowding. Some EDs have increased coverage by placing an emergency physician in triage to expedite care, however inherently unpredictable patient arrivals and acuity can make this cost-ineffective. The objective of this pilot study was to examine the feasibility, safety, patient and provider acceptance of a novel use of telemedicine (telemed) to provide emergency physician care via remote link to the ED at times of increased need.

Objective Identify the specific patient experience variables that most strongly predict satisfaction as measured by the likelihood to recommend rating. Methods We performed a retrospective analysis of a patient satisfaction survey distributed to patients during their visit to an academic children’s hospital emergency department (ED) during a 3-month period. Any incomplete or incorrectly completed surveys were excluded. The associations between staff communication variables and “likelihood to recommend” were assessed while controlling for daily ED flow data. Results A total of 3135 surveys were completed with 825 (26%) excluded for incomplete or incorrect entry. After controlling for daily census, median daily wait time and median daily length of stay, the communication question that asks if the nurse or physician kept them informed while in the examination room had the strongest association (odds ratio, 12.2; 95% confidence interval, 9.3–16.1; P < 0.001), with the response of “always” likely to recommend this ED. Conclusions This study demonstrates that keeping patients and their families informed has a more positive effect on patient satisfaction than any other variable studied even in the setting of increased census and wait times.

Study Objectives: Preliminary (prelim) interpretation of imaging studies is common in Emergency Departments (ED) around the USA. There is concern this practice places patients (pts.) at risk for avoidable adverse outcomes due to disparity between the reading at the time of medical decisionmaking and the final interpretation which may occur many hours later. The objective of this study is to assess the clinical impact of prelim. readings of imaging studies in an ED setting. Methods: This descriptive study was conducted in 2 ED in a single academic medical center, combined census of 62,000/yr. During the study period, Jan 1, 2011 to July 30, 2011, final readings by specialists in various imaging disciplines occurred between the hrs. of 0800 to 2300. Image readings between the hrs. of 2300 and 0800 were performed by radiology residents with ad hoc back up by board certified radiologists at a remote setting and deemed prelim. All prelim. readings were over read the next day by radiology faculty. These readings were entered into the hospital medical record as the official interpretation. Discrepancy between prelim. and final readings were called to the ED and entered into the ED electronic medical record (EMR). Based upon the nature of the discrepancy attempts were made to contact the pt. for appropriate notification and follow-up. The outcome of the follow-up attempt was entered into the ED EMR. The study included a review of all ED EMR recorded discrepancies between prelim. and final readings. Discrepancies were rated on a (1) to (5) scale by the MD investigators. (1) no clinical significance, no action required, (2) minor clinical significance requiring pt. notification only, (3) clinically significant requiring notification and either return to ED or change in outpatient management, (4) potentially major clinical significance requiring immediate return to ED or referral for further imaging and follow-up without which adverse outcome could result, (5) major clinical significance with documented patient harm related to delayed diagnosis. Results: During the study period 37,383 imaging studies were ordered. 7787 (21%) occurred during the hours when prelim. readings were provided. There were 159 (2%) discrepancies recorded in the ED EMR. 17 were categorized as (1), 50 as (2), 50 as (3), 42 as (4) and 0 as (5). Of the category (4) discrepancies 14 patients. could not be contacted and no follow-up could be arranged. Final outcome for these patients is unknown. This group included patients with nodules or masses in the lung, liver, breast, ovary, colon and bone as well as 1 case each of mediastinal mass, cerebral aneurysm, closed loop bowel obstruction, ovarian torsion and suspected hemoperitoneum. Final outcomes in these patients could not be determined. Of the level (4) patients that were contacted for whom follow-up information was available, 1 pt was admitted for ruptured ectopic pregnancy, 1 for iliac vein clot, 1 for pulmonary embolism, 1 for possible vertebral osteomyelitis, 1 for vertebral artery aneurysm and 1 for colitis. One pt. was contacted with a CT diagnosis of appendicitis but no additional follow up information was available. Conclusion: The practice of prelim. interpretation of imaging studies in the ED results in a low frequency of preventable and potentially serious adverse events. Final readings by radiology specialist at the time medical decisions are made in the ED would likely eliminate these events.

Background: Patients' satisfaction is a common parameter tracked by health care systems and Emergency Departments (EDs). Objectives: To determine whether telephone calls by health care providers to patients after discharge from the ED was associated with improved patient satisfaction. Methods: Retrospective analysis of Press Ganey (PG; Press Ganey Associates, South Bend, IN) surveys from two EDs operated by the University of California San Diego Health System. Responses to the YES/NO question, "After discharge, did you receive a phone call from an ED staff member?" was compared to the responses to the question "likelihood of recommending this ED to others" (LR). This variable could be ranked with a score of 1 (very poor) to 5 (very good). Responses were dichotomized into two groups, 1-4 and 5. Chi-squared was performed to assess LR between those answering YES vs. NO to the call back question. Differences in proportion, 95% confidence interval (CI), and p-value are reported. Rankings for percentage of 5s across all EDs in the PG database were compared based upon YES/NO responses. Results: In the 12-month study period, about 30,000 surveys were mailed and 2250 (7.5%) were returned. Three hundred forty-seven (15.4%) checked off YES for the call back question. Percentage of 5s for LR for NO call back was 51.1% and for YES call back was 70.6% (difference = 19.5; 95% CI 14.0-24.6; p < 0.001). These values correlated with an ED ranking of 14th and 85th percentile, respectively. Conclusion: This retrospective study demonstrated a strong association between post-visit patient call back and LR. Further prospective study with control for co-variables is warranted. (C) 2013 Elsevier Inc.

INTRODUCTION:The treatment of acute coronary syndrome (ACS) includes the administration of aspirin. Current guidelines recommend chewing aspirin tablets to increase absorption. While this is intuitive, there are scant data supporting this recommendation. The purpose of this study is to assess which of 3 different aspirin formulations is most rapidly absorbed after ingestion.METHODS:A prospective, open-label, 3-way crossover volunteer study at a tertiary university medical center with human subjects 18 years or older. Fasted subjects were randomly assigned to receive aspirin 1,950 mg as (1) solid aspirin tablets swallowed whole, (2) solid aspirin tablet chewed then swallowed, or (3) a chewable aspirin formulation chewed and swallowed. Serum salicylate measurements were obtained over a period of 180 minutes. Pharmacokinetic parameters were determined.RESULTS:Thirteen males and 1 female completed all 3 arms of study. Peak serum salicylate concentrations were seen at 180 minutes in all groups. Mean peaks were 10.4, 11.3, and 12.2 mg/dL in groups 1, 2, and 3, respectively. Mean area under the time concentration was 1,153, 1,401, and 1,743 mg-min/dL in groups 1, 2, and 3, respectively. No measurable salicylate concentrations were seen in 6 subjects in group 1 at 60 minutes as compared to 1 subject in group 2. All subjects in group 3 had measurable levels at 45 minutes. There were no adverse effects in any of the subjects during the study period.CONCLUSION:Our data demonstrate that the chewable aspirin formulation achieved the most rapid rate of absorption. In addition, the chewable formulation absorption was more complete than the other formulations at 180 minutes. These data suggest that in the treatment of ACS, a chewable aspirin formulation may be preferable to solid tablet aspirin, either chewed or swallowed.

Background: Lice infestation is a commonly encountered disorder in emergency medicine. The louse survives from a blood meal from its host; hence, iron deficiency anemia is a theoretic possibility. A limited number of reports of severe iron deficiency anemia have appeared in the veterinary literature, but a thorough review of the medical literature did not reveal a single instance in human beings. Objective: We report a small case series of patients with heavy louse infestation and profound iron deficiency anemia. Case report: The index case along with two other cases discovered from an exhaustive search of 4 years of the institution's Emergency Department records all had heavy infestation with head and body lice. Laboratory evaluation revealed serum hemoglobin levels under 6 gm/dL, low serum ferritin levels, and microcytic red blood cell indices. All patients were admitted to the hospital, received transfusions, and had evaluation of their anemia. No patient had evidence of gastrointestinal blood loss or alternative explanation for their anemia. Conclusions: Although cause and effect cannot be established from this case series, to the best of our knowledge, this is the first published evidence of a provocative association of louse infestation and severe iron deficiency anemia in humans. (C) 2011 Elsevier Inc.

Background: Express admit units (EAUs) have been proposed as a way to expedite patient flow through the Emergency Department (ED). Objectives: We sought to determine the effect of opening a five-bed EAU unit for temporary placement of admitted patients on our ED length of stay (LOS) and waiting room times (WT). Method: This was a before-and-after interventional study of the 3-month period immediately before (pre-EAU) and after opening (post-EAU) of the EAU. We compared ED LOS and W T for patients admitted and discharged from the ED for both time periods, controlling for daily census and patient acuity. Results: During the post-EAU period, 386 patients (26.2% of total admits) were admitted through the EAU. Overall LOS decreased from 8:21 (interquartile range [IQR] 6:02-11:20) to 7:41 (IQR 5:22-10:16) for all admitted patients (p < 0.001), and from 3:41 (IQR 2:05-5: 58) to 3:35 (IQR 2:00-5:55) for the discharged patients (p = 0.025). After controlling for census and acuity, the LOS decreased an average of 10% (95% confidence interval [CI] 6%-14%;p < 0.001) for admitted patients and 4% (95% CI 2%-7%; p = 0.001) for discharged patients. These changes represented a decreased LOS of about 50 and 9 min, respectively. There were no significant differences in WT (0:44; IQR 0:09-2:07 vs. 0:50; IQR 0:11-2:20 for admitted patients and 0:41; IQR 0:09-1:50 vs. 0:41; IQR 0:10-1:47 for discharged patients). However, after controlling for census and acuity, WT decreased 9% (95% CI 1%-16%; p = 0.022) for discharged patients, which represented a decrease of about 4 min. Conclusions: With an EAU, there was a modest improvement in ED LOS despite an overall increase in daily ED volume. (C) 2010 Elsevier Inc.

STUDY OBJECTIVE:We assess the effect of sequential modifications in laboratory processing, including pneumatic tube transport and fully computerized order management, on laboratory turnaround time in the emergency department (ED).METHODS:This was an observational analysis of a comprehensive computerized database derived from ED, laboratory, and hospital information systems. The setting was an academic urban ED with annual census of 38,000. Participants and interventions included all patients who had laboratory testing (serum sodium level, troponin level, or CBC count) during three 1-month study periods: before pneumatic tube and computerized order management (prepneumatic tube), after pneumatic tube but before computerized order management (postpneumatic tube), and after both pneumatic tube and computerized order management (postpneumatic tube/computerized order management). The primary outcome measure was median laboratory turnaround time, reported with interquartile ranges. Additional measures included ED census and number of laboratory tests ordered during each study period.RESULTS:The monthly ED census was 3,021, 3,428, and 3,066 for the prepneumatic tube, postpneumatic tube, and postpneumatic tube/computerized order management periods. There was a significant decrease in turnaround time with each period and each test over time. For serum sodium testing, the median laboratory turnaround time decreased from 55.9 to 46.7 to 37.2 minutes for prepneumatic tube, postpneumatic tube, and postpneumatic tube/computerized order management periods. For CBC-count testing, median times decreased from 55.6 to 42.2 to 36.3 minutes, respectively. For troponin I testing, median times decreased from 52.8 to 41.8 to 30.6 minutes, respectively.CONCLUSION:Changes in laboratory specimen management, including the use of a pneumatic tube and computerized order management, resulted in a progressive decrease in laboratory turnaround time in the study ED.

Study objective: We evaluate the effect of an Internet-based, electronic referral system (termed IMPACT-ED for Improving Medical home and Primary care Access to the Community clinics Through the ED) on access and follow-up at primary care community clinics for safety net emergency department (ED) patients.Methods: We conducted a nonblinded interventional trial at an urban, safety net, hospital ED with a census of 39,000 annually. IMPACT-ED identified patients who had no source of regular care and lived in a 15-ZIP-code low-income area served by 3 community clinics. Emergency physicians received an automated notification through the electronic medical record to access an imbedded software program for scheduling follow-up clinic appointments. Patients who would benefit from a follow-up clinic visit within 2 weeks as determined by the emergency physician received a computer-gene rated appointment time and clinic map with bus routes as part of their discharge instructions, and the clinics received an electronic notification of the appointment. We compared frequency of follow-up for a 6-month period before implementation when patients received written instructions to call the clinic on their own (pre-IMPACT) and 6 months after implementation (post-IMPACT). Statistical analysis was conducted with chi(2) testing, and corresponding 95% confidence intervals are presented.Results: There were 326 patients who received an appointment (post-IMPACT), of whom 81 followed up at the clinic as directed (24.8%), compared with 399 patients who received a referral (pre-IMPACT), of whom 4 followed up as directed (1.0%), for an absolute improvement of 23.8% (95% confidence interval 19.1% to 28.6%).Conclusion: Although most patients still failed to follow up at the community clinics as directed, the use of an Internet-based scheduling program linking a safety net ED with local community clinics significantly improved the frequency of follow-up for patients without primary care. [Ann Emerg Med. 2009;54:279-284.]

Objective: Spacer devices (SD) in conjunction with metered dose inhalers (MDI) have been shown to be as effective as saline nebulizers for the delivery of beta-agonists. A preliminary study suggests that SDs are not consistently used. The purpose of this study was to investigate patterns of SD ownership and use to identify potential targets for future educational efforts to increase ownership and use of SD. Methods: Cross-sectional convenience sample survey of patients presenting to an academic Emergency Department (ED) with a history of asthma/COPD (chronic obstructive pulmonary disease). Informed consent was obtained. Survey data included demographics, association with a primary care physician (PCP), SD ownership, patterns of use, opinions of efficacy about SD and disease severity assessed by duration of asthma/COPD, prior ED visits, hospitalizations, and history of prior intubation. Patterns of use are described and univariate and multivariate analyses were used to identify factors associated with SD ownership. Results: Of the 313 patients, 55.9% were female, the mean age was 46.0 years (standard deviation 14.7), 54.3% were white, and 143 patients (45.7%) reported owning a SD. A total of 36.4% reported a prior hospitalization for their condition and 24% reported a history of being intubated. Less than half of patients presenting with asthma or COPD exacerbation that reported owning a SD used it the day of presentation to the ED. Logistic regression identified having a PCP and a history of prior hospitalization for asthma/COPD as factors independently associated with SD ownership (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.7 and OR 2.2, CI 1.3–3.5, respectively). Conclusion: A majority of patients with asthma/COPD do not own a SD. These data suggest that there is significant opportunity for educational efforts directed at a broad range of asthma/COPD patients in hopes of increasing ownership and use of SD.

Blood pressure is a standard vital sign in patients evaluated in an Emergency Department. The American Heart Association has recommended a preferred position of the arm and cuff when measuring blood pressure. There is no formal recommendation for arm position when measuring orthostatic blood pressure. The objective of this study was to assess the impact of different arm positions on the measurement of postural changes in blood pressure. This was a prospective, unblinded, convenience study involving Emergency Department patients with complaints unrelated to cardiovascular instability. Repeated blood pressure measurements were obtained using an automatic non-invasive device with each subject in a supine and standing position and with the arm parallel and perpendicular to the torso. Orthostatic hypotension was defined as a difference of >or= 20 mm Hg systolic or >or= 10 mm Hg diastolic when subtracting standing from supine measurements. There were four comparisons made: group W, arm perpendicular supine and standing; group X, arm parallel supine and standing; group Y, arm parallel supine and perpendicular standing; and group Z, arm perpendicular supine and parallel standing. There were 100 patients enrolled, 55 men, mean age 44 years. Four blood pressure measurements were obtained on each patient. The percentage of patients meeting orthostatic hypotension criteria in each group was: W systolic 6% (95% CI 1%, 11%), diastolic 4% (95% CI 0%, 8%), X systolic 8% (95% CI 3%, 13%), diastolic 9% (95% CI 3%, 13%), Y systolic 19% (95% CI 11%, 27%), diastolic 30% (95% CI 21%, 39%), Z systolic 2% (95% CI 0%, 5%), diastolic 2% (95% CI 0%, 5%). Comparison of Group Y vs. X, Z, and W was statistically significant (p < 0.0001). Arm position has a significant impact on determination of postural changes in blood pressure. The combination of the arm parallel when supine and perpendicular when standing may significantly overestimate the orthostatic change. Arm position should be held constant in supine and standing positions when assessing for orthostatic change in blood pressure.