3 results
P117: A multicenter analysis of an emergency physician lead on department flow and the provider experience
- K. Crowder, E. Domm, R. Lipp, O. Robinson, S. Vatanpour, D. Wang, E. Lang
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S107
- Print publication:
- May 2020
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Introduction: Emergency department (ED) flow is a strong predictor of patient safety, quality of care and provider satisfaction. Throughput interventions have been shown to improve flow metrics, yet few studies have considered MD leadership roles and evaluated provider experience. Our objective was to evaluate the emergency physician lead (EPL) role, a novel MD staffing initiative. Methods: This mixed-method observational time series analysis evaluated ED metrics at two tertiary EDs including ED length of stay (LOS), EMS Park LOS and physician initial assessment (PIA) time as well as 72-hour readmit and left without being seen (LWBS) rates. Data was collected from the ED information system database for control (Dec 6, 2017-Feb 28, 2018 SITE1 and Mar 1–May 31, 2018 SITE2), pre (Sept 3-Nov 30, 2018 SITE 1 and Dec 3, 2018-Feb 28, 2019 SITE2) and post (Dec 3, 2018 –Feb 28, 2019 SITE1, Mar 1- May 31, 2019 SITE2) periods for adult patients presenting to each site. Site data was analyzed independently using descriptive and inferential statistics to calculate differences in means, and means were compared using t-tests. A survey elicited provider feedback from ED physicians, nurses, and EMS professionals on the effect of the EPL on throughput, timeliness of admissions and discharges, provider workload, and the EPL as a resource to other professionals. Results: The number of ED visits at SITE1 were 13136 (Ctrl), 13236 (Pre) and 13137 (Post), and at SITE2 were 14371(Ctrl), 13866 (Pre) and 14962 (Post). Mean ED LOS was decreased by 17 min in post vs control and 20 min vs pre at SITE1 (p < 0.01). SITE2 saw an increase in ED LOS by 7 min vs control and 8 min vs pre (p < 0.01). EMS LOS at SITE1 was decreased by 21 min vs control and 22 min vs pre (p < 0.01), but was increased at SITE2 by 2 min vs control (p = 0.09) and 14 min vs pre (p < 0.01). PIA time at SITE1 was decreased by 15 min vs control (p < 0.01) and 13 min vs pre and increased by 5 min vs control and 12 min vs pre at SITE2 (p < 0.01). 72 hour readmit and LWBS rates were unchanged at both sites. Qualitative feedback from ED providers highlighted the early provision of treatments and investigations by the EPL, and many felt the EPL was an important resource. Conclusion: The inclusion of both quantitative and qualitative data in this study provided a robust analysis of the impact of the EPL role and demonstrated modest but important improvements. A site-dependent, carefully considered implementation of the EPL role may improve ED metrics and provider experiences.
MP36: Can one emergency physician improve department flow? A proof-of-concept trial of a physician float role
- K. Crowder, E. Domm, J. Fedwick, C. McGillivray, A. Tse, B. Weber, C. Rebus
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, pp. S53-S54
- Print publication:
- May 2018
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Introduction: Emergency departments (EDs) are overcrowded and patient acuity and volumes are ever-increasing. While changes to the flow of ED patient input and output are outside the control of frontline ED teams, the efficiency of ED throughput can be optimized. One widely studied intervention is the implementation of a physician liaison role to assist in managing overall ED flow. The Physician Float (PF) acts as a triage liaison, second physician for resuscitations, ED procedural sedation physician, and fields ED referral calls. This is a first-iteration proof-of-concept trial to plan, implement and evaluate if the PF role could decrease ED length of stay (LOS) by a goal of 30 minutes, over a four-week period, without adverse changes to left without being seen (LWBS) and bounce-back rates. Methods: The PF role was implemented as a scheduled emergency physician shift in the fall of 2017. Ongoing iterations of this role implementation are being reviewed for re-implementation. The primary outcome measure was ED LOS; secondary outcomes included time-to-physician initial assessment (PIA), EMS offload rates, and LWBS and 72-hour bounce-back rates. Qualitative data including patient concerns and physician feedback were also collected. Data were collected after the trial from a centralized, de-identified ED information system database with time-stamp quantifiers and compared to the following four-week time period where the shift is a regular ED physician shift at the same time. The ED physician and nursing team planned and implemented the PF role, then results were evaluated and shared with the wider ED staff in departmental grand rounds and quality council presentation formats, and recommendations were gathered from to adjust and strengthen future iterations of PF role implementation. Results: Descriptive statistics and Mann-Whitney and Median tests were calculated. On average there were 185 daily ED visits in the trial and comparison periods. Median ED LOS decreased by 12 minutes in the PF trial period (p<0.05). Furthermore, there was a 12 minute decreased ED LOS for all discharged patients (p<0.05). PIA time decreased by 13 minutes for patients that were admitted. The average percentage of EMS offloads within 60 min improved from 75% to 80.7% for admitted patients. LWBS and 72-hour bounce-back rates were unchanged. No additional patient concerns arose related to or during the trial. Physician feedback on the PF role was mainly positive. Conclusion: The defined role of a PF in an ED can decrease ED LOS, albeit not achieving the desired 30-minute reduction on the first iteration, this trial supported proof-of-concept for implementation of a PF role in a tertiary care centre ED. Further iterations are needed to evaluate the scalability and sustainability of this role.
MP35: An educational and audit-and-feedback approach to decreasing unnecessary intravenous therapy in low-acuity emergency patients
- K. Crowder, C. Del Castilho, E. Domm, L. Norrena, P. Nugent
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, p. S53
- Print publication:
- May 2018
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Introduction: Intravenous (IV) therapy in the emergency department (ED) is associated with risk of harm from IV complications, higher ED monitoring requirements and increased ED length of stay (LOS), the latter a measure most cumbersome in lower-acuity patients that are eventually discharged from the ED. The aim of this quality improvement project was to evaluate the effectiveness of educational and audit-and-feedback interventions, with a goal of relative reduction of ED IV therapy by 20% over eight week periods, in lower-acuity patients in the high-turnover intake area of the ED who were discharged from the ED. Methods: The first cycle of the project was education about IV therapy use and alternatives in lower-acuity, ED patients (Canadian Triage Acuity Scale (CTAS) 3 and 4) from July 2 to August 31, 2017. Education was delivered through email information, posters, education sessions with nurse educators, and working groups sharing information. The second cycle of the project, from October 16 to December 15, 2017, also integrated an audit-and-feedback tool whereby physicians received their own pooled ordering data of IVs from the same period the previous year and then trial period as well pooled comparison averages for the physician group in the population of interest. Measures were the percentage of IVs ordered by physicians and administered by nurses in the population of interest in each time period. Results: From July 2 to August 31, 2017, when the intervention was education only, the rate of IV therapy changed from 31% to 37%, which reflects a 19% relative increase in IV use. In the beginning of the second cycle utilizing both education and audit-and-feedback interventions, from October 16 to December 15, 2017, 35% of patients had IV therapy. At the end of the second cycle, 25% of patients had IV therapy, a 28% relative decrease in IV therapy rates. When both cycles are reviewed sequentially, IV therapy rates decreased from 31% to 25%, a relative reduction of IV usage of 19%. Conclusion: In this quality improvement project, an educational initiative for the interdisciplinary team alone did not reduce IV use in lower-acuity patients. Concurrent education and audit-and-feedback interventions were more effective than education alone in decreasing IV therapy in appropriately selected patients in a tertiary ED.