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Managing Families With Multiple Children in the ED

Managing Families With Multiple Children in the ED

It is not uncommon for families to bring multiple children to the ED for evaluation at a single visit. These children often require fewer ED resources than patients presenting individually. “Non-urgent visits can become a significant obstacle to throughput and optimal use of the ED,” says Ilene Claudius, MD. These patients tend to have lower triage acuity and low hospital admission rates when compared with the general patient population. Assessing Urgent Care Needs In the Western Journal of Emergency Medicine, Dr. Claudius and colleagues had a study published that examined the actual need for urgent interventions in children of families registering multiple patients at once and compared these findings with families that registered single patients. Using a retrospective chart review, the investigators considered five interventions to be critical (admission, subspecialty consultation, performance of procedures, IV fluid administration, and observation for more than 6 hours). A sample of 83 patients from 41 families that registered multiple children was compared with 248 singleton controls. Only 4.8% of patients from families registering multiple children required critical ED interventions, compared with a 32.5% rate observed for families registering just one child. “While many children required medical care, our study showed that the vast majority of care that was required by families registering multiple children could have been rendered in a primary care setting,” says Dr. Claudius. “Families presenting with multiple children as patients mainly fell into a non-urgent category in terms of need for ED resource use.” A Continuing Problem The concept of patients using EDs as primary care has been well established in published research. “In many cases, parents may realize that...
Making the Case for More Specialist Training

Making the Case for More Specialist Training

Experts have reported that population growth among the elderly and the increasing prevalence of chronic diseases in these older Americans will have profound implications for the United States healthcare system in the coming decades. An estimated 89 million Americans will be 65 and older by 2050, a figure that is more than double the current population for this age group. In addition, more than 90% of elderly Americans report having one or more chronic diseases. “This trend is likely to continue,” says Timothy M. Dall, MS. “It will be challenging for the medical community to overcome the combination of increased longevity and high rates of chronic diseases like hypertension, diabetes, and obesity.” Primary care physicians (PCPs) play an important role in providing preventive services and caring for the elderly population, but recent data suggest that the need for specialist care is also likely to increase as medical knowledge and treatment options continue to advance. “Specialists play essential roles in diagnosing, treating, and monitoring patients with various health problems,” says Dall. “Understanding the needs and demand for both primary care and specialist services can help inform decisions about the number and mix of healthcare providers that the U.S. will need to train so that care is accessible, of high quality, and affordable.” Forecasting the Future In a study published in Health Affairs, Dall and colleagues forecasted future demand for healthcare services and providers. This forecast was based on projected changes in demographic characteristics and other predictors of healthcare use as well as the estimated impact of expanded medical coverage under the Affordable Care Act. According to the analysis, growth and...

Examining Length of Stay in 8-Hour Shifts

In previous research, studies have documented significant links between length of stay (LOS) over 24-hour periods and hospital occupancy, the number of ED admissions, and other factors. In the May 2012 Western Journal of Emergency Medicine, my colleagues and I published a study that looked at LOS in more discreet time periods than what earlier analyses have reported. We did this because ED crowding and volume can vary greatly during a given 24-hour period. We wanted to find out which factors were associated with LOS and whether this relationship was present during all or only specific 8-hour shifts. In our analysis, independent variables were measured during three 8-hour shifts. Shift 1 was from 7:00 am to 3:00 pm, shift 2 was from 3:00 pm to 11:00 pm, and shift 3 was from 11:00 pm to 7:00 am. For each shift, the numbers of ED nurses on duty, discharges, discharges on the previous shift, resuscitation cases, admissions and ICU admissions, and LOS on the previous shift, were measured. For each 24- hour period, the numbers of elective surgical admissions and hospital occupancy were measured, since these could not be measured in 8-hour time intervals. ED Length of Stay: Roles of Occupancy & Admissions On all three shifts, LOS increased by about 1 minute for each additional 1% increase in hospital occupancy. The mean hospital occupancy in our study was 94.9%; considering this high level of demand for inpatient beds, even a 1% increase in occupancy can lead to significant delays. The demand for inpatient beds often exceeds 100% capacity during the late morning and early afternoon hours on weekdays. To...

ERs Go Mobile with Reservations

More than 100 hospital emergency departments are borrowing an idea from the restaurant industry: online reservations. Additional concierge services such as mobile apps for wait times make ER experiences more agreeable. ERs are going mobile at least partly to increase patient satisfaction scores, which are tied to hospital reimbursement for Medicare patients under the Affordable Care Act. Higher scores = hospital bonuses. The reservation service requires that patients describe their ailment. Patients who indicate they have serious symptoms such as chest pains are directed to go to the hospital or call 911. Critics argue that if someone is able to make an appointment, it’s not an emergency and may encourage inappropriate use of already crowded emergency rooms. They also claim that the service may discriminate against lower-income patients who don’t have access to smartphones or computers. However, the check-in service has undergone legal review and doesn’t appear to violate the Emergency Medical Treatment and Active Labor Act. A hospital’s triage and throughput process remains the same, and care is provided based on the most urgent medical need. Physician’s Weekly wants to know… Do you think scheduled appointments qualify as an...

Wait Times for Psychiatric Patients in the ED

Hospital-based EDs are increasingly overburdened throughout the United States, resulting in a widening gap between the quality of emergency care Americans expect and the quality of care they actually receive. Longer lengths of stay within the ED have led to increased provider stress, greater risks for adverse events, and reduced patient satisfaction. Length of stay for patients seeking psychiatric care in the ED appears to be even longer than that of people without psychiatric concerns. This fact, when coupled with an increasing volume of psychiatric visits to EDs (23% growth between 2000 and 2007), have led to a real crisis for this vulnerable population in psychiatric distress. Identifying patient and clinical factors associated with long ED lengths of stay for psychiatric patients is critical to the development and implementation of targeted quality improvement efforts. To that end, my colleagues and I conducted a study to seek out these factors in this patient population and measure the effect of these variables on time spent within the ED. Our prospective analysis, published in the May 2, 2012 Annals of Emergency Medicine, involved 1,092 adults treated at one of five EDs. Secondary analyses considered patients discharged home and those who were admitted or transferred separately. Factors That Increase Hospital Length of Stay According to the findings from our study, the average length of stay in the ED was 11.5 hours for psychiatric patients, but lengths varied based on certain characteristics. Patients who were discharged home stayed 8.6 hours in the ED, while those admitted to psychiatric units within the hospital stayed 11.0 hours. Patients transferred to outside units within the local healthcare...
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