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Menchine, M. D., Wiechmann, W.Rudkin, S.
Trends in midlevel provider utilization in emergency departments from 1997 to 2006.
Acad Emerg Med. 2009 Oct;16:963-969.
This study looked at specific parameters related to the expansion of midlevel provider (MLP) practice in U.S. emergency departments. Data were analyzed using the National Hospital Ambulatory Medical Care Survey (NHAMCS). The number of patients seen by MLPs increased sharply, from 5.2 million in 1997 (5.5% of all ED cases) to 15.2 million in 2006 (12.7% of all ED cases). In addition, the number of EDs reporting use of MLPs increased from 28.3% in 1997 to 77.2% in 2006.
Sullivan, A. F., Ginde, A. A., Espinola, J. A. et al.
Supply and demand of board-certified emergency physicians by U.S. state, 2005.
Acad Emerg Med. 2009 Oct;16:1014-1018.
These authors used a model to estimate supply and demand of emergency physicians by state, based on 2005 data. Overall, the supply of emergency medicine board-certfied physicians was 58% of required FTEs to staff all EDs, ranging by state from 10% to 104%. The overall picture quantifies significantly more demand than supply.
Dickson, E. W., Anguelov, Z., Vetterick, D. et al.
Use of lean in the emergency department: a case series of 4 hospitals.
Ann Emerg Med. 2009 Oct;54:504-510.
Many emergency departments are looking at the Lean methodology to improve their processes. These authors describe the effects of using Lean on quality of care in 4 EDs. One year after using Lean, 3 out of 4 EDs had reduced length of stay, despite an increase in volume, with concomitant increase in patient satisfaction. Both leadership and front line commitment to the process were critical to success.
Herring, A., Wilper, A., Himmelstein, D. U. et al.
Increasing length of stay among adult visits to U.S. Emergency departments, 2001-2005.
Acad Emerg Med. 2009 Jul;16:609-616.
This study documents what many who practice emergency care already perceive, that length of stay (LOS) is increasing. This was a retrospective study of the NHAMCS database, from 2001-2005. Median LOS increased 3.5% per year, from 132 minutes in 2001 to 154 minutes in 2005. For critically ill patients, which require significantly more resources to manage, LOS increased 7.0% per year, from 185 minutes to 254 minutes. ED LOS was persistently longer for African-American and Hispanic patients, and did not improve over this period.
Carr, B.G., Branas C.C., Metlay J.P., et al.
Access to Emergency Care in the United States.
Ann Emerg Med. 2009 Aug;54:261-269.
For optimal care, rapid access to emergency services is essential. The National Emergency Department Inventories-USA was used to identify location, volume and teaching status of EDs in the US. Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes.
Magid, D. J., Sullivan, A. F., Cleary, P. D. et al.
The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments.
Ann Emerg Med. 2009 Jun;53:715-23.e1.
This study assessed the degree to which EDs are designed, managed and supported in ways that ensure patient safety. 3,562 clinicians from 65 emergency departments responded to the survey. 62% reported insufficient space for delivery of care most or some of the time, with 82% reporting the number of patients exceeding ED capacity most or some of the time. Half of respondents reported that ED patients requiring ICU admission were rarely transferred to the ICU within 1 hour. This report highlights significant safety concerns for US EDs.
Khare, R. K., Powell, E. S., Reinhardt, G. et al.
Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion?
Ann Emerg Med. 2009 May;53:575-585.
These authors used a computer simulation model to assess the effect on ED length of stay of varying the number of ED beds vs altering the time patients spend in the ED. Although there are always important assumptions to consider in computer simulation models, their results suggest that admitting patients to the floor faster led to an improvement in overall ED length of stay, whereas increasing the number of ED beds did not.
Moskop, J. C., Sklar, D. P., Geiderman, J. M. et al.
Emergency department crowding, part 1 - concept, causes, and moral consequences.
Emergency department crowding, part 2 - barriers to reform and strategies to overcome them.
Ann Emerg Med. 2009 May;53:605-617.
This is a 2 part article that discusses in great depth the issues surrounding ED crowding. The first part discusses definitions, causes and moral consequences, finding that the inability to transfer ED patients to inpatient beds is a root cause of crowding. It then goes on to discuss the ramifications of this major problem. The second part examines barriers to resolving the problem of ED crowding and potential strategies to overcome those barriers.
Henneman, P. L., Lemanski, M., Smithline, H. A. et al.
Emergency department admissions are more profitable than non-emergency department admissions.
Ann Emerg Med. 2009 Feb;53:249-255.
This important study compares the contribution margin per case per hospital day of ED admissions with non-ED admissions in a single, 600 bed academic hospital with an annual ED census of 100,000. The fiscal years 2003-2005 were examined. For these combined years, there were 51,213 ED and 57,0004 non-ED admissions. The median contribution margin per day was $769 for ED admissions and $595 for non-ED admissions. They conclude that ED admissions generate a higher contribution margin than non-ED admissions.
Handel, D. A.John McConnell, K.
The financial impact of ambulance diversion on inpatient hospital revenues and profits.
Acad Emerg Med. 2009 Jan;16:29-33.
This is a retrospective review of ambulance diversions in relation to revenue and profits from one academic medical center from July 2003- December 2006. A total of 166,460 ED patients were included in the analysis. For patients admitted from the ED, average weekly revenues during periods of high diversion were $265K higher than periods of no diversion. The overall increase in profitability was significant for periods of severe divert compared to no divert ($119K per week). The authors conclude that there is no financial disincentive from an inpatient perspective for the boarding of admitted patients in the ED and increasing periods of diversion.
Kansagra, S. M., Rao, S. R., Sullivan, A. F. et al.
A Survey of Workplace Violence Across 65 U.S. Emergency Departments.
Acad Emerg Med. 2008 Dec;15:1268-1274.
Workplace violence in emergency departments is becoming a major issue for staff in many institutions. These authors collected data from 69 U.S. EDs, ultimately analyzing 3,518 surveys from 65 sites. Over a 5 year period, a median of 11 attacks per ED was reported. Key informants at 20% of EDs reported that guns or knives were brought to the ED on a daily or weekly basis. Nurses were less likely to feel safe when compared to other surveyed staff. This is clearly a major issue for staff in our nation's emergency departments.
Hwang, U., Richardson, L., Livote, E. et al.
Emergency Department Crowding and Decreased Quality of Pain Care.
Acad Emerg Med. 2008 Dec;15:1248-1255.
These authors studied the relationship between two major concerns for ED leadership: overcrowding and pain management. They retrospectively studied a total of 1,068 visits at an academic, tertiary care ED in 2005. They found that fewer patients received analgesics during periods of high census, with a direct correlation between total ED census and increased time to pain assessment, time to analgesic medication ordering and time to medication administration. They conclude that ED crowding negatively impacts patient care in the area of pain management.
Weber, E. J., Showstack, J. A., Hunt, K. A. et al.
Are the uninsured responsible for the increase in emergency department visits in the United States?
Ann Emerg Med. 2008 Aug;52:108-115.
The number of ED visits has increased 28% between 1992 and 2005, and the current trend continues upward. These investigators looked at several parameters from 1996 to 2004, using the national Community Tracking Study Household Surveys. The proportion of adult ED visits by persons without insurance was stable over the study period, ranging from 14.5% to 16.1%.The proportion of visits by persons with family income greater than 400% of the federal poverty level increased from 21.9% to 29% (p=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% to 59% (p=.002). They conclude that the increase in ED visits cannot be primarily attributed to the uninsured, and that a major contribution to the increase is from ED use by nonpoor persons and those whose usual source of care is a physician's office.
Hoot, N. R.Aronsky, D.
Systematic review of emergency department crowding: causes, effects, and solutions.
Ann Emerg Med. 2008 Aug;52:126-136.
These authors conducted a PubMed search to identify research related to ED crowding, grading the methodology for each study. 93 articles met their inclusion criteria, which focused on crowding causes, effects and solutions. The methods and results for each high quality study are summarized. This is an excellent reference article for those interested in addressing the issues and challenges surrounding overcrowding in EDs.
Singer, A. J., Viccellio, P., Thode, H. C. J., et al.
Introduction of a stat laboratory reduces emergency department length of stay.
Acad Emerg Med. 2008 Apr;15:324-328.
It is well known that ED length of stay (LOS) is a major determinant of patient satisfaction, and laboratory delays are a frequent cause of increased LOS. These authors looked at LOS in their ED for a one month period, before and after installation of a stat lab in the central laboratory. Implementation of the stat lab resulted in reduction of median LOS from 466 minutes to 402 minutes for admitted patients. The effects of the stat lab on LOS of discharged patients was less marked, although there were significant increases in the percentages of laboratory tests with test turnaround time within 30 minutes.
Vieth, T. L.Rhodes, K. V.
Nonprice barriers to ambulatory care after an emergency department visit.
Ann Emerg Med. 2008 May;51:607-613.
We frequently hear from patients about attempts to see their primary provider that were unsuccessful. In this study, research assistants called a random sample of 603 ambulatory clinics, posing as patients, to get a follow up appointment from their ED visit. Only 242 of 603 (40%) pseudopatient scenarios resulted in a follow up appointment within 1 week of ED visit. Multiple barriers were identified and discussed, including busy signals, clinic closures, voicemail or personnel too busy to take the call. If clinic personnel were reached, 55% were put on hold, with average hold time of 2.43 minutes. On average, it required 1.7 calls to reach appointment staff. Total telephone time averaged 11.1 minutes for successful appointments. This study documents the many barriers to obtaining timely follow up care for ED visits.
Hsia RY, MacIsaac D, Baker LC.
Decreasing reimbursements for outpatient emergency department visits across payer groups from 1996 to 2004.
Ann Emerg Med. 2008 Mar; 51(3):265-74
There continues to be concern that decreases in payments to emergency departments will adversely affect overall operations. Using the Medical Expenditure Panel Survey data from 1996-2004, these authors examined charges and payments across insurance. Overall, the mean charge for an outpatient ED visit increased from $713 in 1996 to $1,390 in 2004. The mean payment increased from $410 (57% of charge) in 1996 to $592 (42% of charge) in 2004. The proportion of charges paid in 2004 varied from 56% for privately insured visits to 33% for Medicaid visits. The authors conclude that the persistent declines in payments may threaten the survival of EDs and their role as safety nets in the health system.
Kanter, R. K.Moran, J. R.
Pediatric preparedness of US emergency departments: a 2003 survey.
Pediatrics. 2007 Dec;120(6):1229-1237.
These authors sent a survey to assess pediatric preparedness to all US emergency departments in 2003. A total of 1,489 useable surveys (29%) were received for analysis. 89% of pediatric ED visits occurred in non-children's hospitals, with 26% occurring in rural or remote facilities. Of note, 75% of respondents saw less than 7,000 children annually. Only 6% of EDs had all recommended equipment and supplies, with neonatal or infant equipment frequently lacking. The authors conclude that there is significant opportunity for improvement in pediatric preparedness. While this study has led to some controversy, it supports concerns raised by the Institute of Medicine regarding preparedness for pediatric emergency care in our nation's emergency departments.
Burt C.W., Middleton K.R.
Factors associated with ability to treat pediatric emergencies in US hospitals.
Ped Emerg Care. 2007 Oct;23:681-689.
These authors sought to understand factors associated with the availability of pediatric services and expertise in US hospitals for treating pediatric emergencies. They used data from the 2002-2003 NHAMCS survey, compared with guidelines developed by the American Academy of Pediatrics and American College of Emergency Physicians. Pediatric volume, teaching hospital status, geographic region, and per capita income of the community were strongly related to better preparedness on each of their measures. Many hospitals that did not offer specialized pediatric care lacked transfer agreements with hospitals offering such care.
Kanter, R. K.Moran, J. R.
Hospital emergency surge capacity: an empiric New York statewide study.
Ann Emerg Med. 2007 Sep;50(3):314-319.
Disaster planning and preparation for major surges in ED volume remain challenges for most EDs. Current national standards call for hospitals to accommodate surges of 500 new patients per million population in a disaster. This article presents data from New York State hospital occupancy rates and estimates the ability to accommodate new patients. Total hospital beds for the period studied included a peak capacity of 2,707 children and 46,613 adults. Based on calculated average occupancy rates, there was an average statewide capacity for a surge of 268 new pediatric and 555 adult patients per million population. The authors conclude there are insufficient pediatric beds to meet disaster needs, and suggest that modified standards may be required to meet pediatric needs during a mass-casualty event. Clearly, other states may also have insufficient surge capacity.
Holroyd, B. R., Bullard, M. J., Latoszek, K., et al.
Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial.
Acad Emerg Med. 2007 Aug;14:702-708.
Many processes have been explored for improving patient flow to reduce ED overcrowding. In this study, a "triage liaison physician" (TLP) was placed in triage, whose role was to initiate patient management, assist triage nurses, answer medical consult or transfer calls, and manage ED administrative matters. The study was divided into three 2-week blocks. Within each block, 7 days were randomized to TLP shifts, and the other 7 days to control shifts (no TLP). Overall, length of stay was reduced by 36 minutes (4.3 vs 5 hours; p<0.001), along with a modest decrease in left without being seens. Although there are some important limitations to this study, it is an article worth reading and a process change worthy of consideration.
Hsiao, A. L., Santucci, K. A., Dziura, J., et al.
A randomized trial to assess the efficacy of point-of-care testing in decreasing length of stay in a pediatric emergency department.
Pediatr Emerg Care. 2007 Jul;23:457-462.
Point of care (POC) laboratory testing is one enhancement that emergency departments use to reduce throughput times. This is a prospective, randomized, controlled trial of pediatric patients requiring blood work. Of 225 patients, 114 were randomized to the POC testing group, and 111 to the routine blood testing group. Significantly less time was required for results to become available with POC vs. routine testing (5 vs 70 minutes; p<0.001). A significant decrease of 38.5 minutes (p<0.001) in length of stay was also noted. The authors conclude that POC testing is effective in improving throughput time and improving patient flow.
Li, G., Lau, J. T., McCarthy, M. L., et al.
Emergency department utilization in the United States and Ontario, Canada.
Acad Emerg Med. 2007 Jun;14:582-584.
Lack of health insurance is thought to be a major contributing factor to ED overcrowding in the U.S. Using the National Hospital Ambulatory Medical Care Survey for U.S. data, and the National Ambulatory Care Reporting System for Canadian data, this study compared all 2003 ED visits in the U.S. with those of Ontario, Canada. Health care in Canada is finance through a national health insurance program. There were no differences in the annual ED visit rate (both were 40 visits per 100 population). Other data were compared, with the conclusion that ED visit rates and patterns are similar in the U.S. and Ontario, Canada, and that differences in health insurance do not appear to impact overall utilization of emergency services.
Rodriguez, R. M., Anglin, D., Hankin, A., et al.
A longitudinal study of emergency medicine residents' malpractice fear and defensive medicine.
Acad Emerg Med. 2007 Jun;14:569-573.
Using case scenarios in a prospective, longitudinal study of emergency medicine residents at 5 programs, these authors sought to evaluate residents' evolution of defensive medicine and malpractice concern. 46 residents were evaluated during the course of their residency. Interns were found to enter programs with a "moderate" malpractice concern, which did not change significantly during the course of the residency. These concerns did not markedly impact their decisions to perform ED procedures.
Schull, M. J., Kiss, A.Szalai, J. P.
The effect of low-complexity patients on emergency department waiting times.
Ann Emerg Med. 2007 Mar;49:257-264.
It is well known that patients frequently present to the ED with minor illnesses and injuries. As managers work to reduce throughput times, the impact of this population has come under scrutiny. This study looked at the impact of low acuity patients on waiting times at Ontario hospitals during a one year period. There were 4.1 million patient visits at 110 EDs during the study period. Low, medium and high complexity patients represented 50.9%, 37.1% and 12% of all patients, respectively. In adjusted analyses, every 10 low complexity patients arriving per 8 hours was associated with a 5.4 minute increase in mean length of stay and a 2.1 minute increase in mean time to physician contact for medium and high complexity patients. The authors conclude that low complexity patients are associated with a negligible increase in ED length of stay and time to first physician contact. Diverting this population of patients away from the ED are unlikely to improve these parameters.
Falvo, T., Grove, L., Stachura, R., et al.
The opportunity loss of boarding admitted patients in the emergency department.
Acad Emerg Med. 2007 Apr;14:332-337.
It is well known that boarding admitted patients in the ED is a major cause of crowding and ambulance diversions. This study examined retrospectively 62,588 patients to a 450 bed community teaching hospital during a one year period. They found that transferring admitted patients from the ED to an impatient unity within 120 minutes would have increased the functional treatment capacity of the ED by 10,397 hours during this period. By reducing other delays related to the admission process, providing services to new patients in ED beds formerly used to board inpatients could have generated nearly $4 million in additional net revenue.
Sacchetti A, Senula G, Strickland J et al.
Procedural sedation in the community emergency department: initial results of the ProSCED registry
Acad Emerg Med. 2007 Jan;14:41-4.6
There is little information on the use of procedural sedation in community emergency departments. This study examines 1,028 procedural sedations on 980 patients from 14 community ED study sites. Ages in this study ranged from 1 month to 95 years. A wide variety of sedating agents were used. Complications occurred in 4.1% of cases, with serious complications, such as assisted ventilation, occurring in 1.1% of cases. All complications were managed by the ED physician, and none required a change in disposition. They conclude that procedural sedation in the community ED setting appears to be safe and effective over a wide range of procedures and ages.
Falvo T, Grove L, Stachura R et al.
The financial impact of ambulance diversions and patient elopements.
Acad Emerg Med. 2007 Jan;14:58-62.
The objective of this study was to establish a method to quantify the revenue lost as a result of patient elopements (left without being seen) and ambulance diversion. It is a retrospective, descriptive study in one institution with an annual volume of 62,588 patients in fiscal year 2005. The study describes the assumptions made regarding patients not seen as a result of overcrowding, and applies these financial assumptions to this population. The result for this ED was a net revenue loss of nearly $4 million during the 12 month study period. While studies utilizing financial assumptions applied to a group of patients for whom data are lacking has limitations, this methodology demonstrates specific and significant net revenue loss from systems problems commonly encountered.
Ding R, McCarthy ML, Li G et al.
Patients who leave without being seen: their characteristics and history of emergency department use.
Ann Emerg Med. 2006 Dec;48:686-693.
Patients who have left without being send (LWBS) remain a concern for many reasons. This article from the Johns Hopkins emergency department used a pair-matched, case-control design to explore the influence of patient attributes on the likelihood of leaving prior to completion of the visit. An impressive 1,476 pairs were evaluated during a 6 month period in 2004. Younger age, being uninsured or covered by Medicaid, and a previous uncompleted visit, were significantly associated with risk of LWBS. The authors conclude that EDs should make every effort to minimize LWBS patients, as this group of patients is less likely to receive care elsewhere.
Sullivan AF, Richman IB, Ahn CJ et al.
A profile of US emergency departments in 2001.
Ann Emerg Med. 2006 Dec;48:694-701.
The authors collected data on US emergency departments from 2 independent sources, and contacted those hospitals that did not provide data to further improve the database. The article provides some great data on the state of US emergency departments, with some excellent graphics in the article. As one example, one-third of EDs have a volume of less than 8,760 patients. The national median for ED visits is 15,711.
 Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04.
This is a summary from the Centers for Disease Control and Prevention, with some excellent statistics and information.
Institute of Medicine Editorials:
Rowe BH, Channan P, Bullard M et al.
Characteristics of Patients Who Leave Emergency Departments without Being Seen.
Acad Emerg Med. 2006 August;13:848-859.
Patients who leave the emergency department without being seen (LWBS) frequently present a clinical and financial concern for hospitals. Sampled data were obtained from 2 Canadian hospitals (one pediatric, one adult), resulting in 711 LWBS patients during 77 days of sampling (4.5% LWBS rate). Not surprisingly, the most common reason for leaving was "fed up with waiting" (45%). Of the LWBS patients, 60% sought care within 1 week, 14 were hospitalized, and one required urgent surgery. They conclude that while complications are rare, LWBS can be associated with adverse outcomes.
Hunt KA, Weber EJ, Showstack JA et al.
Characteristics of frequent users of emergency departments.
Ann Emerg Med. 2006 July;48:1-8.
Using data from the 2000-2001 Community Tracking Study Household Survey, these authors examined adult ED visits, defining a frequent user as having 4 or more visits. The 8% of users with frequent visits were responsible for 28% of adult ED visits. The vast majority of frequent visits (84%) had health insurance and a usual source of care (81%). Characteristics associated with frequent use included poor physical health, poor mental health, 5 or more outpatient visits annually, and family income below the poverty threshold.
McConnell KJ, Richards CF, Daya M et al.
Ambulance diversion and lost hospital revenues.
Ann Emerg Med. 2006 July; in press.
Ambulance diversion is well known problem faced in many emergency departments across the country. This article examines hospital revenue lost for each hour of ambulance diversion at an urban, academic ED. Each hour on diversion was associated with $1,461 in lost hospital revenue. Increasing ICU beds resulted in a significant decrease in ambulance diversion, resulting in more patients, and $175,000 in additional monthly revenue.
Institute of Medicine, The National Academies
Future of Emergency Care
Report released June 14, 2006
This major report, a culmination of work over the past 2 years, offers advice and direction from the prestigious Institute of Medicine as to how we as a nation need to address the challenges in our system of emergency care. The report focuses on 3 broad areas: emergency medical services, hospital- based emergency care, and emergency care for children. The above link goes to a summary page, with further links available to download pdf summaries or to read the reports on line. Any manager working in the emergency care field should become familiar with the findings of this report.
Mohanty SA, Washington DL, Lambe S et al.
Predictors of on-call specialist response times in California emergency departments.
Acad Emerg Med. 2006 May;13:505-512.
This study assessed waiting times for on-call specialists for 1,798 patients in 30 California EDs during a six month period. The vast majority (86%) responded within 30 minutes; however, 10% did not respond at all. In addition, after controlling for potential confounders, the authors found that for every $10,000 increase in hospital zip code income, the odds of a response within 30 minutes increased by 123%. They conclude that policy should focus on making more funding available for on-call specialists in poor areas.
Green SM.
Is there evidence to support the need for routine surgeon presence on trauma patient arrival?
Ann Emerg Med. 2006 May;47:405-411.
Dr. Green, a noted researcher for highlighting old assumptions about the provision of sedation in emergency departments, once again has written eloquently on a challenging topic: the need for surgeon presence on trauma patient arrival. Many institutions grapple with the difficulty in implementing related policies. The American College of Surgeons has guidelines for trauma centers that require surgical presence for patients with potentially serious injuries. Yet, in looking at the literature, as well as systems in Europe and Canada, the evidence is lacking for such a need. This article, and its accompanying editorial, are well worth taking a look at.
Burt CW, McCaig LF, Valverde RH.
Analysis of ambulance transports and diversions among US emergency departments.
Ann Emerg Med. 2006 April;47:317-326.
This study used data from the 2003 ED component of the National Hospital Ambulatory Medical Care Survey, providing information from 405 EDs on 40,253 visits. There were 16.2 million arrivals by ambulance nationally; 37% of these resulted in hospital admission. About 45% of EDs reported ambulance diversions at some point during the previous year, resulting in a total of about 500,000 diversions- 1 ambulance diversion per minute.
Yarris LM, Moreno R, Schmidt TA et al.
Reasons why patients choose an ambulance and willingness to consider alternatives.
Acad Emerg Med. 2006 April;13:401-405.
Everyone who works in the emergency department has experienced patients arriving by ambulance with minor complaints. These researchers surveyed 315 patients transported by ambulance; exclusion criteria included medically unstable patients or those with significant trauma. They found that nearly 80% of patients were willing to consider at least one alternative method of transportation, such as car or taxi. This study implies that alternative methods of transport may be widely acceptable, with improved utilization of ambulance resources.
Hunt KA, Weber EJ, Showstack JA et al.
Characteristics of frequent users of emergency departments.
Ann Emerg Med, in press, published on line March 30, 2006.
These authors, using data from a 2000-2001 national survey, defined frequent ED visits as 4 or more visits. Of 45.2 million adult ED visits, 8% had frequent visits, accounting for 28% of total adult visits. Most frequent users had health insurance (84%) and 81% had a usual source of healthcare. They found that while the majority of adult frequent ED visitors had insurance and a usual source of care, they were more likely to be in poor health. This is a study well worth taking a look at.
National Emergency Department Inventory
Emergency Medicine Network, February 2006.
This chart shows the distribution of ED volumes nationally and by state for 2001. Surprisingly, the median number of ED visits nationally is only 15,711, with a whopping 35% of EDs having an annual volume of less than 10,000 patients.
Zibners LM, Bonsu BK, Hayes JR et al.
Local weather effects on emergency department visits
Ped Emerg Care. 2006 Feb;22:104-106.
This is another study that examines if weather data can be used to predict emergency department volume. Its conclusions are similar to previous studies, suggesting that temperature and precipitation data do not predict how busy the shift the will be.
Sacchetti A, Baren J, Carraccio C.
The paradox of the nested pediatric emergency department.
Acad Emerg Med. 2005 Dec;12:1236-1239.
This interesting study explores the impact on emergency physician pediatric skills of establishing a
limited hours pediatric emergency department (nested pediatric emergency department, or nPED) within
a general ED. Three models are examined: 1) the nPED, in which treating physicians cared only for
patients presenting to the pediatric ED during operating hours (late afternoons, evenings), 2) the
Total ED (tED) model, in which treating physicians cared for all patients, regardless of time of
presentation, and 3) the restricted (rPED) model, in which treating physicians only cared for children
presenting outside the hours of the nPED.
Using these hypothetical models, the authors suggest that creating an nPED to establish improved
pediatric care during busy hours may paradoxically create less optimal care during hours when
the nPED is not open. Physicians working in the rPED model see substantially fewer children during
their practice, and do less pediatric procedures. In the rPED model, a physician restricted from an
nPED would experience only 27% of the pediatric encounters of a physician practicing solely in an nPED.
While there are no guidelines suggesting how much pediatric experience is sufficient to maintain
clinical skills, this study does raise an important concern, which deserves attention at both the
institutional and national policy levels.
Karro J, Dent AW, Farish S.
Patient perceptions of privacy infringements in an emergency department.
Emerg Med Australas. 2005 Apr;17(2):117-23.
Identifying a "privacy incident" as overhearing personal information, having body parts exposed, or seeing others' body parts, this study documents the obvious: patients do not like interference with their right to privacy. Specific risk factors included length of stay and absence of a walled cubicle.
Gorelick MH, Yen K, Yun HJ.
The effect of in-room registration on emergency department length of stay.
Ann Emerg Med. 2005 Feb;45(2):128-33.
Discusses the positive impact of establishing in-room registration in a 45,000 visit pediatric emergency department. While many factors clearly influence throughput times, this study suggests that getting patients into rooms immediately following triage significantly decreases total ED time and increases patient satisfaction.
Cross-training your staff necessitates caution
ED Management, January 2004
Thomas DO.
Special considerations for pediatric triage in the emergency department.
Nurs Clin North Am. 2002 Mar;37(1):145-59, viii.
Emphasizes the importance of pediatric triage skills in the emergency department.
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