Tired of wasting time in ER waiting rooms?

Value added wait time is a big focus for our patients, they want to get back home ASAP and stop being a patient.  This study from the Annals of Emergency Medicine looks at the effects of waiting room work-ups.  Pretty intuitive…they work!

Initiating Diagnostic Studies on Patients c AP in the Waiting Room Decreases Time Spent in an ED Bed (and Total ED LOS): A RCT

Begaz T, et al. Ann Emerg Med. 2017 Mar;69(3):298-307.

STUDY OBJECTIVE: The effect of clinician screening of patients in the emergency department (ED) waiting room is unclear. This study aims to determine the effect of initiating laboratory and imaging studies from the ED waiting room on time in a bed, total ED time, and likelihood of patients leaving before completion of service.

METHODS: This was a prospective, randomized, controlled trial evaluating 1,659 nonpregnant adults with a chief complaint of abdominal pain, conducted in a public hospital ED when all ED beds were occupied and patients were in the waiting room awaiting definitive evaluation. After a brief screening examination, stable patients were randomized to either rapid medical evaluation (RME)+waiting room diagnostic testing (WRDT) or RME-only groups. Patients randomized to the RME+WRDT group had laboratory and imaging studies ordered at the discretion of the screening provider while in the waiting room. The primary outcome was time in an ED bed. Secondary outcomes were total ED time and rate of leaving before completion of service. Linear and logistic regression models were used to compare outcomes between groups.

RESULTS: Between July 2014 and May 2015, 1,659 patients completed the study, 848 patients in the RME+WRDT group and 811 in the RME-only group. Baseline demographic characteristics were similar between groups. Patients in the RME+WRDT group had a significantly shorter mean time in an ED bed than the RME-only group, 245 minutes compared with 277 minutes (adjusted difference of 31 minutes; 95% confidence interval [CI] 16 to 46 minutes). The RME+WRDT group also had significantly shorter mean total ED time from arrival to disposition than the RME-only group, 460 minutes compared with 504 minutes (adjusted difference 42 minutes; 95% CI 22 to 63 minutes). Of the 1,659 patients enrolled, 181 left before completion of service: 78 of 848 patients (9%) in the RME+WRDT group compared with 103 of 811 (13%) in the RME-only group (difference 3.5%; 95% CI 0.5% to 6.5%). By the end of their ED visit, patients in the RME+WRDT group had significantly more types of diagnostic studies ordered than those in the RME-only group, 2.59 versus 2.03 total unique test categories by location ordered (difference 0.56; 95% CI 0.44 to 0.68).

CONCLUSION: Initiating diagnostic testing in the waiting room reduced time spent in an ED bed, total ED time, and rates of leaving before completion of service. For clinicians screening patients in the waiting room, initiating diagnostic evaluations may improve throughput in crowded EDs.



Management of Sepsis and Septic Shock: JAMA Clinical Guidelines Synopsis Howell MD, et al. JAMA 2017 Jan 19

This article serves as a counterpoint to my previous post calling into question current dogma around evidence based sepsis protocols.


Food For Thought “Six myths promoted by the new surviving sepsis guidelines”

I will admit to having been on the Rivers train (EGDT) and many subsequent iterations related to protocolized sepsis therapy for over a decade.  This article by Josh Farkas does a good job of summarizing some different perspectives on the current state of evidence bases sepsis therapy.  What it doesn’t address is how protocolized sepsis therapy helps to create a shared mental model across disciplines which, I would argue may often be as important as individualized therapies with regard to patient outcomes.


5. When diuretics may not be the place to start in the ED treatment of HF

5. When diuretics may not be the place to start in the ED treatment of HF

Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.



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