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Liu, Shan

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Liu

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Shan

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Liu, Shan
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    Established and Novel Initiatives to Reduce Crowding in Emergency Departments
    (Department of Emergency Medicine, University of California, Irvine School of Medicine, 2013) Liu, Shan; Hamedani, Azita G.; Brown, David; Asplin, Brent; Camargo, Carlos
    Introduction: The American College of Emergency Physicians (ACEP) Task Force on Boarding described high-impact initiatives to decrease crowding. Furthermore, some emergency departments (EDs) have implemented a novel initiative we term “vertical patient flow,” i.e. segmenting patients who can be safely evaluated, managed, admitted or discharged without occupying a traditional ED room. We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.). Methods: We surveyed the physician leadership of all U.S. academic EDs from March to May 2010 using a 2-minute online survey. Academic ED was defined by the primary site of an emergency residency program. Results: We had a response rate of 73% (106/145) and a completion rate of 71% (103/145). The most prevalent hospital-based initiative was inpatient discharge coordination (46% [47/103] of respondents) while the least fully initiated was surgical schedule smoothing (11% [11/103]). The most prevalent ED-based initiative was fast track (79% [81/103]) while the least initiated was physician triage (12% [12/103]). Vertical patient flow had been implemented in 29% (30/103) of responding EDs while an additional 41% (42/103) reported partial/in progress implementation. Conclusion: We found great variability in the extent academic EDs have implemented ACEP’s established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow. Future studies should examine barriers to implementing these crowding initiatives and how they affect outcomes such as patient safety, ED throughput and patient/provider satisfaction.
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    Outcomes Considered Most Important by Emergency Physicians When Determining Disposition of Patients with Pulmonary Embolism
    (Springer-Verlag, 2010) Kabrhel, Christopher; Sacco, Weston; Liu, Shan; Hariharan, Praveen
    Purpose: Clinical decision rules for the disposition of patients with pulmonary embolism (PE) are typically validated against an outcome of 30-day mortality or disease recurrence. There is little justification for this time frame, nor is it clear whether this outcome reflects emergency department (ED) decision making. Aims: To determine which outcomes emergency physicians (EP) consider most relevant to disposition decisions. Methods: Survey of attending EPs in geographically diverse US states using acute PE as the diagnostic framework. Responses required single-answer multiple choice, a numerical percentage, rank-ordered responses, or a five-point Likert scale. We distributed the survey via e-mail to 608 EPs. Results: We received responses from 292 (48%) EPs: 88% board certified, 91% trained in emergency medicine, and 70% work in academics. Respondents reported discharging 1% of patients with PE from the ED, but 21% reported being asked to do so by an admitting service. EPs were more interested in knowing 5-day (in hospital) outcomes [192/265, 72% (95% exact CI=66%–78%)] than 30-day outcomes [39/261, 15% (95% exact CI=11%–20%)] or 90-day outcomes [29/263, 11% (95% exact CI=8%–15%)]. On a Likert scale, 212/241 (88%, 95% exact CI=83%–92%) agreed or strongly agreed that they considered 5-day (in hospital) clinical deterioration when making a decision to admit or discharge a patient from the ED compared to 184/242 (76%, 95% exact CI=70%–81%) and 73/242 (30%, 95% exact CI=24%–36%) for 30 and 90 days, respectively. A wide variety of clinical outcomes beyond death or recurrent PE were considered indicative of clinical deterioration. Conclusions: Five-day (in hospital) outcomes that incorporate a variety of clinical deterioration events are of interest to EPs when determining the disposition of ED patients with PE. Researchers should consider this when developing and validating clinical decision rules.