case study in emergency department

Case Studies in Emergency Medicine

LEARNing Rounds: Learn, Evaluate, Adopt, Right Now

• © 2020
• Colin G. Kaide 0 ,
• Christopher E. San Miguel 1

Wexner Medical Center, Ohio State University, Columbus, USA

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• Discusses physiology, pathophysiology, diagnosis, and treatment of each disease
• Presented in an easy-to-read, bulleted format with many images
• Includes not only the usual cases that present to the ED but also “can’t miss” very specific cases

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About this book

This book contains a variety of medical case studies from actual patients presenting to the emergency department. It includes not only typical cases that present to the ED but also less common, yet very important cases that one can't afford to miss.

Using a concise, easy-to-read, bulleted format, the book helps readers to learn, evaluate, adopt new practices, right now (LEARN). Emergency Medicine Case Studies - LEARNing Rounds: Learn, Evaluate, Adopt, Right Now is an essential resource for a variety of emergency medicine clinicians including experienced physicians, residents, physician assistants, nurse practitioners, nurses, and medical students rotating in the emergency department. Finally, this book can be used as a basis for small group discussions, especially in emergency medicine training programs.

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• Case studies in emergency medicine
• Diagnosis in the emergency department
• Emergency medicine case studies
• Physiology and pathophysiology of diseases
• Rare cases in the emergency department
• Treatment in the emergency department

Table of contents (68 chapters)

Front matter, bleeding on anti-xa drugs: “ does all bleeding really stop ”.

• Colin G. Kaide, Kelsey Kauffman

Beta-Blocker Overdose: “You know, the green pill.”

• Katherine H. Buck, Colin G. Kaide

Acute Blast Crisis/Hyperviscosity Syndrome: Blasting Off!

• Colin G. Kaide, Geremiha Emerson

Black Widow Spider Bite: “Can’t We Just Get a Divorce?”

• Annaliese G. Seidel, Colin G. Kaide

Radiology Case 1

• Priyanka Dube, Joshua K. Aalberg

Botulism: “I don’t need to talk, but I do need to swallow!”

• Daniel Z. Adams, Colin G. Kaide

Button Battery Ingestion: The Battery That Is Not as Cute as a Button

• Ashley Larrimore, Justin Carroll

Central Retinal Artery Occlusion with Sudden Vision Loss— “Ay, Ay, My Eye!”

• Bradley M. End, Colin G. Kaide

Cervical Fractures: Who Did Jefferson Bite?

• David Hartnett, Michael Barrie

Radiology Case 2

Cyanide poisoning— “i’m mr. blue…”.

• Jessica A. Everett, Colin G. Kaide, Hannah Hays

ECG Surprise Attack!: de Winter Aches and Pains

• Nicholas S. Fern, Amal Mattu

ECG Surprise Attack!:  Chest Pain and the “Forgotten Lead”

Defibrillator malfunction: it’s electric boogie, woogie, woogie.

• Matthew Malone, Ashish Panchal

Radiology Case 3

Difficult airway and omg, there’s blood everywhere: navigating the difficult airway.

• Caitlin Rublee, Michael Barrie

Disseminated Neonatal Herpes Simplex Virus: Simplex Can Be Very Complex!

• Seth Linakis, Maegan Reynolds

Dural Venous Sinus Thrombosis: “ Not My Usual Migraine ”

• Rahul M. Rege, Brooke M. Moungey

Endocarditis: Osler’s Challenge

• Brit Long, Alex Koyfman

Editors and Affiliations

Colin G. Kaide, Christopher E. San Miguel

About the editors

Colin G. Kaide, MD, FACEP, FAAEM

Associate Professor of Emergency Medicine

Wexner Medical Center at the

Ohio State University

Columbus, OH

Christopher E. San Miguel, MD

Assistant Professor of Emergency Medicine

Bibliographic Information

Book Title : Case Studies in Emergency Medicine

Book Subtitle : LEARNing Rounds: Learn, Evaluate, Adopt, Right Now

Editors : Colin G. Kaide, Christopher E. San Miguel

DOI : https://doi.org/10.1007/978-3-030-22445-5

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer Nature Switzerland AG 2020

Softcover ISBN : 978-3-030-22444-8 Published: 29 January 2020

eBook ISBN : 978-3-030-22445-5 Published: 14 November 2019

Edition Number : 1

Number of Pages : XXIII, 694

Number of Illustrations : 53 b/w illustrations, 118 illustrations in colour

Topics : Emergency Medicine

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• Volume 8, Issue 2, 2024
• Articles in Press
• Volume 8, Issue 1, 2024
• Volume 7, Issue 4, 2023
• Volume 7, Issue 3, 2023
• Volume 7, Issue 2, 2023
• Volume 7, Issue 1, 2023
• Volume 6, Issue 4, 2022
• Volume 6, Issue 3, 2022
• Volume 6, Issue 2, 2022
• Volume 6, Issue 1, 2022
• Volume 5, Issue 4, 2021
• Volume 5, Issue 3, 2021
• Volume 5, Issue 2, 2021
• Volume 5, Issue 1, 2021
• Volume 4, Issue 4, 2020
• Volume 4, Issue 3, 2020
• Volume 4, Issue 2, 2020
• Volume 4, Issue 1, 2020
• Volume 3, Issue 4, 2019
• Volume 3, Issue 3, 2019
• Volume 3, Issue 2, 2019
• Volume 3, Issue 1, 2019
• Volume 2, Issue 4, 2018
• Volume 2, Issue 3, 2018
• Volume 2, Issue 2, 2018
• Volume 2, Issue 1, 2018
• Volume 1, Issue 4, 2017
• Volume 1, Issue 3, 2017
• Volume 1, Issue 2, 2017
• Volume 1, Issue 1, 2017

Clinicopathological Cases from the University of Maryland

54-year-old woman with chest pain.

• Wynne, Zachary R. ;
• Hu, Kami M. ;
• Bontempo, Laura J. ;
• Gatz, J. David

Chest pain is a common presentation to the emergency department (ED) that can be caused by a multitude of etiologies. It can be challenging to differentiate life-threatening conditions from more benign causes. A 54-year-old woman presented to the ED complaining of chest pain with dyspnea in the setting of recent blunt trauma. This case offers a thorough yet practical approach to the diagnostic workup of chest pain with dyspnea in the ED setting. The surprising final diagnosis and case outcome are then revealed.

Case Series

Using point-of-care ultrasonography to diagnose traumatic arthrotomy of the knee: a case series.

• Mullings, Jordan ;
• Ashworth, Henry ;
• Kongkatong, Matthew ;
• Mantuani, Daniel

Case Series: Three patients in their early 20s presented to the ED complaining of knee trauma with wounds in proximity to the joint. Mechanisms of injury included a gunshot wound in one case and blunt trauma (motor vehicle collision and bicycle crash) in two cases. In all three cases TAK was suggested on POCUS examinations by the presence of intra-articular hyperechoic foci consistent with air artifact. All three cases had TAK confirmed by orthopedic evaluation.

Discussion: Ultrasound may have utility in the evaluation of patients presenting with knee trauma where TAK is a concern. The SLT is generally considered the gold standard test for diagnosis of TAK, but it is invasive and has a wide range of diagnostic accuracy. Intra-articular air has been found to be a sensitive marker for TAK in CT studies. Thus, additional investigations into the diagnostic accuracy of POCUS for this finding should be undertaken.

• 1 supplemental video

Case Reports

Defibrillator lead perforation leading to concerning electrocardiogram findings: case report.

• Rosenberg, Bryan ;
• Hockstein, Max ;
• Hadadi, Cyrus

Case Report: We report the case of a 71-year-old woman experiencing chest pain after an ICD placement two weeks earlier. On presentation, she exhibited ST-segment elevation on her ECG. Computed tomography confirmed ICD lead migration. The patient’s hemodynamics were normal, and she was discharged home after a five-day hospital stay following a lead revision.

Conclusion: Although rare, ICD lead perforation is a potential cause of chest pain and ischemic ECG changes. Emergency physicians should consider lead perforation as a potential differential diagnosis when evaluating chest pain in patients with ICDs, taking into account the potential complications of coronary angiography.

A Critical Combination of Esophageal Rupture and Upside-down Stomach: A Case Report

• Tipton, Kay Nicole ;
• Schroder, Daniel

Introduction: Spontaneous esophageal rupture, or Boerhaave syndrome, and upside-down stomach are rare pathologies associated with grave sequelae. Boerhaave syndrome can have a mortality rate as high as 44%. Upside-down stomach accounts for less than 5% of hiatal hernias and can lead to incarceration and volvulus.

Case Report: An 80-year-old woman presented to the emergency department with sudden onset, severe epigastric pain. Physical examination revealed normal vital signs with mild epigastric tenderness. Imaging obtained revealed a large hiatal hernia and findings concerning for esophageal perforation. The patient was started on 3.375 grams of intravenous piperacillin/tazobactam, and transfer to a tertiary care facility was initiated. After transfer, esophagography confirmed a perforation near the gastroesophageal junction and findings consistent with an upside-down stomach. The patient underwent successful repair of the esophageal perforation and gastropexy followed by intensive care unit admission and ultimately discharge.

Conclusion: Boerhaave syndrome and upside-down stomach are two conditions with high associated morbidity and mortality requiring prompt intervention. Information obtained in the history and physical examination including acute onset of chest pain after vomiting, tachypnea, subcutaneous emphysema, and hypoxia can assist in the diagnosis of the described pathologies. These signs and symptoms can be subtle on examination but are important in raising clinical suspicion for an otherwise rare etiology for acute onset chest pain.

Permissive Hypotension in a Patient with Severe Hypernatremia: A Case Report

• Hlady, Andrea ;
• Kerner, David ;
• Walker, Laura

Case Report: We present the case of a medically complex patient who had gradually worsening alteration of mental status and mean arterial pressures in the 50s on presentation to the emergency department.

Conclusion: Final diagnoses included severe hypernatremia and hypovolemic shock secondary to poor oral intake. We used judicious fluid repletion with gradual improvement in sodium levels and permissive hypotension to avoid rapid osmotic shifts. Balancing reperfusion and the risk for osmotic effects of aggressive fluid resuscitation can be a challenging situation for the multidisciplinary team.

Ruptured Ovarian Artery Aneurysm in a Postmenopausal Female: Case Report

• Patel, Raj ;
• Russell, Amy ;
• Randall, Melanie M.

Case Report: We present a case of a postmenopausal female presenting to the emergency department with flank pain. Point-of-care ultrasound showed free fluid in the abdomen. She was diagnosed with an ovarian artery aneurysm on computed tomography angiography and treated successfully with embolization.

Conclusion: Ruptured ovarian artery aneurysm is an uncommon cause of intra-abdominal hemorrhage in women.

Acute Abdominal Pain and a Whirlpool Sign on Computerized Tomography: A Case Report

• Libby, Christopher ;
• Stern, Evan ;
• Hoelle, Robyn

Case Report: We present a case of a 75-year-old female who presented with non-specific abdominal pain. The rare whirlpool sign on computed tomography identified a mesenteric volvulus as the cause of small bowel obstruction. She was taken to the operating room and, after successful resection of the small bowel, she recovered and ultimately was discharged home.

Conclusion: Early identification of a whirlpool sign and early surgical consultation are key to providing the best chance for salvage of ischemic small bowel due to mesenteric volvulus and to prevent a fatal outcome.

Emergency Department Doppler Assessment of a Central Retinal Artery Occlusion: Case Report

• McGuire, Duncan ;
• Calleja, Robert ;
• Pai, Eric ;

Introduction: Vision loss is a symptom found frequently in patients presenting to the emergency department (ED). Central retinal artery occlusion (CRAO) is an uncommon yet time-sensitive and critical cause of painless vision loss in which delayed diagnosis can lead to significant morbidity. Emergency medicine literature documents the ability to diagnose a CRAO using ultrasound by identifying the hyperechoic thrombus coined the retrobulbar spot sign.

Case Report: We present the case of a patient presenting with painless monocular vision loss for which CRAO was diagnosed in the ED using point-of-care ultrasound enhanced by the utilization of serial Doppler examinations as well as calculation of the central retinal artery resistive index.

Conclusion: Despite the pre-existing literature on point-of-care ultrasound investigation of central retinal artery occlusion, there are no emergency medicine case reports describing serial examination of the central retinal artery by spectral Doppler or calculation of arterial resistive index to improve this evaluation and monitor progression of the pathology. [2024;7(5)1–5.]

Transcatheter Arterial Embolization for Atraumatic Splenic Rupture in TEE-negative Endocarditis: A Case Report

• High, Daniel P. ;
• Acosta-Rullán, Jose M. ;
• Herrera, Danay ;
• Danckers, Mauricio ;
• Heller, Daniel ;
• Zapata, Daniel

Case Report: We present a case of a 56-year-old immunocompetent female with porcine bioprosthetic mitral valve replacement, automated implanted cardioverter-defibrillator, and atrial fibrillation on apixaban who was found to have in-hospital atraumatic splenic rupture complicating infective endocarditis with Haemophilus parainfluenza. The rupture was treated successfully by endovascular embolization. Usual treatment with six weeks of antibiotics provided durable cure without further complication, and no surgical intervention was needed for either the valve or spleen.

Conclusion: Transcatheter arterial embolization should be considered early in atraumatic splenic rupture. Relevant abdominal and cerebral imaging should be considered in all cases of suspected or confirmed infective endocarditis where unexplained symptoms are present.

Peritonsillar Abscess and Post-aspiration Bleed Identified with Point-of-care Ultrasound Using Endocavitary Probe: A Case Report

• Floyd, Jaclyn ;
• Dahl, Brandon ;
• Whited, Matthew ;
• Kurzweil, Ami

Case Report: A 19-year-old male presented to the ED with complaints of severe sore throat and fever for the prior five days. A POCUS using an endocavitary probe with sterile cover demonstrated hypoechoic debris with a “swirl sign.” Ultrasound was used to successfully guide needle aspiration by using in-plane needle guidance. The patient had significant bleeding after needle aspiration, and repeat POCUS clearly identified a new pocket of blood that had formed and was contained in the soft tissue. We monitored the size of the hematoma in real time with ultrasound to ensure the hematoma had no rapid expansion and was stable.

Conclusion: Among the differential diagnoses for sore throat, the diagnosis of peritonsillar abscess is particularly concerning as it is both common and generally requires swift intervention. Presentations can range from a mild infection to a life-threatening emergency with potential airway compromise. The two primary avenues for treatment include either needle aspiration or incision and drainage. Ultrasound can successfully identify the abscess and other landmarks for safe and successful drainage, as well as early identification of complications.

Diabetic Ketoalkalosis: A Case Report

• Brill, April ;
• Chheda, Nirav ;
• Strama, Daniel ;
• Soundarajan, Ramesh

Case Report: A 52-year-old female with a history of insulin-dependent diabetes mellitus type 2 presented to the ED with abdominal pain, nausea, and vomiting for three days. Her diagnostic workup revealed diabetic ketoacidosis but with concurrent metabolic alkalosis. Standard treatment for DKA was initiated, and there was improvement of her mentation and resolution of metabolic derangements.

Conclusion: Overlooking a diagnosis of DKA because of alkalosis on venous blood gas testing could lead to inappropriate treatment and, therefore, increased risk of morbidity and mortality in the affected patient.

Inferior Pancreaticoduodenal Artery Pseudoaneurysm Causing Biliary Obstruction: A Case Report

• Meloy, Patrick ;
• Lindquester, Will S. ;
• Stebbins, Jeffrey ;
• Bromberek, Elaine

Case Report: Here we present the case of a 64-year-old male patient with previous history of alcohol use disorder leading to chronic pancreatitis and prior embolization of an inferior pancreaticoduodenal pseudoaneurysm, who presented to the emergency department (ED) with abdominal pain, nausea, and vomiting, and was found to have a large recurrent inferior pancreaticoduodenal pseudoaneurysm with associated obstructive cholangitis and pancreatitis via contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The patient was managed emergently by interventional radiology angiography with embolic coiling and percutaneous biliary catheter placement, and he subsequently underwent biliary duct stenting with gastroenterology. The patient was successfully discharged after a brief hospitalization after resolution of his pancreatitis and associated hyperbilirubinemia.

Conclusion: Pancreaticoduodenal artery aneurysms and pseudoaneurysms are rare and dangerous visceral pathologies. Patients can be diagnosed rapidly in the ED with CT imaging and need

Severely Painful and Pruritic Forearm Rash: A Case of Caterpillar Envenomation in South Florida

• Autrey, Cody M. ;
• Martinez, Stephanie A. ;
• Remaly, Michael ;
• Boccio, Eric

Case Report: We present the case of a patient presenting to the emergency department (ED) with acute-onset severe left forearm pain with associated pruritic rash incurred while working in a retail store. Initial therapeutic management included administration of analgesics, antihistamines, and steroids. After obtaining a comprehensive history and consulting with the Poison Control Center, we suspected an asp caterpillar envenomation. Following extraction of the caterpillar spines with silk tape, the patient’s symptoms improved. After a period of observation in the ED, the patient was discharged home without any known sequelae.

Conclusion: Although asp caterpillars typically inhabit trees and foliage, human exposure to the caterpillar may occur in developed environments. Effective history-taking, prompt communication with toxicologic experts, and complete removal of intact spines are essential for early identification and effective clinical management of asp caterpillar envenomation.

Use of Point-of-care Ultrasound to Diagnose Rectus Abdominis Strain in the Acute Setting: A Case Report

• Sanoja, Alejandro J. ;
• Shalaby, Michael

Case Report: We report a rare case of rectus abdominis muscle tear in an amateur bodybuilder diagnosed by point-of-care ultrasound (POCUS) in the emergency department (ED). The patient had presented to the ED three separate times after strenuous exercise, received costly diagnostic workups, and ultimately was diagnosed on the third visit with grade 2 bilateral rectus abdominis tear. The patient was given appropriate education and sports medicine follow-up. He underwent rehabilitation focused on trunk and core stability. At eight-week follow-up, the patient had made a full recovery.

Conclusion: To our knowledge, a case of bilateral rectus abdominis tear diagnosed by ultrasound in the emergency setting has not been previously published. Our case report highlights the utility of POCUS in diagnosing musculoskeletal pathology and preventing costly bounce-back visits.

Silicone Embolism Syndrome Causing Altered Mental Status and Respiratory Failure After an Unlicensed Gluteal Silicone Injection: A Case Report

• Lin, Christopher ;
• Robison, Jeremiah

Case Report: We describe a case in which a previously healthy, 28-year-old female presented with new-onset seizures and acute respiratory distress syndrome (ARDS) in the setting of a recent cosmetic procedure with silicone injections to the gluteal region. The patient’s hospital course was complicated by altered mental status, respiratory failure, rapid hemodynamic compromise, and eventual death.

Conclusion: In rare cases, one possible complication of cosmetic procedures is silicone embolism syndrome, which is characterized by pneumonitis, alveolar hemorrhage, and ARDS. The patient described in this report also experienced neurologic symptoms including seizure and altered mental status. This is a clinical diagnosis that relies upon thorough history-taking and detailed physical exam. Documentation on this phenomenon is limited, and medical management has not yet been standardized for this condition. Morbidity and mortality remain high.

Cardiac Arrest During a Ferric Derisomaltose Infusion Followed by Complete Heart Block: A Case Report

• Scott, Michael ;
• Jansen, Natalie ;
• Bilello, Leslie A.

Introduction: Ferric derisomaltose is the newest available parenteral iron formulation. Studies have demonstrated a good safety profile with improved tolerability compared to alternative parenteral iron formulations. To date there have been no reported acute, life-threatening cardiac events associated with ferric derisomaltose.

Case Report: An 86-year-old male who had previously tolerated routine iron infusions received a first dose of ferric derisomaltose at an outpatient infusion clinic. Six minutes into the infusion the patient became unresponsive with no palpable pulse. Return of spontaneous circulation was achieved after two minutes of chest compressions. Electrocardiogram showed complete heart block requiring transcutaneous pacing and vasopressor administration. The patient was transferred to the emergency department for stabilization and then admitted to the cardiac intensive care unit. During admission, the patient received a dual-chamber, permanent pacemaker without complication and was ultimately discharged.

Conclusion: It may be reasonable to consider parenteral iron as a toxicological etiology for patients presenting with complete heart block temporally associated with parenteral iron administration, particularly in patients with underlying conduction abnormalities.

When Educational Images Don’t Reflect the Population: Phlegmasia Cerulea Dolens, a Case Report

• Bornstein, Kasha ;
• LaRosa, Elizabeth ;
• Byrd, Kelsey ;
• Laney, Daniel ;
• Ferral, Hector ;
• Murphy-Lavoie, Heather

Introduction: Phlegmasia cerulea dolens (PCD) is an uncommon, potentially life-threatening complication of acute deep venous thromboses that requires a timely diagnosis. The name of the condition, the visual diagnostic criteria, and the preponderance of cases in the literature referencing findings exclusively in patients with lighter skin complexions means that PCD may not be on the differential diagnosis for the patient with more melanated skin who is experiencing this time-sensitive vascular emergency.

Case Report: We describe one case of PCD in a patient with darker skin complexion and the importance of identifying clinical findings, regardless of skin color, given the paucity of reference images for PCD in darker complected patients. Our literature review yielded 60 case reports for PCD. Only two papers included images referencing patients of color.

Conclusion: Accurate diagnosis requires recognition of diagnostic findings, which may vary significantly between phenotypically distinct populations. Many pathognomonic physical exam findings rely on descriptors based on presentation in phenotypically white patients.

Profound Alkalosis and Prolonged QT Interval Due to Inappropriate Gastrostomy Tube Loss: A Case Report

• Turner, Forrest ;
• Friedman, Brandon ;
• Meyers, H. Pendell ;
• Smith, Stephen W.

Introduction: Severe metabolic alkaloses are relatively rare but can carry a high mortality rate. Treatment involves supportive care and treatment of underlying causes.

Case Report: A 55-year-old male dependent on a gastrojejunostomy tube presented to the emergency department for altered mental status. The patient had metabolic alkalosis, electrolyte abnormalities, and prolonged QT interval on electrocardiogram. Examination and history revealed that chronic drainage of gastric fluid via malfunctioning a gastrojejunostomy tube resulted in profound alkalosis. The patient recovered with supportive care, electrolyte repletion, and gastrojejunostomy tube replacement.

Conclusion: This case highlights the importance of gastrointestinal acid-base pathophysiology.

Face-off Droop: A Case Report of Pediatric Stroke

• Robertson, Duncan ;
• Peirce, Hayden F. ;
• Nicpon, Marek D. ;
• Otterson, Eric M. ;
• O'Connor, Laurel ;
• Rissmiller, Julia G. ;
• Binder, Zachary W.

Introduction: Cerebrovascular accidents rarely occur in children; the incidence of ischemic stroke in patients <16 years of age is between 0.6–7.9/100,000. However, they are the fourth most common cause of acute neurological deficits in the pediatric population, and possible cases should be evaluated with a high index of suspicion to ensure timely intervention.

Case Report: We describe a previously healthy 17-year-old male who presented to the pediatric emergency department with a left facial droop and hemiparesis consistent with a stroke. The patient’s age and lack of comorbidities made this an extremely uncommon presentation. Our patient’s neurologic symptoms were believed to have been caused by a recent traumatic clavicular injury sustained two weeks prior, which subsequently led to vascular insult.

Conclusion: Cerebrovascular accidents are an important cause of morbidity and mortality in pediatric patients. Cerebrovascular accidents in children are most often secondary to congenital causes; however, care should be taken to assess for acquired causes, such as trauma to major blood vessels. While rarely implicated in traumatic injuries, arterial structures posterior to the medial clavicle can result in severe complications.

Images in Emergency Medicine

Clinical images in emergency medicine: cushing’s disease.

• Vadhan, Jason D. ;
• Hansen, Nathaniel ;
• Benitez, Fernando L. ;
• Velez, Larissa I.

Case Presentation: A 22-year-old female presented to the emergency department with a two-month history of worsening fatigue, unintentional weight gain, and progressive facial swelling. Physical examination findings included hirsutism, moon facies, and abdominal striae. Subsequent brain magnetic resonance imaging revealed the presence of a 2.4-centimeter pituitary macroadenoma, confirming the diagnosis of Cushing’s disease. The patient was then admitted for neurosurgical tumor resection.

Discussion: Cushing’s disease is exceedingly rare and often presents with symptoms resembling more prevalent disorders, contributing to delays in diagnosis. Therefore, maintaining a high index of suspicion for this disease is crucial for emergency physicians.

• 1 supplemental ZIP

Rash and Fever in a Returned Traveler

• Kons, Helena ;
• Herron, Elliott D. ;
• Pacheco, Zachary S. ;
• Shufflebarger, Erin F.

Discussion: Dengue is one of many viral illnesses that should be considered in returning travelers presenting with fever and other nonspecific symptoms. Emergency physicians must keep a broad differential when evaluating fever in returned travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Atraumatic Orbital Emphysema in a Young Woman

• Albornoz, Eladio ;
• Wildemuth, Janet ;
• Valenzuela, Josephine

Discussion: Atraumatic orbital emphysema is a rare clinical condition more common in early middle-aged female patients with certain historical features such as chronic sinusitis, facial surgery or trauma, tobacco smoking, or current upper respiratory symptoms. While most cases will resolve spontaneously, rarely this condition can lead to vision-threatening orbital compartment syndrome, requiring lateral canthotomy or needle decompression.

One in a Million: A Woman Presenting with Unilateral Painful Ophthalmoplegia

• Bennett, Kevin ;

Case Presentation: A 52-year-old female presented to the emergency department with four days of right periorbital pain, ipsilateral temporal headache, diplopia, and photophobia. Physical examination of the right eye revealed painful ophthalmoplegia, cranial nerves III and VI paresis, increased intraocular pressure, and mild proptosis. Magnetic resonance venogram and magnetic resonance imaging orbits with contrast demonstrated an abnormal signal surrounding the right cavernous sinus/petrous apex. Tolosa-Hunt syndrome (THS) was diagnosed. Per neurology recommendations, the patient was placed on a steroid regimen over the course of three weeks. She was discharged on hospital day nine following resolution of symptoms. She had no recurrence of symptoms or residual deficits noted at her two-week follow-up appointment.

Discussion: With an estimated annual incidence of one case per million, THS is a sinister etiology of unilateral headache, painful ophthalmoplegia, and oculomotor palsy. Tolosa-Hunt syndrome is caused by granulomatous inflammation in the cavernous sinus and is highly responsive to corticosteroids. Magnetic resonance imaging studies of the cavernous sinus and orbital apex are highly sensitive for THS and characteristically show enlargement and focal-enhancing masses within the affected cavernous sinus.

Child with Closed Head Injury and Persistent Vomiting

• Khan, Abdullah

Case Presentation: We present the case of a six-year-old child with autism who presented with persistent vomiting in the setting of a closed head injury (CHI). Computed tomography of the head was normal, but due to persistent vomiting a radiograph of the abdomen was done, which showed multiple, rare-earth magnets in the abdomen. There was no history of witnessed ingestion. These magnets had caused enteroenteric fistula formation leading to persistent vomiting.

Discussion: In the setting of CHI, vomiting can be a sign of concussion or intracranial hemorrhage. In cases of CHI where intracranial pathology is ruled out and vomiting still persists, it is important to explore intra-abdominal causes of vomiting, especially in developmentally challenged children as they have higher incidence of unwitnessed foreign body ingestions.

CPC-EM Full-Text Issue

• Valenzi, Nicole

• Open access
• Published: 15 June 2020

Strategies to measure and improve emergency department performance: a scoping review

• Elizabeth E. Austin   ORCID: orcid.org/0000-0002-8438-2362 1 ,
• Brette Blakely 1 ,
• Catalin Tufanaru 1 ,
• Amanda Selwood 1 ,
• Jeffrey Braithwaite 1 &
• Robyn Clay-Williams 1  

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine volume  28 , Article number:  55 ( 2020 ) Cite this article

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Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs’ capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance.

Methods and findings

We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/ ). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies’ titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains.

Conclusions

ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.

Introduction

Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide [ 1 ]. EDs must continue to provide care during periods of crowding, and respond to expected changes (e.g., seasonal increase in demand) and unexpected changes (e.g., unanticipated events and varying demand) [ 2 ]. However, crowding impedes ED staffs’ capacity to provide timely, safe and quality care. It extends the time patients spend in ED, and threatens patient outcomes [ 3 ].

Crowding in EDs is the product of input, throughput and output factors such as the volume of patients arriving to be seen, the time taken to assess and treat patients, and the availability of beds in hospital wards [ 4 ]. Interventions (e.g., decision-making structure, resource allocation, procedures) to address these factors have been widely implemented, with mixed results [ 5 , 6 , 7 , 8 ]. Identifying effective interventions known to have improved care can support the uptake of those interventions in different contexts. Understanding the characteristics of those interventions and their limitations can inform the development of new strategies to address common patient flow problems.

Ideally, the design and selection of performance measures should align with the system’s purpose and improvement strategy in order to identify the extent to which the system is working effectively. It is unsurprising then that input, throughput and output measures such as wait-time, length of stay and patient satisfaction have been used to report on EDs’ performance [ 4 , 9 ]. Understanding how ED performance has been measured in the past will support the selection of measures and inform the development of new measures to address gaps in performance knowledge.

The purpose of this scoping review was to map the research evidence provided by reviews on strategies to measure and improve ED performance. The review questions addressed were: (1) how is ED performance measured, (2) what are the interventions used to improve ED performance and (3) what is the role(s) of patients in improving ED performance, and (4) what are the outcomes attributed to interventions used to improve ED performance.

Study design

We conducted a scoping review of the literature from inception of bibliographic databases to July 2019 related to strategies to measure and improve ED performance. The study protocol was prospectively registered in December 2018 in the Open Science register ( https://osf.io/73r4t ). This protocol guided the review in adherence with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA) [ 10 ].

Inclusion criteria

Systematic reviews of primary research studies, reviews of reviews (umbrella reviews), and other research syntheses not fulfilling all criteria for systematic reviews published in the English-language peer-reviewed literature were included that met the following additional criteria: (1) review studies involving clinicians, patients, and/ or administrators in the ED or review studies that measure ED performance without involving participants (e.g., Length of Stay or patient mortality retrieved from aggregate hospital data); (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on studies in a hospital ED context in any country or healthcare system.

Search strategy

To identify eligible studies, we developed a comprehensive search strategy using medical subject headings and text words for the general concepts of performance measures, interventions, and patient involvement. Cochrane Database of Systematic Reviews, Scopus, Embase, CINAHL and PubMed were searched on 14 January 2019. No date limits were used. English only publications were considered. An updated search was completed on 9 July 2019 and included a date filter (publications from 1 January 2019 to 31 December 2019). The full search strategy for all databases is shown in Appendix A (See Additional file  1 ).

An example, illustrating the search strategy for PubMed, is as follows:

((((emergency Service, Hospital [mh]) OR emergency department [tw])) AND (((((quality of health care [mh]) OR quality improvement [mh]) OR quality [tw]) OR improvement [tw]) OR performance [tw])) AND ((((((((review [ti]) OR systematic review [ti]) OR meta-analysis [ti]) OR meta-synthesis [ti]) OR scoping review [ti]) OR integrative review [ti]) OR overview [ti]) OR umbrella review [ti])

Study selection

The results of the searches were entered into EndNote citation management software (version 8.2; Thompson Reuters, New York, NY), and duplicates were removed. For each review, title, abstract, and full-text were independently screened by pairs of reviewers for inclusion according to pre-established criteria. Disagreements were resolved via discussion. Abstracts flagged as potentially relevant by reviewers underwent full-text review.

Data extraction and quality assessment

The data was extracted by independent reviewers by using an extraction tool specifically designed for the review. The data extraction form was piloted for usability prior to data extraction. The extraction form included information on Author(s), year of publication, country where review was conducted, type of review, review objectives and questions, number of studies included, types of intervention/s, intervention characteristics, type of measure used and/ or type of outcome measured.

The quality of the included papers was assessed using the Risk of Bias in Systematic Reviews (ROBIS) tool for assessing the risk of bias in systematic reviews [ 11 ]. The purpose of this assessment was only to allow for the quality of the included reviews to be mapped/ described. Prior to critical appraisal, the ROBIS was piloted on a sample of reviews. The quality of included reviews was explored by pairs of independent reviewers. Disagreements were resolved via discussion.

Data processing and analysis

A narrative synthesis was performed for this review, including numerical statistical summaries, textual commentaries, and tabular and graphical representations.

The combined searches yielded 4981 articles, including 1996 duplicate articles. Of these, 2985 abstracts and 134 full-texts were reviewed with 77 articles meeting inclusion criteria. Figure  1 illustrates the PRISMA diagram for the identification, screening, and inclusion processes.

PRISMA flow diagram for study selection

An additional table outlines the characteristics of the included articles addressing ED performance measures (See Additional file  2 ). An additional table outlines the characteristics of the included articles addressing interventions, and patient role in ED performance (See Additional file  3 ). An additional table outlines the evidence contribution of the included reviews to each review question (See Additional file  4 ). Distribution of included reviews published per year (2000–2019) is provided in Fig.  2 . Figure  3 shows the distribution of locations where published reviews were conducted (based on the country affiliation of the first author).

Distribution of published reviews over time

Distribution of published reviews by country affiliation of first author

Quality assessment

Using the ROBIS tool, 31 reviews were assessed as being low bias, 31 as high bias, and 15 as unclear bias. The ROBIS risk of bias assessment results for each domain and the overall risk of bias for individual reviews are presented in an additional file (See Additional file  5 ). Figure  4 displays a summary ROBIS assessment across all included reviews, graphically presenting the results of the ROBIS assessment for each domain and the overall rating.

Graphical presentation for ROBIS results across all included reviews. 1 study eligibility criteria prespecified and appropriate for the review question. 2 sensitivity of the search. 3 rigour of the data collection process. 4 appropriateness of the synthesis for the review question. 5 overall risk of bias. “Low”, “high”, or “unclear” represents the rated level of concern about bias associated with each domain [ 11 ]

How ED performance is measured

Three reviews reported on ED performance measures [ 12 , 13 , 14 ]. Madsen (2015) extracted evidence for 202 individual indicators of ED performance from 127 articles, categorising them into process (e.g., time to diagnosis, physician workload), outcome (e.g., mortality, ambulance diversion), satisfaction (e.g., rate of complaints, patient participation in own care), structural/ organisational (e.g., admission rate, resources) and equity (e.g., weekday/weekend variation, sex, race, age) performance measures. Data sources used to generate the indicators are ED information technology, questionnaires, chart reviews, and multihospital databases [ 12 ]. Sørup (2013) identified 55 different performance measures and categorised ED performance measures into patient related measures focusing on safety (e.g., medication errors, unplanned reattendance), patient centeredness (e.g., complaints, left-without-being-seen), and satisfaction; employee related measures focusing on occupational profile (e.g., educational positions), and work environment; and operational performance focusing on planning (e.g., occupancy rate), utilisation (e.g., number of ECG’s taken, number of consultations), efficiency (e.g., ED admission transfer rate, length of stay), and time intervals (e.g., time to registration, triage, treatment). Stang (2015) examined crowding measures linked with quality of care including ED volume, number of patients in the waiting room, and ED length of stay.

Interventions used to improve ED performance and their characteristics

The remaining 74 articles addressed interventions used to improve ED performance. Interventions to improve ED performance address either practices and processes or team composition. Interventions addressing how tasks were performed in ED were identified as practice and process interventions. Interventions addressing the discipline or training of professionals practicing in ED were identified as team composition interventions.

Practices and processes

Six domains of clinical practice and processes have been targeted for interventions. They are: triage, care transitions, process re-design, point-of-care testing, observation units, and technology.

Designed to expedite care, triage processes sort patients according to urgency or type of service required [ 15 ]. Twelve reviews examined interventions relating to triage systems and processes. Triage based interventions included having a physician present [ 8 , 16 , 17 , 18 , 19 ] also called a triage liaison physician [ 20 ], a triage team consisting of at least 2 medical personnel (nurse or physician) [ 21 , 22 ], dedicated triage resources (e.g., ECG machine and ECG technician [ 23 ]), triage education [ 23 ], variations of basic triage [ 15 ], triage protocols [ 24 , 25 ], and nurse-led triage services [ 26 ]. A description of the characteristics for each type of triage intervention is provided in Table  1 .

Care transitions (handover processes)

Care transitions involved patient handover, which is the process of transferring accountability and responsibility for patient care to another person [ 27 ]. Seven reviews examined interventions relating to patient handover processes and transitions in care. Patient handover processes and transitions in care interventions include handover tools [ 27 , 28 , 29 , 30 ], bedside registration [ 19 , 31 ], discharge planning [ 31 ], discharge communication [ 32 ], process protocols and guidelines [ 27 , 29 , 30 ], handover training [ 29 ], dedicated offload nurse for triaging and assessing EMS patients [ 30 ], nurse discharge coordinators [ 33 ]. A description of the characteristics for each type of care transition intervention is provided in Table  2 .

• Process re-design

Process re-design refers to changes in how tasks are performed. Twenty-three reviews examined interventions relating to process re-design. Processes that have been re-designed included clinical guidelines and protocols [ 25 , 31 , 34 , 35 , 36 ], patient assignment and referral processes [ 4 , 31 , 36 , 37 , 38 ], organisational processes (e.g., communication, administration) [ 19 , 25 , 35 , 39 , 40 ], nurse-initiated care processes [ 8 , 17 , 21 , 41 , 42 , 43 , 44 ], clinical decision supports [ 45 , 46 , 47 ], and lean management/ lean thinking interventions [ 48 , 49 , 50 ]. A description of the characteristics for each type of process re-design intervention is provided in Table  3 .

• Point-of-care testing

Point-of-care testing refers to laboratory analysis located in the ED [ 8 , 21 ]. Five reviews examined point of care testing in ED [ 8 , 19 , 21 , 51 , 52 ]. Point-of-care testing has been used for a range of diagnostic tests including cardiac troponin [ 51 ], metabolic [ 19 ], urinalysis, pregnancy testing, cardiac markers, glucose [ 19 ], influenza, and respiratory syncytial virus [ 52 ].

• Observation units

Observation Unit interventions refer to ED-based observation units [ 31 ]. Twelve reviews examined observation units in ED [ 4 , 8 , 17 , 18 , 19 , 25 , 31 , 39 , 53 , 54 , 55 , 56 ]. ED based observation units have been developed for specific clinical needs such as Chest pain and Asthma [ 31 , 39 ], for specific processes such as assessment and procedures (e.g., Rapid Assessment Zones/ Pods) [ 18 , 55 ], medically stable patients likely to require admission (e.g., Medical Assessment Units) [ 4 , 8 , 17 ], or further investigations (e.g., Short Stay Units) [ 8 , 17 , 54 , 56 ], management for more than 4 h (e.g., ED managed Acute Care Unit) [ 19 ], or to manage referrals from GPs (e.g., Quick Diagnostic Units) [ 18 ]. A description of the characteristics for each type of process re-design intervention is provided in Table  4 .

Technology has been increasingly integrated into the ED [ 57 ]. Seven reviews examined interventions addressing technology in the ED. Technology has been introduced into EDs in the form of health information technology such as computerised clinical support systems (e.g., decision supports and provider entry forms) [ 45 , 58 ], mobile devices [ 57 ], and telecommunication technology [ 59 ], computer simulation [ 60 ], and eHealth records access [ 61 , 62 ]. A description of the characteristics for each type of technology intervention is provided in Table  5 .

Team composition interventions

Different roles and specialties have been integrated into the ED. These included advanced nursing roles, physiotherapy, general practitioners, scribes and physician assistants, pharmacy, and mental health services, as well as the development of professional skills.

Advanced Nursing Roles . Seven reviews examined interventions relating to advancing nursing roles in the ED. Advanced nursing interventions primarily include the nurse practitioner role [ 17 , 18 , 63 , 64 , 65 , 66 ] sometimes called advanced nurse practitioner/ advanced clinical practitioner/ advanced practice nurse [ 66 , 67 ], clinical nurse specialists [ 65 ], certified registered nurse anaesthetists [ 65 ], and Clinical Initiatives Nurse (CIN [ 17 , 68 ];. Advanced nursing roles typically require further education and require a minimum of 2 years emergency nursing experience [ 68 ]. A description of the characteristics for each type of advanced nursing role intervention is provided in Table  6 .

Physiotherapy

Three reviews examined interventions relating to physiotherapy roles in ED [ 69 , 70 , 71 ]. The role of physiotherapists in ED includes the assessment and management of acute and subacute musculoskeletal conditions, recent burns and diabetic wounds, provision of in-service training to other ED staff, liaising with nursing, medical, and allied health staff, and ensuring safe discharge from ED including arranging community services [ 69 , 70 , 71 ]. Physiotherapists have also been trained to read and request imaging and to prescribe a limited number of medications [ 69 , 70 ].

General practitioners

Two reviews examined interventions relating to general practitioner roles in ED [ 72 , 73 ]. There are different models in which general practitioners have been introduced into ED [ 72 , 73 ]. General practitioners have been used to staff non-urgent (rather than urgent) streams when patients are triaged into separate streams [ 72 , 73 ]. General practitioner services are also available onsite next to the ED and patients self-select or are redirected to these services from the ED. General practitioners have also been involved in the triage of patients presenting to the ED [ 72 , 73 ]. General practitioners have also been fully integrated into ED, providing care jointly with ED staff on a range of primary care and higher acuity emergency cases [ 72 , 73 ].

Scribes and physician assistants

Four reviews examined interventions relating to models of care using support staff such as scribes and physician assistant roles in ED [ 8 , 18 , 74 , 75 , 76 ]. A description of the characteristics for scribes and physician assistants interventions is provided in Table  7 .

Two reviews examined interventions relating to pharmacy roles in ED [ 77 , 78 ]. The scope of pharmacy roles in the ED varied. In the ED, pharmacists conduct consultations including interpreting results and providing pharmacotherapy recommendations [ 77 , 78 ]. ED pharmacy programs also included pharmacists tracking patients medication due times for repeat medications, completing medication histories, documenting patient body weight, height, and allergies [ 77 , 78 ]. Pharmacists have also been involved ED patient follow-up on culture and susceptibility results, adjusting or discontinuing therapy as needed [ 77 , 78 ].

Mental health services

Two reviews examined interventions relating to mental health services in ED [ 79 , 80 ] including Liaison Mental Health Services [ 79 , 80 ], co-located Psychiatry Liaison Personnel/ Spaces [ 80 ], Psychiatry Specialist Services [ 80 ]. A description of the characteristics for each type of mental health services intervention is provided in Table  8 .

Professional development

Nine reviews examined professional development interventions in ED. Professional development interventions included eight-hour customer service training related to applying industry customer service principles to health care, benchmarks, and taught customer service skills such as negotiating agreement and resolution of expectations [ 31 , 39 ]; and a 10 week medical Spanish language course [ 39 ]. The provision of audit/ feedback (from a supervisor/ colleague/ external coder) on clinical practice has been implemented in a variety of formats including weekly case specific, every 6 weeks individual feedback with group discussion; or individual feedback provided via email, written, verbal, electronic, and combination of media, one on one, group, (e.g., patient outcomes, quality of documentation [ 81 , 82 , 83 ]. Other interventions include cross-training nurses to care for patients in a designated area [ 25 ], monthly staff education/ workshops about hand hygiene with elements of targeted feedback [ 84 ], and clinical education to improve nurses’ and medical staffs’ knowledge of pain management through an education program [ 42 , 85 ].

The role(s) of patients in improving ED performance

Patients are consumers of healthcare services provided by EDs. The delivery of healthcare depends on the relationship between clinicians and patients and the degree to which patients play an active or passive role [ 86 ]. Two reviews examined the role of patients in improving ED performance [ 42 , 86 ]. Patients’ role in improving ED performance has been primarily addressed by involving patients in shared decision making. Shared decision-making involves active patient involvement with the clinician, sharing information and collaboratively taking steps to reach agreement about which treatment to implement [ 86 ]. Shared decision making has been addressed through decision supports [ 86 ], and education [ 42 ]. A description of the characteristics for each type of patient role intervention is provided in Table  9 .

The outcomes attributed to interventions used to improve ED performance

The outcomes attributed to interventions used to improve ED performance identified by the review can be categorised into five key areas: Time, proportion, process, cost, and clinical outcomes. Time-based measures record time stamps/ intervals, and sub-cycle intervals [ 25 ]. Measures of time intervals varied, however, the most commonly used were length of stay (LOS) in ED and waiting time. Proportion-based measures record elements of ED performance rates [ 25 ]. Measures of proportion-based measures varied widely and included admissions, resource use, and treatment follow-up rate. Process-based measures document elements of ED process performance [ 25 ]. Direct and indirect measures of quality of care, including left without being seen, did not wait, as well as patient and provider satisfaction, were commonly reported ED process performance measures. Cost-based measures indicate the financial implications of health care provided. Measures of cost varied and lacked detail, and were often reported simply as “costs” [ 18 , 51 , 62 ]. Clinical-based measures indicate the medical outcomes for patients of the health care provided. Measures of clinical outcomes reported varied, however, and the most commonly used were adverse events and readmission.

Overall, time-based and process-based outcome domains were the most widely used measures for interventions with 24 out of the 30 individual interventions reporting at least one of each of these domains. Proportion-based outcomes were similarly well reported on for interventions with 21 out of the 30 interventions reporting proportion-based measures. Cost-based and clinical-based outcomes were the least utilised domains with only 12 and 17 interventions respectively reporting at least one outcome in these domains.

Team composition

The time-based outcome was the most widely used domain for team composition interventions, with 10 of the 13 interventions reporting at least one time-based measure. Proportion-based measures were reported for nine of the 13 interventions with process-based and clinical-based measures reported for 8 of the interventions. Cost-based outcomes were the least utilised, with six interventions reporting at least one outcome in this domain. An additional file provides a full list of intervention performance measures reported for the included interventions (See Additional file  6 ). Figure  5 displays a summary of the types of interventions within practices and processes and team composition, as well as graphically presenting the proportion of the total number of outcome measures reported for each domain for each intervention.

Overview of the outcome measures used for ED interventions. The rich picture summarises the types of interventions identified by this review. The graphs for each intervention present the proportion of outcome measures reported for each domain for each intervention. Each proportion was calculated as the number of identified outcome measures in the domain divided by the total number of outcome measures for the intervention. CNS, clinical nurse specialist; CRNA, certified registered nurse anaesthetist; CIN, clinical initiatives nurse; RAZ/RAP, rapid assessment zone/ rapid assessment pod; MAU, medical assessment unit; ED, Emergency Department; QDU, quick diagnosis unit

In this review we aimed to map the research evidence of strategies to measure and improve ED performance. There was strong alignment between how ED performance is measured, the types of ED interventions implemented, and the outcome measures used to assess effectiveness of those interventions.

While EDs worldwide may share a common purpose [ 87 , 88 , 89 ], the differences and complexity within each ED system is reflected in the vast number of measures used to understand different aspects of ED performance. Similarly, the different ways these measures have been categorised reflects differences in the interpretation of that common purpose. For EDs and the communities they serve, the selection of performance measures is critical to ensuring a comprehensive, accurate and precise picture of ED performance is developed. It is equally important to develop a shared understanding how ED performance data is collected to ensure that measures used for performance assessment or comparison are valid.

The results of our review show that the delivery of care in ED has evolved over the last 20 years with the implementation of a wide range of interventions to improve ED performance. The interventions identified by this review address very specific aspects of how care is provided in ED, suggesting that a systems perspective has not been applied. Crucially, EDs are complex adaptive systems and any intervention implemented to improve performance is likely influenced by existing models of care, as well as a variety of contextual factors such as funding, availability of skilled workforce, and the physical space available.

Changing patient involvement in the provision of care also plays a role in ED performance. The small number of reviews identified by this review that involved patient perspectives suggests that care delivery in the ED is likely driven by clinicians and protocols, with patients as passive consumers of care. In the crowded and frantic ED context, achieving patient-centred care is likely a challenging task [ 33 ]. Our findings suggest that achieving active participation by patients in ED care delivery is possible, but more research is needed on the implications for ED performance and patients’ clinical and psychosocial outcomes.

Intervention outcome measures allow us to determine if the intervention to improve ED performance was successful or if it had unintended outcomes. While the use of all five types of outcome measures synthesised in our review would provide clinicians, hospital administrators and researchers with the most insight into ED performance and intervention effectiveness, implementation of the full suite of measures may not be possible in some contexts. Most studies reported the use of three or fewer types of outcome measures. Measures of time were commonly combined with proportion or process measures. The use of time, proportion and process measures provides insight into the speed of healthcare provision, the quantity of resources used (e.g., diagnostic tests), and the quality of patient management (e.g., clinical documentation). However, intervention implementation decisions are often made based on department budgets or the availability of funding. As such, the inclusion of cost measures is increasingly important to inform clinicians’ and administrators’ decisions about ED performance and intervention effectiveness. Finally, measures of clinical outcomes are also important for examining the assumption that system changes in healthcare provide improved patient safety and clinical outcomes, and this is a neglected area for many interventions.

Limitations

This scoping review is the first, to our knowledge, to synthesise the many review articles to comprehensively describe the different strategies that have been used to measure and improve ED performance. Limitations of the current study include our pragmatic choice to only include reviews published in English and the potential biases of the included studies. The published reviews examining the effectiveness of interventions in the ED context might have suffered from publication bias, with negative results less likely to be published. As a result of this publication bias, it is unclear what interventions are unsuccessful or if particular context characteristics result in unsuccessful interventions, or negatively impact on patient care.

Over the last two decades, the way care has been delivered in ED has changed dramatically in response to increased demand and increasing complexity, and it is likely that it will continue to change over the next two decades. In turn, the way we measure ED performance has changed with our capacity to collect and analyse data. We need to think critically about the performance measures we use to define ED performance to ensure we are capturing a complete and dynamic picture that accurately reflects how an ED is performing. As shown by this review, a number of different strategies have been used to improve ED performance. As both internal and external pressures on ED continue to grow, future intervention initiatives will be needed to ensure the tragic consequences of crowding in ED are avoided. Crucially, a comprehensive range of meaningful outcome measures for interventions needs to be used to accurately establish the effectiveness of ED interventions and inform system changes and decision-making.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

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Acknowledgements

We would like to acknowledge and thank Ms. Teresa Winata for providing support in the proof-reading process. We would also like to acknowledge and thank Mr. Drew McTavish for providing support in the development of Figures.

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EEA, BB, JB and RCW made substantial contributions to the conception of the work. EEA, CT and AS made substantial contributions to the acquisition, analysis and interpretation of the data. All authors approved the submitted version and have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Supplementary information

Additional file 1: appendix a..

The full search strategy for all databases.

Additional file 2: Table 1.

Characteristics of the included reviews on ED performance measures.

Additional file 3: Table 2.

Characteristics of the included reviews on interventions to improve ED performance.

Additional file 4: Table 3.

The evidence contribution to the review questions of the included reviews.

Additional file 5: Table 4.

The ROBIS Risk of Bias results for each domain and the overall risk of bias for the included reviews

Additional file 6: Table 14.

The performance measures reported by the included reviews for each intervention.

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Austin, E.E., Blakely, B., Tufanaru, C. et al. Strategies to measure and improve emergency department performance: a scoping review. Scand J Trauma Resusc Emerg Med 28 , 55 (2020). https://doi.org/10.1186/s13049-020-00749-2

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DOI : https://doi.org/10.1186/s13049-020-00749-2

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Episode 30 Part 1 Procedures: Central Lines, Surgical Airways & Pericardiocentesis   with Jordan Chenkin & Jamie Blicker

Episode 29 Hand Emergencies  with Andrew Arcand & Laura Tate

Episode 28 Aortic Dissection, Acute Limb Ischemia & Compartment Syndrome  with David Carr & Anil Chopra

Episode 27 Drugs of Abuse – Stimulants & Opiates   with Margaret Thompson & Lisa Thurgur

Episode 26 Low Back Pain Emergencies   with  Walter Himmel & Brian Steinhart

Episode 25 Pediatric & Adult Syncope   with Anna Jarvis & Eric Letovsky

Episode 24 COPD & Pneumonia   with Anil Chopra & John Foote

Episode 23 Vaginal Bleeding in Early Pregnancy   with Ross Claybo & Dave Dushenski

Episode 22 Whistler’s Update in Emergency Medicine Conference 2012

Episode 21 Pulmonary Embolism   with John Foote & Anil Chopra

Episode 20 Atrial Fibrillation   with Clare Atzema, Nazanin Meshkat & Bryan Au

Episode 19 Part 2 Pediatric Abdominal Pain: Gastroenteritis, Constipation & Bowel Obstruction   with Anna Jarvis & Stephen Freedman

Episode 19 Part 1 Pediatric Abdominal Pain: Approach & Appendicitis   with Anna Jarvis & Stephen Freedman

Episode 18 Part 2 POCUS: More Point of Care Ultrasound   with Jordan Chenkin, Greg Hall, Jason Fischer & Paul Hannam

Episode 18 Part 1 POCUS: Pearls, Pitfalls & Controversies   with Jordan Chenkin, Greg Hall, Jason Fischer & Paul Hannam

Episode 17 Part 2 Stroke: Dabigitran & Intracranial Hemorrhage   with Walter Himmel & Dan Selchen

Episode 17 Part 1 Stroke: Emergency Stroke Controversies   with Walter Himmel & Dan Selchen

Episode 16 Acute Monoarthritis   with Joel Yaphe & Indy Ghosh

Episode 15 Part 2 Acute Coronary Syndromes: Management   with Eric Letovsky, Mark Mensour & Neil Fam

Episode 15 Part 1 Acute Coronary Syndromes: Risk Stratification   with Eric Letovsky, Mark Mensour & Neil Fam

Episode 14 Part 2 Headache: Thunderclap Headache – Cervical Artery Dissection & Cerebral Venous Thrombosis   with Anil Chopra & Stella Yiu

Episode 14 Part 1 Headache: Migraine Headache & Subarachnoid Hemorrhage   with Anil Chopra & Stella Yiu

Episode 13 Killer Coma Cases   with Brian Steinhart & David Carr

Episode 12 ACLS Guidelines   with Steven Brooks & Michael Feldman

Episode 11 Cognitive Decision Making & Medical Error   with Doug Sinclair & Chris Hicks

Episode 10 Trauma Pearls & Pifalls   with Dave MacKinnon & Mike Brzozowski

Episode 9 Nontraumatic Eye Emergencies   with Simon Kinsgley & George Porfiris

Episode 8 Emergency Airway Controversies   with Jonathan Sherbino, Mark Mensour & Andrew Healy

Episode 7 Medical & Surgical Emergencies in Pregnancy  with Dave Dushenski & Shirley Lee

Episode 6 Transient Ischemic Attack  with Walter Himmel & Dan Selchen

Episode 5 Renal Colic, Toxicology Update & Body Packers   with Lisa Thurgur & Paul Rosenberg

Episode 4 Acute Congestive Heart Failure   with Brian Steinhart & Eric Letovsky

Episode 3 Pediatric Head Injury   with Rahim Valani & Jen Riley

Episode 2 Excited Delirium   with Margaret Thompson & Dan Cass

Episode 1 Occult Fractures & Dislocation   with Arun Sayal & Natalie Mamen

Cardiovascular

Gastroenterology, genitourinary, hematology & oncology.

Episode 132 Approach to Resolved Seizure   with Paul Koblic & Aylin Reid

Episode 14 Part 2 Headaches: Thunderclap Headache – Cervical Artery Dissection & Cerebral Venous Thrombosis   with Anil Chopra & Stella Yiu

Episode 14 Part 1 Headaches: Migraine & Subarachnoid Hemorrhage   with Anil Chopra & Stella Yiu

Ophthalmology

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Episode 136 Part 2 Shoulder Injuries: Occult Injuries &  Humerus Fractures   with Arun Sayal & Dale Dantzer

Episode 50 Recognition & Management of Pediatric Sepsis & Septic Shock  with Gina Neto & Sarah Reid

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Episode 74 Opioid Misuse in EM   with David Juurlink & Reuben Strayer

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Emergency department crowding hits crisis levels, risking patient safety.

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In a pair of new studies, Yale researchers document a widespread and increasing level of overcrowding in America’s emergency departments (EDs), a crisis that puts patient safety and access to care at risk.

For the studies, the researchers examined, respectively, the progression in recent years of two measures of ED function and hospital capacity: boarding time — or how long patients remain in the ED after physicians have determined they should be admitted to the hospital — and how often patients leave the ED before receiving care.

Their findings, they say, help characterize the bigger issues that underlie ED crowding. And they show that the issue worsened during the COVID-19 pandemic. Their methods also yield more timely assessments of these key indicators, which historically have been hard to come by.

“ This is not an ED management issue,” said Arjun Venkatesh , an associate professor of emergency medicine at Yale School of Medicine and an author of the studies. “These are indicators of overwhelmed resources and symptoms of deeper problems in the health care system.”

The studies were both published Sept. 30 in JAMA Network Open.

It was during the 1980s that ED crowding emerged as an issue of national concern. The problem has only gotten worse in the decades since, with negative effects for patients and hospital staff alike. For patients, studies have found that ED crowding is correlated with discomfort, reduced privacy, treatment delays, and higher risk of prolonged disease and death. ED crowding also leads to increased violence toward staff, greater clinician and nurse turnover, and high rates of burnout. A recent study found nearly 63% of surveyed U.S. physicians experienced burnout in 2021.

In one of the new studies , researchers found that boarding times — or the amount of time patients were kept in the emergency department after clinicians had determined they should be admitted — were related to hospital occupancy rates, or the percentage of staffed inpatient beds that are occupied. The Joint Commission, an independent national health care accrediting body, has recommended that boarding time not exceed four hours.

For the study, Yale researchers evaluated these measures in U.S. hospitals during the COVID-19 pandemic, from January 2020 to December 2021. They found that when occupancy exceeded 85%, boarding times exceeded this four-hour standard. In fact, under those circumstances, the median ED boarding time was 6.58 hours. Boarding times also worsened throughout this time period, outpacing occupancy rates.

This relationship makes sense, says Alexander Janke, lead author of the studies, because when occupancy is high, there are few available beds to move patients from the ED. And with diminishing capacity, wait times are compounded.

“ Hospitals must have some flexible capacity so there are places for patients with emergencies requiring hospitalization to go,” said Janke, who conducted the research while a fellow at Yale School of Medicine and is now at the University of Michigan. “And that capacity doesn’t exist in a lot of places.” Which means patients stay in the ED until space opens at their destination and ED beds remain occupied, limiting the number available to new patients.

This latter impact can affect ED wait times. And when those are long, patients are more likely to leave before being evaluated. In the second study, researchers assessed the rates at which patients in U.S. hospitals decided to leave EDs before even being seen by a clinician.

From January 2017 to December 2021, the median rate of patients leaving without being seen nearly doubled from 1.1% to 2.1%. At the worst performing hospitals, those rates were as high as 10% by the end of 2021, a number Janke called “astonishing.”

“ It’s a measure of access to care,” he said. “If you have to wait hours and hours to be evaluated in the ED, then that’s not the access to care that we have required by law in [the Emergency Medical Treatment and Active Labor Act, or EMTALA].” (Enacted in 1986, EMTALA requires universal provision of emergency care by hospitals that accept Medicare payments.)

These findings, the researchers say, offer a snapshot of the current state of EDs in the United States, and provide critical data that typically are difficult to obtain in a timely manner. Though hospitals are required to report certain measures on a yearly basis, those data often aren’t released publicly for another two or three years, rendering them irrelevant, said Janke.

“ The health care system is a living, breathing organism, and it’s like we measured its vital signs one time three years ago and that’s how we make public policy,” he said. “You and I should know whether the acute care system where we live has the capacity to address, say, a heart attack or a stroke in a family member. This is a problem that affects population health.”

The researchers want people outside of the ED community to recognize this population-level effect and the impacts of ED crowding.

“ We hope our findings begin to draw attention and accountability for the human toll of the ED boarding crisis,” said Ted Melnick , associate professor of emergency medicine at Yale School of Medicine and an author of the studies.

For both studies, the researchers collected data from a large electronic health record vendor, an approach that’s particularly helpful in the absence of other national or local data.

“ Future partnerships with electronic health record vendors can continue to shed light on crises like this,” Melnick said.

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Stranded in the ER, Seniors Await Hospital Care and Suffer Avoidable Harm

Every day, the scene plays out in hospitals across America: Older men and women lie on gurneys in emergency room corridors moaning or suffering silently as harried medical staff attend to crises.

Even when physicians determine these patients need to be admitted to the hospital, they often wait for hours — sometimes more than a day — in the ER in pain and discomfort, not getting enough food or water, not moving around, not being helped to the bathroom, and not getting the kind of care doctors deem necessary.

“You walk through ER hallways, and they’re lined from end to end with patients on stretchers in various states of distress calling out for help, including a number of older patients,” said Hashem Zikry, an emergency medicine physician at UCLA Health.

Physicians who staff emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been — even worse than during the first years of the covid-19 pandemic, when hospitals filled with desperately ill patients.

While boarding can happen to all ER patients, adults 65 and older, who account for nearly 20% of ER visits, are especially vulnerable during long waits for care. Also, seniors may encounter boarding more often than other patients. The best estimates I could find, published in 2019, before the covid-19 pandemic, suggest that 10% of patients were boarded in ERs before receiving hospital care. About 30% to 50% of these patients were older adults.

“It’s a public health crisis,” said Aisha Terry, an associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences and the president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.

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What’s going on? I spoke to almost a dozen doctors and researchers who described the chaotic situation in ERs. They told me staff shortages in hospitals, which affect the number of beds available, are contributing to the crisis. Also, they explained, hospital administrators are setting aside more beds for patients undergoing lucrative surgeries and other procedures, contributing to bottlenecks in ERs and leaving more patients in limbo.

Then, there’s high demand for hospital services, fueled in part by the aging of the U.S. population, and backlogs in discharging patients because of growing problems securing home health care and nursing home care, according to Arjun Venkatesh, chair of emergency medicine at the Yale School of Medicine.

The impact of long ER waits on seniors who are frail, with multiple medical issues, is especially serious. Confined to stretchers, gurneys, or even hard chairs, often without dependable aid from nurses, they’re at risk of losing strength, forgoing essential medications, and experiencing complications such as delirium, according to Saket Saxena, a co-director of the geriatric emergency department at the Cleveland Clinic.

When these patients finally secure a hospital bed, their stays are longer and medical complications more common. And new research finds that the risk of dying in the hospital is significantly higher for older adults when they stay in ERs overnight, as is the risk of adverse events such as falls, infections, bleeding, heart attacks, strokes, and bedsores.

Ellen Danto-Nocton, a geriatrician in Milwaukee, was deeply concerned when an 88-year-old relative with “strokelike symptoms” spent two days in the ER a few years ago. Delirious, immobile, and unable to sleep as alarms outside his bed rang nonstop, the older man spiraled downward before he was moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton said.

Several weeks ago, Zikry of UCLA Health helped care for a 70-year-old woman who’d fallen and broken her hip while attending a basketball game. “She was in a corner of our ER for about 16 hours in an immense amount of pain that was very difficult to treat adequately,” he said. ERs are designed to handle crises and stabilize patients, not to “take care of patients who we’ve already decided need to be admitted to the hospital,” he said.

How common is ER boarding and where is it most acute? No one knows, because hospitals aren’t required to report data about boarding publicly. The Centers for Medicare & Medicaid Services retired a measure of boarding in 2021. New national measures of emergency care capacity have been proposed but not yet approved.

“It’s not just the extent of ED boarding that we need to understand. It’s the extent of acute hospital capacity in our communities,” said Venkatesh of Yale, who helped draft the new measures.

In the meantime, some hospital systems are publicizing their plight by highlighting capacity constraints and the need for more hospital beds. Among them is Massachusetts General Hospital in Boston, which announced in January that ER boarding had risen 32% from October 2022 to September 2023. At the end of that period, patients admitted to the hospital spent a median of 14 hours in the ER and 26% spent more than 24 hours.

Maura Kennedy, Mass General’s chief of geriatric emergency medicine, described an 80-something woman with a respiratory infection who languished in the ER for more than 24 hours after physicians decided she needed inpatient hospital care.

“She wasn’t mobilized, she had nothing to cognitively engage her, she hadn’t eaten, and she became increasingly agitated, trying to get off the stretcher and arguing with staff,” Kennedy told me. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”

When I asked ER doctors what older adults could do about these problems, they said boarding is a health system issue that needs health system and policy changes. Still, they had several suggestions.

“Have another person there with you to advocate on your behalf,” said Jesse Pines, chief of clinical innovation at US Acute Care Solutions, the nation’s largest physician-owned emergency medicine practice. And have that person speak up if they feel you’re getting worse or if staffers are missing problems.

Alexander Janke, a clinical instructor of emergency medicine at the University of Michigan, advises people, “Be prepared to wait when you come to an ER” and “bring a medication list and your medications, if you can.”

To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses with you,” said Michael Malone, medical director of senior services for Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “Whenever possible, try to get up and move around.”

Friends or family caregivers who accompany older adults to the ER should ask to be at their bedside, when possible, and “try to make sure they eat, drink, get to the bathroom, and take routine medications for underlying medical conditions,” Malone said.

Older adults or caregivers who are helping them should try to bring “things that would engage you cognitively: magazines, books … music, anything that you might focus on in a hallway where there isn’t a TV to entertain you,” Kennedy said.

“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry of UCLA. “Also, bring something to eat and drink in case you can’t get to the cafeteria or it’s a while before staffers bring these to you.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit  kffhealthnews.org/columnists  to submit your requests or tips.

Related Topics

• Navigating Aging
• Public Health
• Emergency Medicine

Copy And Paste To Republish This Story

By Judith Graham Updated May 6, 2024 Originally Published May 6, 2024

“You walk through ER hallways, and they’re lined from end to end with patients on stretchers in various states of distress calling out for help, including a number of older patients,” said Hashem Zikry, an emergency medicine physician at UCLA Health.

Physicians who staff emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been — even worse than during the first years of the covid-19 pandemic, when hospitals filled with desperately ill patients.

“It’s a public health crisis,” said Aisha Terry, an associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences and the president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.

What’s going on? I spoke to almost a dozen doctors and researchers who described the chaotic situation in ERs. They told me staff shortages in hospitals, which affect the number of beds available, are contributing to the crisis. Also, they explained, hospital administrators are setting aside more beds for patients undergoing lucrative surgeries and other procedures, contributing to bottlenecks in ERs and leaving more patients in limbo.

Then, there’s high demand for hospital services, fueled in part by the aging of the U.S. population, and backlogs in discharging patients because of growing problems securing home health care and nursing home care, according to Arjun Venkatesh, chair of emergency medicine at the Yale School of Medicine.

The impact of long ER waits on seniors who are frail, with multiple medical issues, is especially serious. Confined to stretchers, gurneys, or even hard chairs, often without dependable aid from nurses, they’re at risk of losing strength, forgoing essential medications, and experiencing complications such as delirium, according to Saket Saxena, a co-director of the geriatric emergency department at the Cleveland Clinic.

Ellen Danto-Nocton, a geriatrician in Milwaukee, was deeply concerned when an 88-year-old relative with “strokelike symptoms” spent two days in the ER a few years ago. Delirious, immobile, and unable to sleep as alarms outside his bed rang nonstop, the older man spiraled downward before he was moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton said.

Several weeks ago, Zikry of UCLA Health helped care for a 70-year-old woman who’d fallen and broken her hip while attending a basketball game. “She was in a corner of our ER for about 16 hours in an immense amount of pain that was very difficult to treat adequately,” he said. ERs are designed to handle crises and stabilize patients, not to “take care of patients who we’ve already decided need to be admitted to the hospital,” he said.

How common is ER boarding and where is it most acute? No one knows, because hospitals aren’t required to report data about boarding publicly. The Centers for Medicare & Medicaid Services retired a measure of boarding in 2021. New national measures of emergency care capacity have been proposed but not yet approved.

“It’s not just the extent of ED boarding that we need to understand. It’s the extent of acute hospital capacity in our communities,” said Venkatesh of Yale, who helped draft the new measures.

Maura Kennedy, Mass General’s chief of geriatric emergency medicine, described an 80-something woman with a respiratory infection who languished in the ER for more than 24 hours after physicians decided she needed inpatient hospital care.

“She wasn’t mobilized, she had nothing to cognitively engage her, she hadn’t eaten, and she became increasingly agitated, trying to get off the stretcher and arguing with staff,” Kennedy told me. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”

“Have another person there with you to advocate on your behalf,” said Jesse Pines, chief of clinical innovation at US Acute Care Solutions, the nation’s largest physician-owned emergency medicine practice. And have that person speak up if they feel you’re getting worse or if staffers are missing problems.

Alexander Janke, a clinical instructor of emergency medicine at the University of Michigan, advises people, “Be prepared to wait when you come to an ER” and “bring a medication list and your medications, if you can.”

To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses with you,” said Michael Malone, medical director of senior services for Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “Whenever possible, try to get up and move around.”

Friends or family caregivers who accompany older adults to the ER should ask to be at their bedside, when possible, and “try to make sure they eat, drink, get to the bathroom, and take routine medications for underlying medical conditions,” Malone said.

Older adults or caregivers who are helping them should try to bring “things that would engage you cognitively: magazines, books … music, anything that you might focus on in a hallway where there isn’t a TV to entertain you,” Kennedy said.

“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry of UCLA. “Also, bring something to eat and drink in case you can’t get to the cafeteria or it’s a while before staffers bring these to you.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit  kffhealthnews.org/columnists  to submit your requests or tips.

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• Open access
• Published: 17 May 2024

Antibiotic susceptibility patterns and trends of the gram-negative bacteria isolated from the patients in the emergency departments in China: results of SMART 2016–2019

• Ying Fu 1 , 2 ,
• Feng Zhao 1 , 2 ,
• Jie Lin 1 , 2 ,
• Pengcheng Li 3 &
• Yunsong Yu 4 , 5 , 6  

BMC Infectious Diseases volume  24 , Article number:  501 ( 2024 ) Cite this article

197 Accesses

8 Altmetric

Metrics details

The study aims were to evaluate the species distribution and antimicrobial resistance profile of Gram-negative pathogens isolated from specimens of intra-abdominal infections (IAI), urinary tract infections (UTI), respiratory tract infections (RTI), and blood stream infections (BSI) in emergency departments (EDs) in China.

From 2016 to 2019, 656 isolates were collected from 18 hospitals across China. Minimum inhibitory concentrations were determined by CLSI broth microdilution and interpreted according to CLSI M100 (2021) guidelines. In addition, organ-specific weighted incidence antibiograms (OSWIAs) were constructed.

Escherichia coli ( E. coli ) and Klebsiella pneumoniae ( K. pneumoniae ) were the most common pathogens isolated from BSI, IAI and UTI, accounting for 80% of the Gram-negative clinical isolates, while Pseudomonas aeruginosa ( P. aeruginosa ) was mainly isolated from RTI. E. coli showed < 10% resistance rates to amikacin, colistin, ertapenem, imipenem, meropenem and piperacillin/tazobactam. K. pneumoniae exhibited low resistance rates only to colistin (6.4%) and amikacin (17.5%) with resistance rates of 25–29% to carbapenems. P. aeruginosa exhibited low resistance rates only to amikacin (13.4%), colistin (11.6%), and tobramycin (10.8%) with over 30% resistance to all traditional antipseudomonal antimicrobials including ceftazidime, cefepime, carbapenems and levofloxacin. OSWIAs were different at different infection sites. Among them, the susceptibility of RTI to conventional antibiotics was lower than for IAI, UTI or BSI.

Conclusions

Gram-negative bacteria collected from Chinese EDs exhibited high resistance to commonly used antibiotics. Susceptibilities were organ specific for different infection sites, knowledge which will be useful for guiding empirical therapies in the clinic.

Peer Review reports

Antimicrobials are frequently used in emergency departments (EDs) in China and a study noted that the proportion of emergency patients treated with antibiotics was as high as 39.31 to 43.45% from 2016 to 2019 [ 1 ]. Antibiotic stewardship in EDs should avoid administration of broad-spectrum antibiotics, shorten their use times, as well as minimizing their unnecessary use [ 2 ]. However, as patients presenting to EDs are often in an acute state, physicians have to make decisions in a very short time frame and they prescribe antibiotics empirically. For critically ill infected patients, guidelines recommend to start antibiotic treatment in the first hour of recognition [ 3 ], which means that it is frequently impossible to get microbiology results to guide the choice of antimicrobial therapy. In order to support the choice of empiric antibiotic treatments, consensus guidelines as well as local antibiotic drug susceptibility detection and various antimicrobial surveillance programs have been introduced in China [ 4 , 5 ].

One approach to individualized empiric antibiotic therapy is the Weighted-Incidence Syndromic Combination Antibiogram, which is comprised of information about the likelihood a treatment regimen will be effective for all relevant organisms for a given infection based on existing large datasets [ 6 , 7 , 8 ]. A similar approach is the organ-specific weighted incidence antibiogram (OSWIA), which estimates probable susceptibilities of organ specific isolates to specific antibiotics [ 9 ]. The Study for Monitoring Antimicrobial Resistance Trends (SMART) global surveillance program monitors in vitro susceptibilities of clinical Gram-negative bacilli to antimicrobial agents obtained from blood stream infections (BSI), intra-abdominal infections (IAI), urinary tract infections (UTI) and respiratory tract infections (RTI). The purpose of the present study was to determine the prevalence and susceptibilities of various bacteria to conventional antibiotics in patients attending Chinese EDs through a retrospective analysis of the SMART data collected from 2016 to 2019 and to determine differences of organ distributions between the infecting bacterial strains.

In this study, the patient informed consent was waived and authorized by the Ethics Committee of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (Approval Number: 20210811-33).

All bacterial isolates were collected from discarded clinical specimens of hospitalized patients with BSI, IAI, UTI and RTI between 2016 and 2019 who were admitted to the EDs of 18 hospitals across China (Supplementary Table  1 ). The IAI specimen is derived from tissues or organs within the abdominal cavity, including the stomach, intestines, liver, spleen, pancreas, kidneys that have been infected by pathogens, resulting in infectious diseases [ 10 ]. RTI refers to an infection of the tissues in the respiratory system by pathogens such as viruses, bacteria, or fungi. RTI specimens from the respiratory tract included nasal and throat swabs, sputum samples, bronchoalveolar lavage fluid, respiratory secretions, and others [ 11 ]. Identification of isolates was initially made by each hospital laboratory and then the specimens were sent for laboratory re-identification using MALDI-TOF/MS (Bruker Daltonics, USA). Any duplicate isolates collected from the same patient were excluded from the data analysis.

Antimicrobial susceptibility testing

Testing was carried out in the Peking Union Medical College Hospital clinical microbiology laboratory using the Trek Diagnostic System (Thermo Fisher Scientific). Clinical isolates and reference strains were detected using the microbroth dilution method. Minimum inhibitory concentrations (MICs) were determined with reference to the antimicrobial breakpoint of the CLSI M100 (2021) [ 12 ]. The antibiotics tested were amikacin (AMK), cefepime (FEP), ceftazidime (CAZ), aztreonam (ATM), ceftriaxone (CRO), colistin (COL), ertapenem (ETP), levofloxacin (LVX), cefoxitin (FOX), imipenem (IPM), tobramycin (TOB), meropenem (MEM) and piperacillin–tazobactam (TZP).

Definition of antimicrobial-resistant strains

Carbapenem resistance of Escherichia coli ( E. coli ) and Klebsiella pneumoniae ( K. pneumoniae ) refers to resistance to any of IPM, MEM or ETP. Carbapenem-resistant Pseudomonas aeruginosa ( P. aeruginosa ) was defined as resistance to IPM or MEM.

Quinolone resistance to E. coli, K. pneumoniae and P. aeruginosa was defined as resistance to LVX.

Third generation cephalosporin resistance to E. coli and K. pneumoniae was defined as resistance to any CRO or CAZ, and the strains susceptible or intermediate to carbapenems (IPM, MEM or ETP). P. aeruginosa resistant to third-generation cephalosporin was defined as resistance to CAZ (CAZ-resistant PA) and the strains susceptible or intermediate to carbapenems (IPM, MEM).

OSWIA calculation

Data were retrospectively analyzed to establish the distribution of bacteria in various organs for BSI, IAI, UTI and RTI. OSWIA values were determined as previously described [ 9 ].

Patient characteristics and specimen source

Between January 01, 2016 and December 31, 2019, a total of 656 isolated were obtained from ED patients. The patient characteristics are detailed in Table  1 . The patients average age was 60.6 years (range: 1–101), comprising 388 males and 268 females. Most infections were hospital-acquired (HA) (58.1%), while 249 (38.0%) were community-acquired (CA) and for 26 data were not applicable. The isolates included 210 strains from IAI collected during surgery from the peritoneal fluid, appendix, abscesses, pancreas, gall bladder, liver and stomach. A total of 122 strains from BSI, 112 strains from UTI mainly from the urine, and 208 strains from RTI taken from bronchoalveolar lavage, endotracheal aspirate, thoracentesis or sputum were identified, as well as 4 strains from unconfirmed organs.

Distribution of Gram-negative bacteria obtained from BSI, IAI, UTI and RTI

Enterobacterales were the most common Gram-negative bacilli isolated from emergency patients with BSI, IAI and UTI (Fig.  1 ). E. coli accounted for 48.4% in BSI, 58.6% in IAI and 72.3% in UTI, while K. pneumoniae accounted for 24.6%, 21.4% and 11.6%, respectively and other Enterobacterales were much less common than E. coli and K. pneumoniae . The pathogen distribution in RTI was distinctly different from the other three infection types, with P. aeruginosa and K. pneumoniae being the most common species each accounting for about 40% of the Gram-negative pathogens. Since the composition ratio of Gram-negative bacteria was different at different infection sites (Fig.  1 , Supplementary Table  2 ) the varying patterns between infected organs should be considered when prescribing empirical treatments.

Distribution of Gram-negative bacilli in BSI, IAI, UTI and RTI. Abbreviations: BSI, blood steam infection; IAI, intra-abdominal infection; UTI, urinary tract infection

Distribution of Gram-negative bacteria from 2016 to 2019

The distribution of Gram-negative pathogens was stable between 2016 and 2019, with E. coli , K. pneumoniae and P. aeruginosa being the top 3 species, accounting for more than 80% of the clinical isolates (Fig. 2 , Supplementary Table 3 ).

Composition ratio of Gram-negative bacteria in EDs from 2016 to 2019.  Abbreviation: ED, emergency department.

Distribution of Gram-negative bacteria in different age groups of patients

Among the strains collected, regardless of the organ of origin, the predominant species were P. aeruginosa, E. coli and K. pneumoniae . However, the composition ratio of the main bacterial groups were different in infection sites within age groups (Fig.  3 a-d) and were generally different especially in the age group ≤ 39 years (Fig.  3 e, Supplementary Table  4 ).

Comparison of the composition ratio of microbiota in different infected organs and age groups.  Abbreviations: BSI, blood steam infection; IAI, intra-abdominal infection; RTI, respiratory tract infection; UTI, urinary tract infection.

Monitoring of drug susceptibility

Drug resistance rate monitoring of major gram-negative bacteria from 2016 to 2019.

E. coli exhibited < 10% resistance to AMK, COL, ETP, IPM, MEM and TZP, with the exception in 2016 to TZP, but generally TZP resistance rates were reduced between 2016 and 2019. Otherwise, resistance rates were more than 30%, with the exception of FOX (16.2%). K. pneumoniae exhibited < 20% resistance only to AMK and 6.4% to COL between 2016 and 2019. P. aeruginosa only exhibited low resistant rates of 13.4% to AMK, 11.6% to COL and 10.8% to TOB from 2016 to 2019 (Table  2 ).

Detection rate and drug susceptibility of specific antibiotic-resistant bacteria from 2016 to 2019

Isolation of carbapenem-resistant, quinolone-resistant or third-generation cephalosporin-resistant e. coli, k. pneumoniae and p. aeruginosa.

In isolates, the carbapenem-resistant E. coli and P. aeruginosa showed an overall downward trend. However, the rate of detection of carbapenem-resistant E. coli was relatively low, being only 1.3% in 2019, while for carbapenem-resistant P. aeruginosa  in 2019 it was 30.0% and for carbapenem-resistant K. pneumoniae strains in 2019, 34.1%, the rate being higher than in 2018 (18.5%). The rate of detection of quinolone-resistant E. coli  or  K. pneumoniae showed a decreasing trend in the four years studied, being 55.7% in 2019 for the detection of quinolone-resistant E. coli  and 36.4% for K. pneumoniae . The detection rate of quinolone-resistant P. aeruginosa was 26.7% in 2019 and lower than in 2018 (42.9%). The detection rates of third-generation cephalosporin-resistant E. coli and K. pneumoniae as well as P. aeruginosa showed an irregular trend from 2016 to 2019, being between 44.3%–63.2% and 9.1%–24.1% as well as 2.9%–15.4%, respectively throughout the years. Compared to E. coli, there were only few numbers of third-generation cephalosporin-resistant K. pneumoniae and P. aeruginosa isolates found between 2016 and 2019 (Fig. 4 , Supplementary Table 5 ).

Isolation (detection) rate of carbapenem-resistant, quinolone-resistant, third-generation cephalosporin-resistant E. coli , K. pneumoniae  and P. aeruginosa from 2016 to 2019

Specific drug resistance rates (%) of strains to antibiotics from 2016 to 2019

For E. coli , the resistance rate of carbapenem-resistant E. coli to AMK was 33.3%, and to the other antibiotics tested were > 60%, apart from COL (25.0%). Quinolone-resistant E. coli exhibited the lowest resistance rates to AMK (4.3%), ETP (5.6%), IPM (5.0%) and MEM (5.6%). The resistance rates of third-generation cephalosporin-resistant E. coli was 2.0% to AMK and 0% to ETP, IPM and MEM.

Carbapenem-resistant K. pneumoniae were 57.1% resistant to AMK and quinolone-resistant K. pneumoniae were 42.0% resistant to AMK, with low resistance rates only found to COL (8.2% and 10.1%), respectively. Third-generation cephalosporin-resistant K. pneumoniae was 6.7% resistant to AMK and 0% to ETP, IPM and MEM.

For carbapenem-resistant P. aeruginosa , the drug resistance to AMK was 30.4%, for TOB 28.0% and for COL (10.9%). For quinolone-resistant  P. aeruginosa, only resistance rates to AMK (24.4%) and TOB (26.1%) as well as COL (9.8%) remained low. Third-generation cephalosporins resistant  P. aeruginosa, showed low resistance rates of 0% to AMK, IPM, MEM and TOB (Table 3 ).

Antimicrobial susceptibility monitoring during empiric treatment of different infection sites and organs

In the weighted susceptibility assessment of different infection sites, it was found that the susceptibility of the same antibacterial drug at different organs and infection sites was different. For example, AMK, TOB, ETP, IPM and MEM were the antibiotics with > 90% susceptibility for BSI, but only AMK and MEM were > 90% effective antibiotics against IAI. High-susceptibility to antibiotics in UTI included AMK, TOB and MEM (all > 90%), and except for AMK, COL and TOB, the susceptibility to other antibiotics at the site of RTI infections was < 80% (Fig. 5 , Supplementary Table 6 ).

Organ distribution related susceptibilities. a Differences in susceptibility of antibiotics at different infection sites. b Differences in weighted drug susceptibilities of antibiotics at different organs and infection sites. Note: *only sites from which more than 10 pathogenic bacteria were collected have been included; #, intermediate rate was shown for COL; -, no detection. Abbreviations: AMK, amikacin; ATM, aztreonam; BSI, blood steam infections; CAZ, ceftazidime; CRO, ceftriaxone; ETP, ertapenem; FEP, cefepime; FOX, cefoxitin; IAI, intra-abdominal infections; IPM, imipenem; LVX, levofloxacin; MEM, meropenem; RTI, respiratory tract infections; TOB, tobramycin; TZP, piperacillin/tazobactam; UTI, urinary tract infections

This study analyzed Chinese data from the global SMART surveilance program and found that the most frequently isolated Gram-negative bacteria were Enterobacterales , a finding similar to previous results from SMART studies and the China Antimicrobial Surveillance Network (CHINET) [ 13 , 14 ]. Enterobacterales are of particular concern given their ability to develop and spread resistance to penicillins, cephalosporins, carbapenems and quinolones [ 12 , 15 , 16 ]. As these are the most commonly used antibiotics in hospitals, such resistance would leave physicians with very limited treatment options. The vast majority of the pathogens were E. coli , K. pneumoniae and P. aeruginosa  (86.4%), with resistance rates for cephalosporins in the range of 31.0%–57.0% and for ATM 44.0%–45.5%, indicating a high rate of ESBL-producing strains [ 17 ], which underlines the global health problem of cephalosporin resistance [ 18 ]. Previous SMART surveilence results found ESBL rates of 46.3%–49.1% for E. coli and 25.6%–26.8% for K. pneumoniae [ 13 ]. In the 2021 CHINET surveillance, resistance to third-generation cephalosporins was detected in 55.6% of E. coli and 43.8% of K. pneumoniae , also indicating the high ESBL prevalence in China [ 14 ]. The resistance rates for the fluoroquinolone LVX (36.6%–56.7%) were in a similar range to cephalosporins in this study, which might reflect the overuse of fluoroquinolones, especially since the development of cephalosporin-resistance [ 19 , 20 ]. They were similar to the rates reported by the 2021 CHINET surveillance of LVX resistance detected as 53.6% for E. coli and 28.3% for K. pneumoniae isolates [ 14 ]. One approach to overcome cephalosporin resistance is the use of combination of a β-lactam and a β-lactamase inhibitor [ 21 ], such as tazobactam, which led to essentially reduced resistance rates of about 10% for otherwise cephalosporin-resistant E. coli and K. pneumoniae in the present study. Of concern is the rising resistance rate of K. pneumoniae to carbapenems , which reached25%–29% in the present study and was similar to the rate of about 25% found in the 2021 CHINET surveillance study [ 14 ].

Resistance rates for COL were generally low, but susceptibility breakpoints have been abolished in recent CLSI guidelines. Treatments with COL should be applied with maximum renally adjusted doses, since the previous MIC of 2 μg/mL could not be achieved in 50% of patients with normal renal functions and acute kidney injury occurs frequently with conventional doses. Recommendations include strongly preferred alternative drugs for active or combination treatments [ 22 , 23 ]. Also, TOB is not commonly used in China, which might explain the low resistance rates found in the present study.

P. aeruginosa was the third most common pathogen detected and the most common Gram-negative pathogen found in RTI. It exhibited > 30% resistance to traditional antipesudomoas antibiotics, including CAZ, FEP, TZP, IPM, MEM and LVX. These results are similar to those reported in a recent SMART study that investigated P. seudomonas resistance to antibiotics in China [ 24 ].

This present survey included only isolates collected in EDs, since patients admitted to EDs are frequently candidates for urgent empiric antibiotic treatment, which should be administered according to the site of infection and the clinical severity of symptoms [ 25 ]. The characteristics of infected patients and physicians' routine treatments in the ED differed compared to other departments. This is because the infected site may initially not be clearly defined, patients cannot be observed for a long period of time, and etiological evidence is rarely available; doctors and nurses in EDs also have a very heavy workload. It is therefore convenient to use drugs which only need administration once a day to ED patients, including ETP once a day, AMK intramuscular injection, as well as LVX once a day, which can be sequenced simultaneously.

In order to offer guidelines for chosing an empiric treatment, organ specific therapy based on pathogen distribution differences and their antibiotic resistance variations have been developed [ 6 , 8 ]. Of these, OSIWA was first applied for HA and CA infections of different intra-abdominal organs [ 9 ]. In the present study, we expanded the evaluation of OSIWA for the empirical treatment of IAI also to UTI, BSI and RTI. When considering the distribution of pathogens at a single infection site – for example E. coli  caused more than 50% of all IAI and more than 60% of all UTI – whereas for RTI infections E. coli  was the pathogen in < 15% of all cases (Fig. 3 ). The OSIWA shown in Fig 5  indicate the probabilities of successful empiric drug treatment for single infections sites. For RTI and IAI the choice of empirical antibiotics with expected efficacy was limited, but for UTI and BSI more antibiotics are available.

Limitations of the present survey were the relatively low sample numbers since only isolates from EDs have been included, which have had an influence on the resistance patterns reported and combination treatments with β-lactams, aminoglycoside and fluoroquinolone were not considered. In addition, since in the SMART data collection detailed data regarding resistance mechanisms are not included, susceptibility test results only can infer the mechanism of ESBL production in cephalosporin but not in carbapenem resistance.

The pathogens isolated from BSI, IAI, UTI and RTI between 2016 and 2019 in Chinese EDs were mainly E. coli, K. pneumoniae and P. aeruginosa ,but therewere considerable resistance pattern differences as well as organ distributions between the bacterial strains. OSIWA determinations led to organ specific antibiotic drug effectiveness patterns, which should help to guide the choice of suitable empirical antibiotic treatments, especially for urgent infected cases in EDs.

Availability of data and materials

The SMART database is not public and is only accessible to SMART investigators, but the data that support the findings of this study are directly available from MSD China or from the corresponding author Yunsong Yu upon reasonable request and with permission of MSD China. 

Abbreviations

blood stream infections

community acquired

ceftazidime

China Antimicrobial Surveillance Network

ceftriaxone

emergency departments

hospital acquired

intra-abdominal infections

levofloxacin

minimum inhibitory concentrations

organ-specific weighted incidence antibiograms

respiratory tract infections.

Study for Monitoring Antimicrobial Resistance Trends

piperacillin–tazobactam

urinary tract infections

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Acknowledgements

The authors thank Shanghai BIOMED Science Technology Co., Ltd (Shanghai, China) for providing editorial assistance and MSD China for their financial support.

This study was sponsored by funding from Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, New Jersey, USA. The funding body was involved in the study design, analysis and interpretation of data, as well as the decision to submit the article for publication.

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Fu, Y., Zhao, F., Lin, J. et al. Antibiotic susceptibility patterns and trends of the gram-negative bacteria isolated from the patients in the emergency departments in China: results of SMART 2016–2019. BMC Infect Dis 24 , 501 (2024). https://doi.org/10.1186/s12879-024-09294-0

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Maternal Vaccine Effectiveness Against Influenza-Associated Hospitalizations and Emergency Department Visits in Infants

• 1 Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
• 2 Influenza Division, National Center for Immunization and Respiratory Disease, US Centers for Disease Control and Prevention, Atlanta, Georgia
• 3 Vanderbilt University Medical Center, Nashville, Tennessee
• 4 University of Pittsburg Medical Center Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 5 Seattle Children’s Research Institute, Seattle, Washington
• 6 Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
• 7 University of Missouri, Kansas City School of Medicine, Children’s Mercy Kansas City, Kansas City
• 8 University of Rochester School of Medicine and Dentistry, Rochester, New York
• 9 University of California Los Angeles Mattel Children’s Hospital, Los Angeles
• Editorial Influenza Vaccination in Pregnancy—Rolling Up Sleeves for Pregnant Persons and Infants Matthew J. Zuber, MD; April Miller, MD, MPH; Katherine A. Poehling, MD, MPH JAMA Pediatrics

Question   Is maternal influenza vaccination during pregnancy associated with a reduction in influenza-associated hospitalizations and emergency department (ED) visits in infants younger than 6 months?

Findings   In this case-control study of 3764 infants younger than 6 months, maternal vaccination was associated with a reduction in influenza-associated hospitalizations and ED visits in infants. Vaccine effectiveness was highest among hospitalized infants, those younger than 3 months, and those born to mothers vaccinated in the third trimester.

Meaning   The findings in this study indicate that maternal influenza vaccination during pregnancy provided important protection for the infant in the first few months of life before infants are eligible for vaccination.

Importance   Influenza virus infection during pregnancy is associated with severe maternal disease and may be associated with adverse birth outcomes. Inactivated influenza vaccine during pregnancy is safe and effective and can protect young infants, but recent evidence, particularly after the 2009 novel influenza A (H1N1) pandemic, is limited.

Objective   To evaluate the effectiveness of influenza vaccination during pregnancy against laboratory-confirmed influenza-associated hospitalizations and emergency department (ED) visits in infants younger than 6 months.

Design, Setting, and Participants   This was a prospective, test-negative case-control study using data from the New Vaccine Surveillance Network from the 2016 to 2017 through 2019 to 2020 influenza seasons. Infants younger than 6 months with an ED visit or hospitalization for acute respiratory illness were included from 7 pediatric medical institutions in US cities. Control infants with an influenza-negative molecular test were included for comparison. Data were analyzed from June 2022 to September 2023.

Exposure   Maternal influenza vaccination during pregnancy.

Main Outcomes and Measures   We estimated maternal vaccine effectiveness against hospitalizations or ED visits in infants younger than 6 months, those younger than 3 months, and by trimester of vaccination. Maternal vaccination status was determined using immunization information systems, medical records, or self-report. Vaccine effectiveness was estimated by comparing the odds of maternal influenza vaccination 14 days or more before delivery in infants with influenza vs those without.

Results   Of 3764 infants (223 with influenza and 3541 control infants), 2007 (53%) were born to mothers who were vaccinated during pregnancy. Overall vaccine effectiveness in infants was 34% (95% CI, 12 to 50), 39% (95% CI, 12 to 58) against influenza-associated hospitalizations, and 19% (95% CI, −24 to 48) against ED visits. Among infants younger than 3 months, effectiveness was 53% (95% CI, 30 to 68). Effectiveness was 52% (95% CI, 30 to 68) among infants with mothers who were vaccinated during the third trimester and 17% (95% CI, −15 to 40) among those with mothers who were vaccinated during the first or second trimesters.

Conclusions and Relevance   Maternal vaccination was associated with reduced odds of influenza-associated hospitalizations and ED visits in infants younger than 6 months. Effectiveness was greatest among infants younger than 3 months, for those born to mothers vaccinated during the third trimester, and against influenza-associated hospitalizations.

• Editorial Influenza Vaccination in Pregnancy—Rolling Up Sleeves for Pregnant Persons and Infants JAMA Pediatrics

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Sahni LC , Olson SM , Halasa NB, et al. Maternal Vaccine Effectiveness Against Influenza-Associated Hospitalizations and Emergency Department Visits in Infants. JAMA Pediatr. 2024;178(2):176–184. doi:10.1001/jamapediatrics.2023.5639

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Emergency department care experiences among people who use substances: a qualitative study

People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for …

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• v.11(9); 2021

Understanding diagnostic processes in emergency departments: a mixed methods case study protocol

Michelle daniel.

1 Emergency Medicine, University of California San Diego School of Medicine, La Jolla, California, USA

SunYoung Park

2 School of Art and Design and School of Information, University of Michigan, Ann Arbor, Michigan, USA

Colleen M Seifert

3 Psychology, University of Michigan, Ann Arbor, Michigan, USA

P Paul Chandanabhumma

4 Family Medicine, University of Michigan, Ann Arbor, Michigan, USA

Michael D Fetters

Eric wilson.

5 Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA

Andrew B Canvasser

Hardeep singh.

6 Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

7 Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

Kalyan Pasupathy

8 Mayo Clinic Department of Health Sciences Research, Rochester, Minnesota, USA

Prashant Mahajan

9 Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA

Associated Data

bmjopen-2020-044194supp001.pdf

Introduction

Diagnostic processes in the emergency department (ED) involve multiple interactions among individuals who interface with information systems to access and record information. A better understanding of diagnostic processes is needed to mitigate errors. This paper describes a study protocol to map diagnostic processes in the ED as a foundation for developing future error mitigation strategies.

Methods and analysis

This study of an adult and a paediatric academic ED uses a prospective mixed methods case study design informed by an ED-specific diagnostic decision-making model (the modified ED-National Academies of Sciences, Engineering and Medicine (NASEM) model) and two cognitive theories (dual process theory and distributed cognition). Data sources include audio recordings of patient and care team interactions, electronic health record data, observer field notes and stakeholder interviews. Multiple qualitative analysis methods will be used to explore diagnostic processes in situ, including systems information flow, human–human and human–system interactions and contextual factors influencing cognition. The study has three parts. Part 1 involves prospective field observations of patients with undifferentiated symptoms at high risk for diagnostic error, where each patient is followed throughout the entire care delivery process. Part 2 involves observing individual care team providers over a 4-hour window to capture their diagnostic workflow, team coordination and communication across multiple patients. Part 3 uses interviews with key stakeholders to understand different perspectives on the diagnostic process, as well as perceived strengths and vulnerabilities, in order to enrich the ED-NASEM diagnostic model.

Ethics and dissemination

The University of Michigan Institutional Review Board approved this study, HUM00156261. This foundational work will help identify strengths and vulnerabilities in diagnostic processes. Further, it will inform the future development and testing of patient, provider and systems-level interventions for mitigating error and improving patient safety in these and other EDs. The work will be disseminated through journal publications and presentations at national and international meetings.

Strengths and limitations of this study

• Prospective, observational studies informed by theory which explore diagnostic processes in situ are uncommon, yet urgently needed to improve understanding of emergency department (ED) diagnosis.
• Study findings will provide critical, contextualised knowledge of how ED diagnosis and management is accomplished through interactions of patients, providers and tools, informing the design of interventions to mitigate error.
• A transdisciplinary team including safety experts, data scientists, systems engineers, cognitive psychologists and emergency physicians contributed to this mixed methods study design.
• The focus on one adult and one paediatric academic ED is methodologically critical to achieve a deep understanding of cognition in context, but may limit transferability to other settings.

Diagnosis and management of patients in emergency departments (EDs) involves highly complex cognitive processes under time pressure that are susceptible to errors, which we define as missed opportunities for improving diagnosis, regardless of patient outcomes. 1 While precise error rates are unknown, a conservative estimate of 5% of the 139 million ED visits annually suggests ~6.9 million errors per year. 2 Errors typically result from a complex interplay of factors arising from patients (eg, presenting symptoms, health literacy, disease complexity, behaviours), provider/care-team performance (eg, cognitive load, information gathering and synthesis, coordination) and systems (eg, health information technology, overcrowding, interruptions). 3 Current methods to study errors are suboptimal as they largely focus on retrospective analyses of what went wrong rather than understanding and contextualising diagnostic processes as they occur in the ED. Novel prospective studies are urgently needed to improve the understanding of ED diagnostic processes and to facilitate the development of interventions to improve patient safety.

We assembled a transdisciplinary team with expertise in emergency medicine, cognitive psychology, informatics, systems engineering, human–computer interaction (HCI) and design, anthropology, public health, mixed methods research and data science to address this gap. With support from the Agency for Healthcare Research and Quality, we are creating an Improving Diagnosis in Emergency and Acute Care—Learning Laboratory (IDEA-LL) to investigate ED diagnostic processes, study systems vulnerabilities and develop and iteratively test patient, provider and system-oriented interventions to mitigate diagnostic error. The three aims of the parent project (IDEA-LL) are shown in figure 1 .

Improving Diagnosis in Emergency and Acute Care—Learning Laboratory (IDEA-LL) Aims. ED, emergency department; EHR, electronic health record.

Patients that present to the ED often have complex and ambiguous problems that may not result in a ‘diagnosis’ if diagnosis is narrowly conceived of as a ‘label’ or solution to a problem. For the purposes of this study, we will operationalise diagnosis as an ongoing, sense-making process with inherent uncertainty as described by Ilgen et al . 4 Furthermore, we will use the term ‘diagnostic processes’ to encompass both diagnosis and related management processes.

Conceptual models of diagnostic and management reasoning typically break the process down into multiple components (eg, information gathering, hypothesis formation, differential diagnosis generation, development of a treatment plan). 5 A model recently proposed by the National Academies of Sciences, Engineering and Medicine (NASEM) incorporates these dynamic components and links diagnosis and management by healthcare teams to patient and system outcomes in a feedback loop. 3 This model, recently adapted by ED experts into the modified ED-NASEM model, 6 provides an overarching framework for exploring diagnostic processes in the current study.

Two complementary theories of human cognition also inform this work: dual process theory 7 and distributed cognition theory . 8 Dual process theory characterises information processing as it occurs ‘in the head’ of an individual. This theory holds that clinicians process information via two primary pathways: system 1 (pattern recognition) and system 2 (analytical thinking), and that experts switch back and forth between these two systems. 9 10 Inappropriate reliance on either system can result in errors. 11 12 Distributed cognition theory views information processing as occurring ‘out in the world’. 8 Cognitive tasks such as diagnosis are accomplished through their distribution across multiple individuals (eg, patients, nurses, physicians), external tools (eg, electronic health record (EHR), computer-based searches, medical devices), spatial arrangements and time. 13 Many of these tasks occur outside of the diagnosing clinician’s purview, including the prehospital setting and after patient disposition. Collaborative systems of people and tools (also known as ‘artefacts’) implement dynamic processes constituting a shared cognitive system to create a diagnosis, with breakdowns anywhere in the system potentially leading to error. 14–18 Individual cognitive processes ‘in the head’ are difficult to access in real time and must be inferred through observation or questioning; however, information processing in a distributed cognition system is more readily accessible through observation of interactions ‘out in the world’, which informs our study design.

This paper describes our three-part approach for sub-aims 1.1 and 1.2 in IDEA-LL, which focuses on using systems engineering and cognitive theories to explore ED diagnostic processes, as well as vulnerabilities that may lead to error . The purpose of parts 1 and 2 is to prospectively explore ED diagnostic processes and to understand the distributed cognitive system supporting diagnosis in everyday ED practice. The purpose of part 3 is to elaborate on and enrich the modified ED-NASEM model and to examine perceived strengths and vulnerabilities in emergency care diagnostic processes.

This work will use a prospective mixed methods case study design 19 20 to collect quantitative and qualitative data in an adult and a paediatric ED. We will use both process measures (ie, tracking specific steps leading to diagnosis including interactions with tools, communications between people and monitoring elapsed time), and multiple qualitative methods (eg, field observations, cognitive ethnography, 21 interviews) to map information capture, transfer and sharing among patients and providers leading to diagnosis. Data collection will occur December 2020–December 2021. An overview of the proposed studies appears in table 1 .

Overview of the proposed studies for sub-aims 1.1 and 1.2

ED, emergency department; NASEM, National Academies of Sciences, Engineering and Medicine.

Our data collection procedures, in accordance with distributed cognition theory, 8 13 will primarily focus on direct observations ‘out in the world’ as diagnosis unfolds within the sociocultural settings of two EDs. We will record how cognitive work is distributed across people and tools in context by recording interactions and documenting its organisation across physical space and time. In addition, we will elucidate individual cognition by obtaining provider responses to brief mini-interviews during clinical work. As interruptions can add to provider cognitive load and potentially alter diagnostic performance, we will conduct interviews opportunistically to minimise interruptions in patient care.

Parts 1, 2 and 3 will be conducted in a single academic tertiary care setting with an adult and a paediatric ED. These EDs serve an urban area (population ~120 000), in addition to a large suburban and rural catchment area. Both EDs are level I trauma centres, with a total annual census of 106 470 visits (74 034 adult and 32 436 paediatric). The EDs have 110 beds (88 adult and 22 paediatric), augmented by hallway and recliner space. The EDs are staffed by ~65 attending physicians, ~64 residents, ~40 advanced practice providers and ~380 nurses. Resident trainees include postgraduate years (PGY) 1–4 with 16 residents per class, and ~170 medical students rotate through the department annually on a 1-month required clerkship. According to health system policy, patients up to age 21 may be seen in the paediatric ED, however, patients ages 18–21 account for a small percentage of the total paediatric population (ie, ~5%).

Sampling, eligibility, recruitment, informed consent and data collection

Part 1: individual patient case as the unit of observation.

We will use purposive sampling of patients presenting to the ED who are at higher risk for diagnostic mishaps such as those with undifferentiated symptoms of abdominal pain, fever, chest pain or shortness of breath. 22–27 While data has linked chest pain symptoms with a wide range of never-miss conditions, 23 27 limited research has explored shortness of breath and never-miss conditions. Both symptoms will be included as they represent undifferentiated symptoms commonly seen in the ED that have been associated with missed diagnosis. We anticipate a minimum sample size of 24 patients based on previous observational studies in medicine. 28 The final sample size will be determined when adequate conceptual depth has been achieved in the findings. 29

Eligibility

Eligible adult patients will be 21 or older and capable of giving informed consent. Eligible paediatric patients will be between 0 and 21 years of age and their legally authorised representative must be capable of giving informed consent. For paediatric patients 13 years of age or older, assent will also be required. We will exclude non-English speaking patients and those with altered mental status due to limitations of obtaining informed consent.

Recruitment of patients

We will enrol patients with three types of undifferentiated presenting symptoms associated with a ‘high-risk’ for diagnostic errors, namely chest pain, shortness of breath and abdominal pain. Working in collaboration with the triage nurse as patients register, research personnel will identify potentially eligible patients at triage. We have a waiver for screening patients for eligibility and capturing initial information exchange prior to approaching for informed consent and enrolment. Informed consent will be conducted once triage is complete. After the patient is roomed, the researcher will notify the care team that the patient has been enrolled in the study. Enrolment will occur during varied ED clinical shifts over a period of 6 months. Participation will be completely voluntary and uncompensated.

Informed consent

Eligibility will be assessed by study personnel. Once determined eligible, patients (and any family or visitors present) will be asked for written informed consent. All primary providers associated with the patient will also be asked for informed consent. Consent from providers will largely be obtained prior to field observations via email, to minimise disruption.

Data collection

A small team of trained observers comprised of qualitative researchers and healthcare engineers will collect the qualitative data. These individuals do not have a background in emergency medicine, and thus no association with a particular professional role that might introduce bias into data collection.

Patient care trajectory assessment

Two observers will work together to follow the diagnostic processing of a patient case from triage to disposition. Since distributed cognition theory focuses on how information flows in interactions, one observer will follow the patient to capture interactions that occur at or near the patient’s bedside. The second observer will follow the ED provider(s) (typically a resident or physician assistant) to capture events related to the care that occurs away from the patient’s bedside. Both observers will use audio recording devices to capture verbatim information exchange. Phone calls are not recorded, so observers will directly query providers about the content of calls. We will capture patient–provider and provider–care team interactions to examine relationships between information input, output and the representation of information in various artefacts, to assess gaps in information exchange among patient, provider and care team members.

Observational data

Observers will use data collection forms developed through pilot observations. These forms will track approximate timing of events to allow for quantification of interactions (eg, communication between care providers and the patient or other providers, estimated duration of events, time spent using tools). Observers will also take extensive field notes first as jottings in the field, then expanded afterwards to full field observations. They will record their inferences and reflections in memos focused on context, content and concepts. 30

Time in care measures

Observational data will be supplemented by information available through the time-stamped EHR (eg, total time in ED, time from arrival to triage, time to room, time to provider, time to intervention (eg, medications, fluids), time to test performance, time from when results are available to when they are reviewed, time when patient data and diagnoses are recorded in the EHR and viewed by care team members).

Mini-interviews

Observers will briefly probe care team members to capture their thought processes during diagnostic work. At the end of the patient observation, the observers will ask patients and providers their perspectives on the complete diagnostic process and any strengths and vulnerabilities from their perspectives.

Part 2: ED provider as the unit of observation

Different contexts and team configurations can influence how cognition is distributed across ED providers and artefacts. 8 10 Thus, we will intentionally sample across different shifts (eg, day, evening, night) and work areas in the EDs to capture a range of patient volumes and staffing models. We will recruit attending physicians, residents, physician assistants and nurses to explore how different roles engage in the ED diagnostic process. These roles represent the core members of ED patient care teams, and intentional sampling by role will help us construct a 360-degree view of distributed cognition. This will allow us to discern how information flows and is processed in the system through interactions with people and artefacts. We anticipate a minimum of 24 provider observations. As in part 1, the final sample size will be determined by attainment of adequate conceptual depth. 29

Eligible providers will be directly involved in patient care. Attending physicians, physician assistants and nurses will have a minimum of 1 year’s experience working in the ED setting. Residents may be PGY 1–4.

Recruitment of providers

Providers will be recruited via email in advance of a shift or in person on the day of a shift by study personnel.

We will obtain informed consent of providers. Providers that refuse participation will not be observed. We anticipate these providers will come into contact with multiple patients and other providers as part of their routine work practices. We will provide an Institutional Review Board (IRB) approved information sheet to ‘incidental contacts’ notifying individuals that the information and communication will be recorded and collected for the purposes of research.

Observations

In part 2, we will shadow ED providers caring for multiple patients over a 4-hour time frame, ensuring capture of either beginning-of-shift or end-of-shift handovers. The provider observations will occur on different days than the patient case observations. Observers will follow a provider as they go about their work routine, communicating with other providers, accessing medical records, sending or answering pages, dictating or writing notes, accessing resources outside the ED, providing instruction to other care team members and so on. Audio recordings will supplement observer field notes to capture the detailed content of information-dense interactions. When providers are interacting with patients, only handwritten notes will be collected. Patients may decline the presence of the observer at any time.

In part 2, the focus is the interactions of people and tools within the sociocultural and sociotechnical context of the ED. In line with distributed cognition theory, observations will document exchanges between primary clinicians with patients, family or visitors, care team members and consultants and others over the 4-hour time frame. Additionally, we will collect details on how clinicians organise their patient cases and digital tools. 31 This study of interactions will capture the questions, orders, instruction, information sharing and recording, corrections, interruptions, workload demands, team dynamics and communication patterns over several hours of a shift. 11 In addition to audio recording, observers will use data collection forms, open-ended field notes and reflexive memos. Notations will be made of contextual factors such as overall ED volume and the number of patients a provider is concurrently managing. We will also capture use of artefacts such as paper or electronic notes used by providers.

During our observations, we will prompt providers to verbalise their thinking at key moments. At the end of the shift, the handover process between providers will be observed, and then individual providers will be briefly interviewed about their impressions of the diagnostic process over that shift.

Potential impact of mini-interviews and observations

In both parts 1 and 2 of this study, we acknowledge that the presence of researchers in the EDs could impact both thinking, that is, cognition and behaviour. By conducting mini-interviews, we could inadvertently alter participants thinking (by promoting synthesis), or at the very least make thinking more conscious. By having observers present, we could alter participant reactions per the ‘Hawthorne effect’, however, such alterations in behaviour have largely been shown to be insignificant. 32

Part 3: interviews with key stakeholders

We plan to conduct semi-structured interviews with attending physicians, residents/advanced practice providers, nurses, prehospital providers and patients. Groups will be purposively sampled based on roles and their experience with diagnostic processes. We anticipate a minimum of 20 interviews.

Eligible providers will be those involved in patient care with a minimum of 1 year’s experience working in or consulting in the ED. Eligible patients or legally authorised representatives will be English-speaking, capable of providing informed consent and have visited the ED within 2–3 weeks preceding the interview.

Recruitment of patients and providers

Patients will be recruited by a study coordinator prior to discharge or admission during their index ED visit. We will also use the patient recruitment portal ( https://umhealthresearch.org/ ). Providers will be recruited through email. A US$25 gift card will be provided to patients/caregivers as compensation for their time.

We will obtain informed consent from all patients, legally authorised representatives and provider participants.

Data collection instrument

An interview guide will be developed using distributed cognition theory and guided by the modified ED-NASEM model 6 of diagnosis. (Please see online supplemental appendix 1 for details of the interview guide.) Questions will direct participants to reflect on their own experiences with ED diagnostic processes. Probes will focus on elucidating key points of interaction among people, artefacts and systems for diagnosis, depicting how information flows through the system, emphasising activities that contribute to or inhibit timely diagnosis and highlighting perceptions of key points that lead to breakdowns and errors.

Supplementary data

Data collection process.

At the beginning of each session, we will brief participants on the nature of the study, explain the format of the session and establish a safe environment for information disclosure. Each interview will be recorded and last approximately 60 min.

Qualitative data entry and cleaning

Recordings from observations and interviews will be transcribed verbatim and stored in a secure location in accordance with IRB procedures. Only de-identified data will be made available to the broader research team. All qualitative data, including field observation notes and transcriptions, will be entered into and analysed using MaxQDA. Time stamped data and other quantitative measures will be entered first into excel, and then exported into SPSS.

Data analysis

Based on the research questions for each part, we will use both inductive and deductive analysis methods, with the latter shaped by the theories previously mentioned. The mixed data analysis will be qualitatively driven; that is, the quantitative measures will play a supportive role relative to an overarching qualitative analysis. 33 34 These mixed data will be merged in response to emerging findings where timing could frame and enhance understanding of qualitatively elucidated information. We will begin iterative data analysis during the data collection process. We will employ both qualitative and quantitative codes for the transcripts, field observation notes and mini-interviews from parts 1 and 2. Quantitative codes will characterise observed behaviours by counting the number and duration of interactions between people or artefacts, event occurrences (eg, pages, consults), dialogue analyses and other behaviours through the calculation of descriptive statistics.

Emergent themes will be identified and added as codes using an open coding method 35 to look for recurring themes. In the open coding method, two to three researchers from different professional backgrounds will analyse the transcripts and participant observation data following techniques described by Marshall and Rossman. 36 Since inductive analysis values the subjectivity of researchers as they make meaning from data, the backgrounds of the study team members conducting the analysis are important: MD and PM are emergency physicians who work in the adult and paediatric EDs under study; CMS is a cognitive psychologist who has a strong background in distributed cognition theory; PPC and MDF are experts in qualitative methodology; and SYP is an expert in HCI, design and complex systems. Each researcher will review a set of initial transcripts independently and code the content of each transcript. Each analyst will independently and continuously compare each incident, event, quote and instance to look for similarities and differences. The researchers will discuss, compare and reconcile differences in coding and create a consensus code template, which will then be used to code the remainder of transcripts. Weekly discussions will be held to interpret the meanings and themes from the beginning of the analysis.

During the data analysis, we will discuss emerging findings or questions with participants through a series of informal conversations to clarify any misconceptions and verify the validity of the themes identified in this study as another form of member checking. 37 To increase the reliability of our findings, we will then triangulate by comparing and contrasting data obtained via interviews and observations. Data collection will end when reasonable conceptual depth 29 has been achieved in the findings. Code reliability will be examined through independent coder comparisons, and differences resolved to consensus.

Integration of the quantitative findings into the analyses will occur through the use of joint display analysis where the quantitative data will be linked with related qualitative findings. 38 39 Additional targeted inquiries will be made of these data based on the emerging themes from the quantitative analysis. We will use multiple diagramming methods 40 (eg, communication, shared spaces, information flow, timelines) to map the process of ED diagnostic work practices. These descriptive data analyses will help develop a comprehensive map of the diagnostic process, identify factors that lead to potential breakdowns and design requirements that will guide our intervention design phase in aim 2 of the larger IDEA-LL study.

Comparison of the adult and the paediatric EDs within the same institutional context will allow the examination of differences such as patient age, illness, interactions, sociocultural context or physical layout that lead to differences in diagnostic processes. These analyses will help us construct a detailed map of the distributed diagnostic processes in the two EDs by identifying when and how key information is introduced, gathered, assembled, communicated, transferred and applied.

Patient and public involvement

To ensure our research focuses on issues relevant to patients and the public, patients will be involved at multiple stages. Part 1 focuses on individual patients with undifferentiated symptoms as they experience the diagnostic process. In part 2, although our focus is on providers treating multiple patients simultaneously, patients will again be invited to participate. Part 3 will include interviews with patients and caregivers so that we may learn from their experiences and solicit their insights on challenges and vulnerabilities in ED diagnostic processes. Thus, parts 1–3 ensure the patient experience will inform the development of future interventions to improve diagnosis.

Many aspects of the ED diagnostic process unfold within an increasingly information-rich environment that is poorly understood, resulting in limited knowledge about how to improve patient safety. Our study findings will shed new light on strengths and vulnerabilities in ED diagnostic processes. 31

A strength of this protocol is the interdisciplinary team that contributed to its development. Team members brought diverse perspectives on conceptual and theoretical models to guide data collection and analysis. Multiple study designs were considered to elucidate facets of cognition and sociotechnical/sociocultural work, and we chose to emphasise interaction processes, allowing us to prospectively learn from ‘what went wrong’ as well as ‘what went right’. 41 This shift in safety perspective has been recently highlighted as critical to understanding and reducing errors. Multilevel qualitative and semi-quantitative data analysis will enable a comprehensive and deep understanding of a distributed system, providing opportunities to examine how information is gathered and interpreted in the diagnostic process.

Another strength of this protocol is the integration of complementary models and theories to guide our data collection and analyses. An exclusive focus on dual process theory or distributed cognition (as is the case with many studies) misses out on the opportunity to appreciate simultaneously occurring processes (ie, what’s ‘in the head’ and ‘out in the world’). These theories will be leveraged to enrich the current modified ED-NASEM model of the diagnostic process, which currently implicitly incorporates some aspects of these theories, but does not do so explicitly.

To our knowledge, there have been few studies that use intensive, qualitatively driven mixed method approaches to examine ED diagnostic processes. Conducting in situ observations of the entire ED care delivery process, focused on individual patients and provider workflow, including physical workflow, documentation workflow, communication workflow and cognitive processes is particularly unique. This study will be one of the first to offer empirical data about how information is gathered, exchanged, recorded and used at the individual, team and system level, highlighting challenges and breakdowns that potentially lead to diagnostic errors in real-world emergency care settings.

This study design with two EDs in the same institutional setting holds constant the impact of certain system and community factors on ED diagnostic processes. Due to the many social and cultural factors influencing ED performance, focusing on two similarly situated EDs can improve our ability to observe system factors (eg, providers’ workflow, system workflow, interruptions, impacts of triage policies and ED care procedures). Additionally, a comparison between two EDs within the adult and paediatric settings allows differences in their diagnostic approaches to become salient.

As case study research, we will examine in great depth an adult and a paediatric ED in a single hospital system. While methodologically critical to achieve deep understanding of cognition in context, this may limit transferability. Further studies under the larger IDEA-LL study will compare ED systems in other settings.

Our findings will provide critical knowledge regarding how diagnostic processes occur across interactions of adult and paediatric patients, providers, care teams and tools in EDs. Findings will help identify opportunities for improving diagnostic processes, particularly those at risk of error in ED work systems. Finally, the results will inform intervention design for mitigating errors in the subsequent aims of IDEA-LL. This is the first step in our study to develop safer diagnostic processes in the ED that prevent patient harm.

Ethical approval for this study has been granted by the University of Michigan IRB (HUM00156261). We plan to share our results in peer-reviewed publications and national/international research platforms, however, we will not share identifying patient/provider information with anyone who is not approved by the IRB.

Supplementary Material

Acknowledgments.

The investigators would like to thank Elizabeth Duffy, MA and Sarah Parker, MPH, for their invaluable support throughout the protocol design process.

Correction notice: This article has been corrected since it was published. Author 'Andrew B Canvasser' has been included in the article.

Contributors: All authors participated in multiple team discussions to conceptualize the manuscript and to refine the methodologies. MD was the primary author of the manuscript with significant text refinement provided by SYP, EW, AC, KP, CMS, PPC, MDF, and PM. In particular, MD, HS, EW and CMS provided the theoretical framing, and CMS, AC, SYP, PPC, KP and MDF contributed methodological expertise. Data analysis a will be conducted by MD, CMS, HS, SYP, PPC, MDF and PM, with all authors contributing to interpretation of the findings. All authors read and approved the final manuscript.

Funding: This project was supported by grant number R18HS026622 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Dr Singh is funded in part by the Houston Veterans Administration (VA) Health Services Research and Development (HSR&D) Centre for Innovations in Quality, Effectiveness and Safety (CIN13-413), the VA HSR&D Service (CRE17-127 and the Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Centre for Patient Safety, the Agency for Healthcare Research and Quality (R01HS27363), the CanTest Research Collaborative funded by a Cancer Research UK Population Research Catalyst award (C8640/A23385) and the Gordon and Betty Moore Foundation.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Ethics statements

Patient consent for publication.

Not applicable.

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Addressing mistreatment of providers by patients and family members as a patient safety event. February 16, 2022

Prescribing errors in post-COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post-COVID-19 outpatient clinic. March 23, 2022

Health care quality and safety in a correctional system: creating goals and performance measures for improvement. August 17, 2022

Surgeon's narcissism, hostility, stress, bullying, meaning in life and work environment: a two-centered analysis. September 27, 2023

Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic review and qualitative meta-synthesis. May 11, 2022

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How health care systems let our patients down: a systematic review into suicide deaths. July 1, 2020

Organizational and social-psychological conditions in healthcare and their importance for patient and staff safety. A critical incident study among doctors and nurses. January 21, 2015

Relationship of adverse events and support to RN burnout. October 8, 2014

Preventable mortality after common urological surgery: failing to rescue? September 3, 2014

Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews. July 23, 2014

Identifying high-risk medication: a systematic literature review. August 13, 2014

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Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system. March 8, 2023

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Officers with Higher Rank Get Better Care than Those with Lower Ranks at Military Hospitals, Study Finds

Officers who outrank their military physicians and personnel who have been recently promoted receive better attention and care in Defense Department health facilities than lower-ranking service members, new research on military emergency room visits has found.

The study, published Thursday in the journal Science , also found racial bias in treatment and care in military ERs, with white physicians "exerting less effort" on Black patients.

While the study also found that white physicians treated higher-ranking Black patients with more care, their treatment was still only on par with lower-ranking white patients. Black military doctors treated lower-ranking patients of either race fairly equally, the study found, but they provided high-ranking Black patients "off-the-charts" care.

Read Next: Marijuana Testing for Recruits Could End Under House's Must-Pass Defense Policy Bill

The researchers, with the University of Texas at San Antonio and Carnegie Mellon University, conducted the study to further understand implicit bias in health care in civilian settings as well as military care. Stephen Schwab, the study's co-author, said that, while bias regarding gender and race is often the subject of research, the role that power dynamics play in medical services is less understood.

The military, with its obvious rank structure, presents opportunities to understand this relationship, he said.

"The military is doing everything it can to reduce these biases. Part of it is understanding the scope of the issue. It's not just race and gender, it's also power and wealth," Schwab, a retired Army lieutenant colonel who now works at the University of Texas at San Antonio, said in an interview with Military.com on Friday.

For the study, the researchers examined data from 1.5 million emergency department visits in the military health system, looking at the rank of a patient compared with the doctor's rank and examining treatment response, including resources expended such as medical tests, imaging and certain prescriptions, and outcomes, such as hospital admissions at the time of the ER visit or within 30 days afterward.

They found that higher-ranking patients received 3.6% more physician effort and resources and were 15% less likely than lower-ranking patients to have poor outcomes.

Lower-ranking patients seen by doctors attending to higher-ranking patients at the same time were 3.4% more likely to have poorer outcomes, according to the study.

"Our findings indicate that power confers nontrivial advantages: 'High-power' patients (who outrank their physician) receive more resources and have better outcomes than equivalently ranked 'low-power' patients. Patient promotions even increase physician effort. Furthermore, low-power patients suffer if their physician concurrently cares for a high-power patient," the researchers wrote.

The military health system serves nearly 1.3 million active-duty personnel of all ranks, in addition to military family members, retirees and their families, in 51 hospitals and 424 clinics. The active-duty force is 18% officer and nearly 82% enlisted, 82.5% male and 17.5% female. Roughly 69% of the force is white, while 31.2% identify as a person of color.

The research looked at how physicians responded to or treated officers of higher rank than themselves, as well as equal and lower-ranked officers, and enlisted personnel.

Additional trends that were observed included a finding that male physicians are more rank-conscious and respond to a patient's "power" more than female doctors did and showed more sex-based discrimination than female physicians.

Male physicians also were significantly more responsive to higher-ranking female patients than male patients, possibly because high-ranking women are still fairly uncommon across the services, perhaps eliciting "more respect and attention," the research said.

Schwab said the findings demonstrate that physicians are "human" and, as such, are susceptible to implicit bias. But there may be other factors at play, such as a high-ranking patient demanding care or unknowingly drawing it as leadership.

The concern with such bias is what Schwab called "the spillover effect": If physicians are spending more time with their peers or those of higher rank, then other patients are getting less attention.

"The effort has to come from somewhere," Schwab said.

Schwab said the research was supported by the military health system through access to records and data support. The study, he added, lends value to medicine as a whole because it is an opportunity to show that implicit bias exists in the profession and the perception of power plays a role.

As a retired financial officer for the military health system, Schwab said he recognized that he likely received more attentive health care in the system from his colleagues than other troops.

"It's hard to tell [bias] as an individual patient because you get the care you get, but I definitely felt I received more respect because of my circumstances," Schwab said.

He said the study was not designed to place blame on physicians; instead, it was meant to raise awareness of implicit bias to influence education and training.

"We want people to recognize that these implicit biases exist, and we can address them by developing physicians that are more representative of society or improving training for our physicians," Schwab said.

A spokesman for the Defense Health Agency said the organization is reviewing the article and its supporting materials but would not comment on the findings until they could be thoroughly reviewed.

DHA spokesman Peter Graves said the agency "is committed to delivering the highest quality of care to all of our patients, regardless of rank, race, color, sex, gender identity, religion, age or any other demographic."

"We always expect the same high standards to be applied to every patient in an exceptional way, anytime, anywhere, always," Graves said.

Related: In Reversal, Defense Department Now Wants to Bring Tricare Beneficiaries Back to Military Health System

Patricia Kime

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Dismissed and discharged: health systems still failing people with poor mental health

22 May 2024

Funded by mind Australia , the world first study found that people with psychosocial disabilities - people who live with disabilities as a result of poor mental health - not only experience distress when dealing with the NDIS, but also face ‘service pullback’ when they present to emergency departments when requiring emergency care.

Speaking with NDIS participants, the nationwide study found that when participants disclosed that they had NDIS support, clinicians wrongly assumed the NDIS provides medical and mental health crisis care.

It’s a concerning finding, particularly following the discrimination, non-inclusivity and lack of equality experienced by people with a disability, identified in the NDIS review and the disability royal commission .

In Australia, 1.1 million people have a psychosocial disability which causes limitations or restrictions in their everyday activities . Additional, 58% of these people also have a nervous or emotional condition, 42% have problems with memory or periods of confusion, 41% have behavioural conditions, and 40% have a mental illness (such as schizophrenia).

86% also have at least one other disabling condition (63% physical disability; 38% intellectual disability; and 33% sensory disability).

UniSA researcher and PhD candidate Heather McIntyre says that the disconnect between the NDIS and emergency departments is failing people with psychosocial disabilities.

“Time and time again we hear about people experiencing distress when they contact the NDIS – they fight to be heard, fight for support, and are often dismissed, so the last thing they need is to go through this again when they require emergency care,” McIntyre says.

“This is particularly concerning for people with a mental health condition, especially those with fluctuating psychosocial disabilities who may struggle with communication.

“Because many emergency department staff aren’t aware of the limitations of NDIS supports, they wrongly assume that the NDIS provides a higher level of care than it does.

“This leaves many people with a psychosocial disability being discharged at emergency without appropriate treatment and returned to the situation that caused them to present in the first place.

“It’s an inequitable and unsafe approach that is putting thousands of people at risk.”

McIntyre says there is an urgent need to strengthen service integration between the NDIS and emergency departments.

“Communication between the two services is not occurring seamlessly, which affects continuity of care. This needs to change,” McIntyre says.

“We must start at the pointy end: emergency department clinicians need more training and education to better understand how the NDIS works and how to best support people with a disability.

“They need to learn how to support people with neurodiversity and hearing impairments, how to build trust and how to really listen, as well as to provide low sensory environments.

“But equally, stronger connections and pathways must be established between NDIS providers and emergency departments so that everyone is on the same page.

“With budget cuts to the NDIS of 14 billion over the next four years, peoples’ disability supports will further be reduced, resulting in more emergency department presentations when supports are insufficient.

“In emergency departments we need to step up care, not ration care, if we are to support people with disabilities who already feel abandoned by the health system.”

………………………………………………………………………………………………………………………….

Notes to editors

The article is available online: McIntyre, H., Loughhead, M., Hayes, L., Allen, C., Barton-Smith, D., Bickley, B. et al. (2024)  ‘ Everything would have gone a lot better if someone had listened to me’: A nationwide study of emergency department contact by people with a psychosocial disability and a National Disability Insurance Scheme plan .  International Journal of Mental Health Nursing, 00, 1–12.

……………………………………………………………………………………………………………………….

Media contact: Annabel Mansfield M: +61 479 182 489 E: [email protected]

Researcher: Heather McIntyre E : [email protected]

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University of Birmingham

Inadequate access to simple elective surgery in developing countries is storing up future health problems for patients and may create a spiral of future health complications putting more people’s lives at risk, a new study reveals.

Analysing the experience of more than 18,000 patients in 640 hospitals across 83 countries, researchers, experts used hernia repair to represent elective health care, concluding that such treatments are essential to prevent over-reliance on emergency systems.

The study reveals that inguinal hernias are treatable with simple day-case surgery, but, if neglected, the need for more complex emergency surgery increases substantially, leading to delayed recovery and far higher total health-care costs.

Led by experts at the University of Birmingham, the NIHR Global Health Research Unit in Surgery study notes that increasing reliance on emergency care has resulted in crisis management becoming routine across a wide range of conditions that respond well to early elective treatment.

Boosting the use of elective surgery for conditions that can be fixed simple and early treatments will reduce the risk of complex, and potentially risky, emergency surgery. Dr Maria Picciochi - University of Birmingham

Study co-author Dr Maria Picciochi, from the University of Birmingham, commented: “Boosting the use of elective surgery for conditions that can be fixed simple and early treatments will reduce the risk of complex, and potentially risky, emergency surgery.”

Study co-author Prof Aneel Bhangu, from the University of Birmingham, also added: “Health policy makers can use our findings as a proxy for other elective conditions, creating a system strengthening approach to integrate surgery into the wider system of health care. This would relieve pressure on emergency pathways and reduce the health burden on society and healthcare services.”

The study shows that inguinal hernias are mostly a disease of working-age patients around the world, and, if neglected, may require bowel resection. This more complex surgical treatment leads to slow recovery and far higher total health-care costs.

Researchers also found a clear global imbalance in access to mesh repair - reflecting poor access to simple medical devices in lower-income countries. Mesh is well proven to reduce long-term hernia recurrence, is simple to place, low-cost and scaleable.

The researchers identified actionable targets for system strengthening, which include:

• Educating communities and community health workers around hernia symptoms;
• Improving referral systems and increasing mesh repair for hernias;
• Establishing a global quality improvement programme in mesh placement for hernias - strengthening supply chains, making mesh affordable and increasing training; and
• Improving capacity for simple, cost-effective surgery.

“Our study showed multiple weaknesses in access and quality in current health-care systems, with a particular disadvantage in lower-income settings,” commented Dr. Picciochi. “As a result, there was higher emergency demand, which further reduced elective capacity and might create downward spirals.

“If weak access and quality persist over several electively treatable conditions, both surgical and non-surgical, multimorbidity can also become established, which makes future elective care harder and emergency care even more complicated.”

Findings of the study and its wider implications will be discussed during the side event hosted by the NIHR Global Surgery Unit at the World Health Assembly, on 28 th May. 

Featured staff

Professor Aneel Bhangu

Professor of Global Surgery

Notes for editors

For more information, please contact our Press Office . For out-of-hours enquiries, please call +44 (0)121 414 2772.

The University of Birmingham is ranked amongst the world’s top 100 institutions, its work brings people from across the world to Birmingham, including researchers and teachers and more than 8,000 international students from over 150 countries. Discover Birmingham .

‘ Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries ’ – NIHR Global Health Research Unit on Global Surgery is published in Lancet Global Health.

Participating countries included: Albania, Algeria, Argentina, Austria, Australia, Aruba, Bosnia and Herzegovina, Bangladesh, Burkina Faso, Bulgaria, Burkina Faso, Burundi, Benin, Brazil, Cambodia, Cameroon, Canada, Chile, China, Colombia, Croatia, Cyprus, Czech Republique, Dominican Republic, Egypt, Ethiopia, France, Gabon, Germany, Georgia, Ghana, Greece, Guatemala, India, Ireland, Iran, Iraq, Italy, Japan, Jordan, Kazakhstan, Kenya, Lebanon, Libya, Lithuania, Madagascar, Malaysia, Mali, Malta, Mexico, Morocco, Namibia, New Zealand, Nigeria, Oman, Pakistan, Palestine, Paraguay, Peru, Poland, Portugal, Qatar, Republic of North Macedonia, Romania, Russian Federation, Rwanda, Saudi Arabia, Serbia, Slovenia, South Africa, Spain, Sri Lanka, Sudan, Sweden, Switzerland, Syria, Thailand, Togo, Tunisia, Turkey, Uganda, United Kingdom, United States, Yemen.

The National Institute for Health and Care Research (NIHR)

The mission of the National Institute for Health and Care Research (NIHR) is to improve the health and wealth of the nation through research.

We do this by:

• Funding high quality, timely research that benefits the NHS, public health and social care;
• Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
• Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
• Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
• Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
• Funding applied global health research and training to meet the needs of the poorest people in low and middle income countries.
• NIHR is funded by the Department of Health and Social Care. Its work in low- and middle-income countries (LMICs) is principally funded through UK Aid from the UK government.

World-leading surgical research team gets fresh funding to save lives

A world-leading global surgical research team led by the University of Birmingham has received £7 million to continue life-saving work in developing countries.

16 February 2022