IntroductionThe emergency department (ED) is under pressure to meet length of stay (LOS) metrics for care in the ED. An aspect that we propose affects LOS is the order for urine sample collection and subsequent urinalysis (UA) as both are time consuming steps. This project’s primary goals are to determine if ordering a UA increases LOS and how often UA contributes to clinical decision-making and/or disposition decisions in the ED. Secondary objectives were to identify factors that contribute to the ordering of a UA and to decipher if LOS was more impacted in patients who were discharged vs. admitted to the hospital.MethodsRetrospective chart review was conducted of patients who presented to our ED in April 2016 during 12 consecutive days. Data were abstracted onto a data collection sheet with the abstractor blinded to study hypotheses. Variables included whether a UA was ordered, times of UA order and result, who ordered the UA (mid-level provider [MLP] vs. physician), whether the UA was cancelled, whether the UA result influenced clinical decision-making (based on the medical decision-making section of the physician chart) or disposition decision, LOS, age, and gender. Descriptive statistics and multivariable regression analysis were used to analyze relationships between the variables collected and their influence on LOS.ResultsThe overall median LOS was 157 minutes, with an interquartile range (IQR) of 81 to 246 minutes. For discharged patients, it was 142 minutes, with an IQR of 46 to 236 minutes. For admitted patients, it was 177 minutes, with an IQR of 118 to 260 minutes. Amongst admitted patients, multivariable regression analysis demonstrated that the following factor was associated with increased LOS: being seen first by the provider-in-triage (PIT) then physician in main ED (p < 0.0001). Amongst discharged patients, multivariable regression analysis demonstrated that the following factors were associated with increased LOS: being seen first by the PIT then physician in main ED (p = 0.0296), being seen by MLP only (p < 0.0001), having a UA ordered (p = 0.0005), being seen on weekend (p = 0.0166), and being an older patient (p = 0.0475). The UA was cancelled in 9% of our patients, and in 60% of cases, these UAs were ordered by the PIT. Patient disposition decision was made prior to UA resulting in 60 cases (25%). The UA was used in clinical decision-making in 118 cases (66%). The following predictor factors were associated via univariate analysis with using a UA for decision-making: being female (p = 0.0050, 95% CI: 0.0068–0.378), being an older patient (p < 0.0001, 95% CI: -0.010 to -0.004), being first seen by the PIT and then a physician (p = 0.0486, 95% CI: 0.0048–0.1555), and discharged patients (p < 0.0001, 95% CI: -0.6749 to -0.4487).ConclusionOur results suggest that having a UA ordered increased ED LOS, especially in patients who are ultimately discharged. In our ED, routine UAs are ordered more often by MLPs than physicians. A routine UA may not impact clinical decision-making up to 33% of the ti...
majority (83.7%) of interruptions occurred in the staff work station and 10.7% in the patient room. There was a significant difference in the number of interruptions experienced by PGY level (F(2,20) ¼5.4, p¼0.01). EM PGY3s faced more interruptions (M¼14.4 interruptions per hour, SD¼2.9) than PGY2s (M¼11.0, SD¼2.59) or PGY1s (M¼9.8, SD¼2.83). NASA-TLX scores were universally higher at the end of the shift across all 6 dimensions (Figure 1); however, significant increases were only observed for mental demand (p¼0.02) and physical demand (p¼0.01). Reaction times were not significantly higher at the end of the shift compared to the beginning of the shift (p ¼ 0.34). No significant differences were observed in performance scores or reaction times with different interruption loads per shift. Conclusions: Residents experienced more interruptions than reported in the literature. Nearly one hour of residents' clinical time was spent dealing with interruptions. The majority of interruptions were face-to-face communication with other health care team members, of medium priority, and occurred at the staff work station. PGY3 EM residents faced significantly more interruptions than their counterparts, which could be reflective of increased responsibility as residents gain seniority. Overall, residents revealed increasing cognitive demand and slower reaction times over the course of the shift. Higher powered studies may be needed to detect differences in performance scores and reaction times with different interruption loads. Further work is needed to assess the positive and negative implications of interruptions on resident workload and what interventions will be most effective to minimize interruptions that occur in the ED workspace.
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