Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.
Much of the specialty training for emergency medicine (EM) residents and a substantial portion of the ambulatory care education and training for upper-level medical students and non-EM residents occur in emergency departments (EDs). ED crowding is an important problem for the specialty of EM, medical education, and health care in general. The effects of crowding on education and training in the ED are unknown. The challenge for EM in studying the effects of crowding on education and training is to use validated measures of crowding, clinical teaching, and educational outcomes in a wide sample of EDs. This article reviews the literature on ED crowding and clinical teaching in EM, and proposes a research agenda for studying the effects of ED crowding on education. cational outcomes. However, those measures are not yet available. Preliminary work might best focus on a few points in time at a few geographically diverse sites to attempt to validate, prospectively, measures of crowding and educational outcomes. In addition, EM educators should begin to develop the content and process for teaching residents and students about clinical productivity and management of crowded situations.-Alan Heins, MD (alan_heins@yahoo.com),
Objectives: To describe the characteristics and feasibility of a physician-directed ambulance destinationcontrol program to reduce emergency department (ED) overcrowding, as measured by hospital ambulance diversion hours.Methods: This controlled trial took place in Rochester, New York and included a university hospital and a university-affiliated community hospital. During July 2003, emergency medical services (EMS) providers were asked to call an EMS destination-control physician for patients requesting transport to either hospital. The destination-control physician determined the optimal patient destination by using patient and system variables as well as EMS providers' and patients' input. Program process measures were evaluated to characterize the program. Administrative data were reviewed to compare system characteristics between the intervention program month and a control month.Results: During the intervention month, 2,708 patients were transported to the participating hospitals. EMS providers contacted the destination-control physician for 1,866 (69%) patients. The original destination was changed for 253 (14%) patients. Reasons for redirecting patients included system needs, patient needs, physician affiliation, recent ED or hospital care, patient wishes, and primary care physician wishes. During the intervention month, EMS diversion decreased 190 (41%) hours at the university hospital and 62 (61%) hours at the community hospital, as compared with the control month.Conclusions: A voluntary, physician-directed destination-control program that directs EMS units to the ED most able to provide appropriate and timely care is feasible. Patients were redirected to maximize continuity of care and optimally use available emergency health care resources. This type of program may be effective in reducing overcrowding.ACADEMIC EMERGENCY MEDICINE 2006; 13:54-60 ª
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