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Objectives: Emergency department (ED) boarding has been associated with several negative patientoriented outcomes, from worse satisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes. The authors expected that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital lengths of stay (LOS).Methods: This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Consecutive patients admitted to the hospital from the ED and discharged between October 2005 and September 2008 were included. An electronic medical record (EMR) system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital LOS, and in-hospital mortality. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities.Results: There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors. 1 ED crowding is caused by periodic mismatches in demand for care and supply of resources in the ED, including staffing and bed space. 2 ED crowding manifests as long waits for patients to be seen by providers, high left-without-being-seen rates, long ED lengths of stay (LOS), and long waiting times before inpatient bed placement (also known as ED boarding).3 The Centers for Medicare and Medicaid Services will include several measures of ED crowding in pay-for-reporting in 2013. 4 The reason for the focus on measuring ED crowding is that it is not only undesirable because patients have to wait longer, but ED crowding has also been associated with several negative patient-oriented outcomes, including delays in important medications and higher complication rates after ED evaluation, including an increase in mortality. [5][6][7][8][9][10][11][12][13] A major contributor to the supply-demand mismatch and resultant crowding is episodes of ED boarding.

Objectives: The Wong-Baker FACES Pain Rating Scale (WBS), used in children to rate pain severity, has been validated outside the emergency department (ED), mostly for chronic pain. The authors validated the WBS in children presenting to the ED with pain by identifying a corresponding mean value of the visual analog scale (VAS) for each face of the WBS and determined the relationship between the WBS and VAS. The hypothesis was that the pain severity ratings on the WBS would be highly correlated (Spearman's rho > 0.80) with those on a VAS.Methods: This was a prospective, observational study of children ages 8-17 years with pain presenting to a suburban, academic pediatric ED. Children rated their pain severity on a six-item ordinal faces scale (WBS) from none to worst and a 100-mm VAS from least to most. Analysis of variance (ANOVA) was used to compare mean VAS scores across the six ordinal categories. Spearman's correlation (q) was used to measure agreement between the continuous and ordinal scales.Results: A total of 120 patients were assessed: the median age was 13 years (interquartile range [IQR] = 10-15 years), 50% were female, 78% were white, and six patients (5%) used a language other than English at home. The most commonly specified locations of pain were extremity (37%), abdomen (19%), and back ⁄ neck (11%). The mean VAS increased uniformly across WBS categories in increments of about 17 mm. ANOVA demonstrated significant differences in mean VAS across face groups. Post hoc testing demonstrated that each mean VAS was significantly different from every other mean VAS. Agreement between the WBS and VAS was excellent (q = 0.90; 95% confidence interval [CI] = 0.86 to 0.93). There was no association between age, sex, or pain location with either pain score. Conclusions:The VAS was found to have an excellent correlation in older children with acute pain in the ED and had a uniformly increasing relationship with WBS. This finding has implications for research on pain management using the WBS as an assessment tool.

This study aimed to develop risk scores based on clinical characteristics at presentation to predict intensive care unit (ICU) admission and mortality in COVID-19 patients. 641 hospitalized patients with laboratory-confirmed COVID-19 were selected from 4997 persons under investigation. We performed a retrospective review of medical records of demographics, comorbidities and laboratory tests at the initial presentation. Primary outcomes were ICU admission and death. Logistic regression was used to identify independent clinical variables predicting the two outcomes. The model was validated by splitting the data into 70% for training and 30% for testing. Performance accuracy was evaluated using area under the curve (AUC) of the receiver operating characteristic analysis (ROC). Five significant variables predicting ICU admission were lactate dehydrogenase, procalcitonin, pulse oxygen saturation, smoking history, and lymphocyte count. Seven significant variables predicting mortality were heart failure, procalcitonin, lactate dehydrogenase, chronic obstructive pulmonary disease, pulse oxygen saturation, heart rate, and age. The mortality group uniquely contained cardiopulmonary variables. The risk score model yielded good accuracy with an AUC of 0.74 ([95% CI, 0.63-0.85], p = 0.001) for predicting ICU admission and 0.83 ([95% CI, 0.73-0.92], p<0.001) for predicting mortality for the testing dataset. This study identified key independent clinical variables that predicted ICU admission and mortality associated with COVID-19. This risk score system may prove useful for frontline physicians in clinical decision-making under time-sensitive and resource-constrained environment.