These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.

Achieving significant improvement in ED throughput is unlikely without determining the most important factors on process outcomes and taking measures to address variations in ED input and bottlenecks in the ED output stream.

The effects of ED input and output factors on renege rate are significant and quantifiable. At least some of the variation in these factors and subsequently their effects are predictable, suggesting that further refinement in the management of ED and inpatient resources could affect improvement in ED renege rate. Continued efforts at quantifying the effects are warranted.

Achieving significant improvement in ED throughput is unlikely without determining the most important factors on process outcomes and taking measures to address variations in ED input and bottlenecks in the ED output stream.

Objectives: The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). Methods:The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions.Results: There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and ⁄ or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. Conclusions:The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider-computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected. ACADEMIC EMERGENCY MEDICINE 2008; 15:908-915 ª 2008 by the Society for Academic Emergency MedicineKeywords: electronic medical records, computerized provider order entry, emergency medicine, medical services, patient care processes E lectronic documentation and computerized provider order entry (CPOE) may in themselves take longer than their paper counterparts, 1,2 but provide an infrastructure that supports improved patient safety, improved information flows, and smoothed patient care processes. [3][4][5][6][7][8][9] Although there are recognized barriers to implementation of CPOE in the emergency department (ED), 10 there are significant potential benefits to doing so. [11][12][13] Published studies of CPOE implementations in the ED have demonstrated improved compliance with guidelines 14 and improved time to administering time-sensitive care. 15 A study of CPOE implementation in the ED by Piasecki et al. 16 found cost savings in terms of nonphysician staff time, but not in physician time. It is also known that implementation of CPOE can lead to unexpected results including effects on workflow and communication.17 A reciprocal impact of CPOE on communication has been previously reported. 18The Barnes-Jewish Hospital ED (affiliated with Washington University in St. Louis, MO) added CPOE and fully electronic nursing documentation to its impleme...

Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.

Background: Reneging (i.e., leaving without being seen) is an important outcome of emergency department (ED) overcrowding. The input-throughput-output conceptualization of ED patient flow is helpful in understanding and measuring the impact of various factors on this outcome.

Objective The incidence of central line associated blood stream infections (CLABSI) attributed to central venous catheters (CVC) inserted in the Emergency Department (ED) is not widely reported. Our goal was to report the incidence of ED CLABSI. Secondary goals included determining the impact of a CVC bundle introduced by infection prevention to decrease CLABSI during our surveillance period. Methods This was a prospective observational study over a 28-month period at an academic tertiary care center. A standardized electronic CVC procedure note identified CVC insertions in the ED. Abstractors reviewed inpatient records to determine ED CVC catheter-days. An infection prevention specialist identified CLABSIs originating in the ED using National Hospital Safety Network (NHSN) definitions from blood culture results collected up to 2 days after ED CVC removal. During the period of surveillance a hospital-wide CVC insertion bundle was introduced to standardize insertion practices and prevent CLABSIs. Institutional CLABSI rates were determined by infection prevention from routine surveillance data. Results Over the 28-month study period, 98 ED physicians inserted 994 CVCs in 940 patients. The ED CVC remained in place for more than 2 days in 679 patients and the median number of days an ED CVC remained in use during the hospital stay was 3 (IQR, 2-7). There were 4,504 ED catheter-days and 9 CLABSIs attributed to an ED CVC. The ED CLABSI rate was 2.0/1,000 catheter-days (95%CI, 1.0 to 3.8). The concurrent institutional intensive care unit (ICU) CLABSI rate was 2.3/1,000 catheter days (95%CI 1.9-2.7). The ED CLABSI rate pre-bundle was 3.0/1,000 catheter days and post-bundle was 0.5/1,000 catheter days (p = .038). Conclusions ED CLABSI rates in this academic medical center were in the range of those reported by the ICUs. The impact of ED CLABSI prevention practices requires further research dedicated to surveying ED CLABSI rates.