Accuracy of rapid disposition by emergency clinicians
Andrew Backay A C , Adam Bystrzycki A , De Villiers Smit A , Martin Keogh A , Gerard O’Reilly A and Biswadev Mitra A BA Emergency & Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, Vic. 3004, Australia. Email: a.bystrzycki@alfred.org.au; m.keogh@alfred.org.au; d.smit@alfred.org.au; g.o’reilly@alfred.org.au
B Department of Epidemiology & Preventive Medicine, Monash University, Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168, Australia. Email: biswadev.mitra@monash.edu
C Corresponding author. Email: andrew.backay@monashhealth.org
Australian Health Review 41(2) 133-138 https://doi.org/10.1071/AH15052
Submitted: 16 June 2014 Accepted: 18 May 2015 Published: 27 July 2015
Abstract
Objectives Rapid disposition protocols are increasingly being considered for implementation in emergency departments (EDs). Among patients presenting to an adult tertiary referral hospital, this study aimed to compare prediction accuracy of a rapid disposition decision at the conclusion of history and examination, compared with disposition following standard assessment.
Methods Prospective observational data were collected for 1 month between October and November 2012. Emergency clinicians (including physicians, registrars, hospital medical officers, interns and nurse practitioners) filled out a questionnaire within 5 min of obtaining a history and clinical examination for eligible patients. Predicted patient disposition (representing ‘rapid disposition’) was compared with final disposition (determined by ‘standard assessment’).
Results There were 301 patient episodes included in the study. Predicted disposition was correct in 249 (82.7%, 95% confidence interval (CI) 78.0–86.8) cases. Accuracy of predicting discharge to home appeared highest among emergency physicians at 95.8% (95% CI 78.9–99.9). Overall accuracy at predicting admission was 79.7% (95% CI 67.2–89.0). The remaining 20.3% (95% CI 11.0–32.8) were not admitted following standard assessment.
Conclusion Rapid disposition by ED clinicians can predict patient destination accurately but was associated with a potential increase in admission rates. Any model of care using rapid disposition decision making should involve establishment of inpatient systems for further assessment, and a culture of timely inpatient team transfer of patients to the most appropriate treating team for ongoing patient management.
What is known about the topic? In response to the National Emergency Access Targets, there has been widespread adoption of rapid-disposition-themed care models across Australia. Although there is emerging data that clinicians can predict disposition accurately, this data is currently limited.
What does this paper add? Results of this study support the previously limited evidence that ED practitioners can accurately predict disposition early in the patient journey through ED, and that accuracy is similar across clinician groups. In addition to overall prediction accuracy, admission, discharge and treating team predictions were separately measured. These additional outcomes lend insight into safety and performance aspects relating to a rapid disposition model of care.
What are the implications for practitioners? This study offers practical insights that could aid safe and efficient implementation of a rapid disposition model of care.
Additional keywords: emergency service, emergency medicine, hospital, hospitalisation, quality improvement, triage.
References
[1] Australasian College for Emergency Medicine (ACEM). ACEM policy on standard terminology. Melbourne: ACEM; 2009.[2] Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006; 184 208–12.
| 16515429PubMed |
[3] Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, McConnell KJ, Pines JM, Rathlev N, Schafermeyer R, Zwemer F, Schull M, Asplin BR. The effect of emergency department crowding on clinically oriented outcomes. Academic Emerg Med 2009; 16 1–10.
| The effect of emergency department crowding on clinically oriented outcomes.Crossref | GoogleScholarGoogle Scholar |
[4] Rondeau KV, Francescutti LH. Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction. J Healthcare Management 2005; 50 327–40.
[5] Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006; 184 213–6.
| 16515430PubMed |
[6] Richardson DB, Mountain D. Myths versus facts in emergency department overcrowding and hospital access block. Med J Aust 2009; 190 369–74.
| 19351311PubMed |
[7] Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med 2000; 35 63–8.
| Overcrowding in the nation’s emergency departments: complex causes and disturbing effects.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c%2Fot1OnsQ%3D%3D&md5=da79f5018d390da046feaf274fe306d7CAS | 10613941PubMed |
[8] Australasian College of Emergency Medicine. Access block and overcrowding in emergency departments. Melbourne: ACEM; 2004.
[9] Forero R, Hillman KM, McCarthy S, Fatovich DM, Joseph AP, Richardson DB. Access block and ED overcrowding. Emerg Med Australasia 2010; 22 119–35.
| Access block and ED overcrowding.Crossref | GoogleScholarGoogle Scholar |
[10] Forero R, McCarthy S, Hillman K. Access block and emergency department overcrowding. Crit Care 2011; 15 216
| Access block and emergency department overcrowding.Crossref | GoogleScholarGoogle Scholar | 21457507PubMed |
[11] Harris A, Sharma A. Access block and overcrowding in emergency departments: an empirical analysis. Emerg Med J 2010; 27 508–11.
| Access block and overcrowding in emergency departments: an empirical analysis.Crossref | GoogleScholarGoogle Scholar | 20584950PubMed |
[12] Fatovich DM, Nagree Y, Sprivulis P. Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J 2005; 22 351–4.
| Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2M3gvVOktw%3D%3D&md5=91a82851b536bee9c0567bd222cbf092CAS | 15843704PubMed |
[13] Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008; 52 126–36.
| Systematic review of emergency department crowding: causes, effects, and solutions.Crossref | GoogleScholarGoogle Scholar | 18433933PubMed |
[14] Commonwealth of Australia. National Health Reform Agreement – National Partnership Agreement on Improving Public Hospital Services. Canberra: Council of Australian Governments (COAG); 2011.
[15] Eller A. Rapid assessment and disposition: applying LEAN in the emergency department. J Healthc Qual 2009; 31 17–22.
| Rapid assessment and disposition: applying LEAN in the emergency department.Crossref | GoogleScholarGoogle Scholar | 19522343PubMed |
[16] Vaghasiya MR Murphy M O’Flynn D Shetty A 2014
[17] Dent AW, Weiland TJ, Vallender L, Oettel NE. Can medical admission and length of stay be accurately predicted by emergency staff, patients or relatives? Aust Health Rev 2007; 31 633–41.
| Can medical admission and length of stay be accurately predicted by emergency staff, patients or relatives?Crossref | GoogleScholarGoogle Scholar | 17973623PubMed |
[18] Brillman JC, Doezema D, Tandberg D, Sklar DP, Davis KD, Simms S, Skipper BJ. Triage: limitations in predicting need for emergent care and hospital admission. Ann Emerg Med 1996; 27 493–500.
| Triage: limitations in predicting need for emergent care and hospital admission.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK287ovFagug%3D%3D&md5=d5b41a3dc254759851ce706b398b54c3CAS | 8604869PubMed |
[19] Brillman JC, Doezema D, Tandberg D, Sklar DP, Skipper BJ. Does a physician visual assessment change triage? Am J Emerg Med 1997; 15 29–33.
| Does a physician visual assessment change triage?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s7ls1Srug%3D%3D&md5=be027d60f5dc7d3400c258afced0bf94CAS | 9002565PubMed |
[20] Mitra B, Cameron PA, Archer P, Bailey M, Pielage P, Mele G, Smit DV, Newnham H. The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients. Intern Med J 2012; 42 444–50.
| The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC38zjvFyjtQ%3D%3D&md5=2f1e77ab584462c1f20e1f8de0a114a5CAS | 21470357PubMed |
[21] Henley JBC, Williamson J, Scott I. Position statement of the Internal Medicine Society of Australia and New Zealand. Standards for medical assessment and planning Units in public and private hospitals. Sydney: Internal Medicine Society of Australia and New Zealand; 2006.
[22] Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a systematic review. Int J Quality Health Care 2009; 21 397–407.
| Effectiveness of acute medical units in hospitals: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[23] Byrne D, Silke B. Acute medical units: review of evidence. Eur J Intern Med 2011; 22 344–7.
| Acute medical units: review of evidence.Crossref | GoogleScholarGoogle Scholar | 21767750PubMed |
[24] Stokes B. Four-Hour Rule Program progress and issues review. Perth: Western Australia Department of Health; 2011.
[25] Cox MR, Cook L, Dobson J, Lambrakis P, Ganesh S, Cregan P. Acute Surgical Unit: a new model of care. ANZ J Surg 2010; 80 419–24.
| Acute Surgical Unit: a new model of care.Crossref | GoogleScholarGoogle Scholar | 20618194PubMed |
