Optimizing Emergency Department Front-End Operations

From Annals of Emergency Medicine:

As administrators evaluate potential approaches to improve cost, quality, and throughput efficiencies in the emergency department (ED), “front-end” operations become an important area of focus. Interventions such as immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated “fast track” service line, tracking systems and whiteboards, wireless communication devices, kiosk self check-in, and personal health record technology (“smart cards”) have been offered as potential solutions to streamline the front-end processing of ED patients, which becomes crucial during periods of full capacity, crowding, and surges. Although each of these operational improvement strategies has been described in the lay literature, various reports exist in the academic literature about their effect on front-end operations. In this report, we present a review of the current body of academic literature, with the goal of identifying select high-impact front-end operational improvement solutions.

Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation

From Annals of Emergency Medicine:

Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.


We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.


We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.


In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

Therapeutic Hypothermia May Be Cost-Effective Postresuscitation Option

From MedPage Today:

On paper, therapeutic hypothermia after out-of-hospital cardiac arrest appears to save lives and improve neurologic outcomes at a cost comparable to other more conventional therapies, according to findings published today.Mathematical modeling determined that hypothermia using a cooling blanket resulted in patients gaining an average of 0.66 quality-adjusted life years (QALY) (95% CI 0.11 to 1.3) compared with conventional care, wrote Raina M. Merchant, MD, of the University of Pennsylvania, and colleagues. The findings were published online in Circulation: Cardiovascular Quality and Outcomes.

The incremental cost was $31,254 (95% CI $5,581 to $77,553), resulting in an incremental cost effectiveness ratio of $47,168 (95% CI $16,673 to $191,369) per QALY.

Therapeutic hypothermia, in which the body temperature is lowered to 32° to 34°C for 12 to 24 hours, is the only postresuscitation therapy that has been shown to improve outcomes in patients with witnessed out-of-hospital cardiac arrest.

Studies by the Hypothermia After Cardiac Arrest group established the efficacy of the therapy, and since 2005 the American Heart Association has recommended that comatose survivors receive this treatment, yet its use remains limited.

A possible explanation for this is the expense associated with therapeutic hypothermia coupled with uncertainty as to its cost-effectiveness — particularly if its use were to increase the number of patients who survived arrest only to live with serious neurologic sequelae, which would contribute not only to poor quality of life but also to ongoing costly treatment.

To address these concerns, the researchers developed a decision model based on published data to compare cost-effectiveness of hypothermia with that of conventional care in a hypothetical cohort of 100 patients following witnessed ventricular fibrillation out-of-hospital cardiac arrest.

Should Emergency Physicians Be Given Immunity From Lawsuits?

From A Happy Hospitalist:

Ohio is the latest state to introduce new legislation that would dramatically increase the legal standard to win a civil suit against a doctor working at an emergency department. It also offers the same protection for doctors helping after floods, tornadoes or other disasters.

The bill says physicians would have qualified civil immunity while working in emergency rooms and be subject only to lawsuits if they showed “willful or wanton misconduct” — a high standard for liability usually reserved to determine punitive damages.

The Ohio bill would specifically apply to services being provided under EMTALA regulations. I would interpret that to mean any physician taking care of a patient that was seen or admitted to the hospital through the emergency room would be protected by this higher standard.  That includes hospitalists and all other subspecialists that care for hospitalized patients admitted through the emergency room.  I can’t recommend admission on an ED patient and then sign off.  By default, that makes me fall under the same rules as an ED doc.

Consumer site listing patient-satisfaction scores

From Modern Healthcare:

Consumer Reports launched patient-satisfaction ratings on its Web site comparing hospitals across the country.

Using data from the federal Hospital Consumer Assessment of Healthcare Providers and Systems Survey, or HCAHPS, Consumer Reports provides its own ranking system represented by symbols for hospitals. Subscribers can search facilities in a state to see how they scored on HCAHPS information. In addition, the reports tie satisfaction scores to how aggressively a hospital treats an illness—a ranking system based on data from the Dartmouth Atlas of Health Care—which Consumer Reports began to provide last year.

Comparing that information indicates patients seem to be more satisfied in hospitals that are more conservative with treatment options, Consumer Reports said in a news release. The reports are published by Consumers Union