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Delays in transfer of admitted patients boarded in the emergency department (ED) to an inpatient bed is a major driver of ED overcrowding. We sought to identify explanatory factors behind ED boarding as well as the impact of boarding on total inpatient length of stay (IP LOS) and inpatient mortality.
We conducted a retrospective single-centre observational study during the period between January 1 and December 31, 2015 at a very high volume community hospital. All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean ED LOS and boarding time as well as patient-specific and institutional factors that were independently associated with prolonged ED LOS (≥24 hours) and prolonged boarding time (≥12 hours) were identified. Mean inpatient length of stay (IP LOS) and the odds of inpatient mortality were calculated for those patients with prolonged ED wait times.
There were 13,872 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher ED wait times than other services. Within Medicine patients, there was a statistically significant greater odds of prolonged ED wait times for patients who were older, had a greater comorbidity burden, and required more specialized inpatient care. Medicine patients with prolonged boarding times also experienced a mean of 0.9 days longer IP LOS even after adjusting for confounders.
Within our cohort, older, sicker patients and those patients requiring more resource-intensive inpatient care had the longest ED wait times. These prolonged wait times are associated with significantly increased IP LOS.
Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism.
This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism.
We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0).
In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.
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