A Rapid Medical Screening Process Improved Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus

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A Rapid Medical Screening Process Improved Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus Daniel B.

1 A Rapid Medical Screening Process Improved Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus Daniel B. Fagbuyi Kathleen Brown, David Mathison, Jennifer Kingsnorth, Sephora Morrison, Mohsen Saidinejad, Jeffrey Greenberg, Michael Knapp, James Chamberlain Children s National Medical Center The George Washington University School of Medicine

2 Disclosures: None Daniel B. Fagbuyi, MD has documented that he and his co-investigators have no relevant financial relationships to disclosure or COIs to resolve

3 Pandemic (H1N1) 2009 Influenza Virus

4 Background At least 10 documented flu pandemics have occurred in the past 300 years Three major pandemics have been well reported in the 20 th century 1918 (Spanish flu), 1957 (Asian flu), and 1968 (Hong Kong flu)

2009 H1N1 Outbreak Occurred very late in the

illness; some severe or fatal Large numbers

Socially disruptive, especially for schools

5 2009 H1N1 Outbreak Occurred very late in the season Remarkable heterogeneity across US Affected young people (< 25yrs) disproportionately Caused widespread illness; some severe or fatal Large numbers of children and families seeking care in EDs Socially disruptive, especially for schools Tens of thousands of health workers and others responding worldwide

6 Background Emergency department (ED) overcrowding is a critical issue on the national agenda further exacerbated by H1N1 pandemic The science of ED surge remains relatively undeveloped Nager AL, Khanna K. Emergency department surge: models and practical implications. J Trauma. 2009;67(2 Suppl):S96-99

7 Background Surge capacity is a healthcare systems ability to rapidly expand normal services to meet the increased demand for qualified personnel, medical care, and public health, in the event of bio-terrorism or other largescale public health emergencies or disasters

8 Background ED surge capacity: ED s ability to rapidly expand normal services to meet the increased demand during public health emergencies or disasters To date, scant data exist on strategies to improve ED surge capacity, throughput, flow, and response during a pediatric disaster, specifically, an infectious disease outbreak

9 Background Identification of best practices designed to reduce the impact of ED overcrowding and improve ED patient flow is a high-priority research area identified by Emergency Medical Services for Children (EMSC) and the Institute of Medicine (IOM) Miller SZ, Rincón H, Kuppermann N. Revisiting the emergency medicine services for children research agenda: priorities for multicenter research in pediatric emergency care. Acad Emerg Med. 2008;15(4): Institute of Medicine (US) Committee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing Pains. Washington, DC2006.

10 Objective To compare ED patient flow metrics during the 2009 H1N1-associated surge in patient volume to that of the 2008 winter influenza season

11 Hypothesis The use of a rapid screening process is associated with improved ED patient flow during high volume surges

12 Methods Design: Retrospective, descriptive comparison study of 2009 H1N1 Influenza Pandemic surge period (intervention) to the Winter 2008 Influenza period (control) Setting: Urban, academic, pediatric tertiary ED

13 Patient selection Inclusion Methods Age > 6 months with Influenza like illness (ILI) defined as fever and respiratory symptoms No history of chronic disease Well-appearing during rapid triage Exclusion Pulse ox <93%

14 Methods Process Elements & Implementation Additional clinical space (office cubicles) Paper medical record Discharge teaching to multiple families concurrently Preprinted instructions and prescriptions Activation based on ED volume and regional influenza activity

15 Methods Staffing Daily RSU staffing plan Activation based on specific patient centric triggers Acuity-based triage-to-provider time Total ED census Total # of patients in triage queue RSU team: 1-2 MDs, 1-2 RNs, and 1 PCT

16 Patient Flow Methods

17 Main ED Assessment Area (Vital signs and RN Assessment) Triage Non-ILI Waiting Area Removable Divider ILI Waiting Area RSU Security Initial Screen for ILI by PCT Entry

18 Emergency Department Checklist for Rapid Influenza Screening (Surge) PMH reviewed Brief history: HR acceptable for fever RR acceptable for fever Pulse ox 95% or greater Mental status normal Hydration adequate Cardiac exam normal (special attention to gallop or muffled heart sounds) Good peripheral perfusion Lung exam normal No hepatosplenomegaly Diagnosis Influenza Viral syndrome URI Other Signature/Initials Date and time

20 Results

21 Non-ILI ILI Patient Volume /12/ /13/ /14/ /15/ /16/ /17/ /18/ /19/ /20/ /21/ /22/ /23/ /24/ /25/ /26/ /27/ /28/2009 Date 10/29/ /30/ /31/ /1/ /2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/2009

22 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

23 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

24 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

25 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

26 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) (odds ratio) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

27 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) (odds ratio) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

28 Winter 2008 (Control) Results 2009 Surge (Intervention) Difference (95% CI) Patients per day (mean) Triage score (mean) Triage to provider time (minutes) ED length of stay (minutes) ( ) ( ) ( ) ( ) Elopement rate 2.8% 2.7% 0.97 ( ) (odds ratio) 48 hour return rate 2.9% 3.0% 1.03 ( ) (odds ratio) Physician staffing (hours per day, mean) Nursing staffing (hours per day, mean) ( ) ( )

29 20 18 Elopements Total daily patient volume

30 Overview RSU opened for a median of 14 hours/day 1777 patients used the RSU (17.7%) None required hospitalization RSU elopement rate was 3% Unscheduled return rate in 48hrs was 1.4% and 3.2% in 7 days 1 patient returned on day #4; admitted for dehydration

31 Limitations The study was performed at a single institution and specific approaches for handling surges in patient volume may be different at other medical centers A randomized controlled trial to compare the rapid screening process to our normal operations was NOT performed We believe that such a study would be unethical by denying an improved patient care experience to a control group

32 Conclusion The use of a rapid screening process aimed at identifying the most common complications of a widespread viral illness can be used to improve ED patient flow during high volume surges

33 Implications Although this study was performed during a surge associated with 2009 H1N1 influenza, the principles can be applied to other viral outbreaks such as enteroviruses and seasonal influenza, and possibly, other similar biological disasters

34 Acknowledgements Thanks to Children s National Medical Center ED staff and my co-investigators

35 A Rapid Medical Screening Process Improved Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus Daniel B. Fagbuyi Kathleen Brown, David Mathison, Jennifer Kingsnorth, Sephora Morrison, Mohsen Saidinejad, Jeffrey Greenberg, Michael Knapp, James Chamberlain Children s National Medical Center The George Washington University School of Medicine

H1N1: Pediatric Surge Capacity Strategies and Lessons Learned

H1N1: Pediatric Surge Capacity Strategies and Lessons Learned Daniel B. Fagbuyi, MD, FAAP MAJ, MC, USAR Medical Director, Disaster Preparedness and Emergency Management Children s s National Medical Center,