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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 26  |  Issue : 1  |  Page : 44-47

Early burn team consultation in the emergency department improves efficiency and patient throughput


1 Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
2 University of Rochester School of Medicine & Dentistry, Rochester, New York, USA

Date of Web Publication11-Mar-2019

Correspondence Address:
Dr. Derek E Bell
Department of Surgery/Division of Plastic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York 14642
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_15_18

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  Abstract 


Objective: The objective of the study is to assess the relationship between expedited burn surgery evaluation and total length of stay (LOS) in the emergency department (ED) in a high-volume tertiary burn care institution and extrapolate these results to the efficiency and cost-effectiveness of patient care.
Methods: A retrospective review was performed of all patients evaluated by the burn surgery team and discharged from the University of Rochester Medical Center ED between November 2012 and June 2013. One hundred and three primary patients were identified and their time from arrival to discharge and the timing of burn surgery consultation were analyzed. Patients were stratified into two groups, early and late, based on how soon after arrival they were seen by the burn surgery service. Tests of statistical significance were performed, comparing total time in the ED, time to evaluation by ED provider, and time to evaluation by the burn surgery service.
Results: Burn surgery was consulted and evaluated the early group significantly sooner than the late group (early mean: 63 min, late mean: 191 min; P < 0.001). Total ED stay (arrival-to-discharge time) was significantly lower for the early burn evaluation group (early mean: 181 min, late mean: 285 min; P < 0.001).
Conclusions: Early burn surgery consultation is associated with a significantly reduced total ED LOS, arguing for immediate burn surgery consultation irrespective of ED provider contact so that patient throughput can be increased. Furthermore, the reduced LOS may translate into higher patient satisfaction, improved patient care, and lower opportunity cost of ED space.

Keywords: Burn evaluation, burn injury consultation, emergency department burns


How to cite this article:
Myers PL, Patel AU, Bell DE. Early burn team consultation in the emergency department improves efficiency and patient throughput. Indian J Burns 2018;26:44-7

How to cite this URL:
Myers PL, Patel AU, Bell DE. Early burn team consultation in the emergency department improves efficiency and patient throughput. Indian J Burns [serial online] 2018 [cited 2019 Nov 21];26:44-7. Available from: http://www.ijburns.com/text.asp?2018/26/1/44/253844




  Introduction Top


Emergency departments (EDs) are facing an unprecedented challenge with overcrowding of patients. Some even suggest that easily accessible specialty consultation services may contribute to overcrowding.[1] As such, there is an ongoing impetus to streamline patient flow due to the increasingly high demands for resources.[2] This would ultimately decrease total cost of the visit and improve patient satisfaction and outcomes. It is shown that the average expenditure per patient is increasing sharply; however, burn injury size is decreasing.[3] As efforts are turned to managing these issues, there is a room for significant improvement of management of lower acuity burn patients.[4] The American Bar Association has established several guidelines for patients appropriate for outpatient care, and patients meeting criteria can be managed safely with in-house wound care and discharged home with diligent outpatient follow-up [Table 1].[5],[6] Expediting this process will not only improve the individual patient's experience but also the overall patient throughput in the ED. This can potentially save money and improve patient satisfaction and clinical outcomes.
Table 1: Practice guidelines for burn care, chapter 3

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Patients' data were obtained from an academic institution providing comprehensive burn care to patients of all ages from the time of acute injury through long-term rehabilitation. The hospital is a nonprofit, Level I trauma center, and academic teaching medical center. The institution sees 1200 new burn visits/ED consults and has greater than 350 burn admissions per year.[7] In the past 5 years, this particular burn center has experienced a 26% increase in the number of consults evaluated in the ED as well as a 26% increase in the volume of urgent outpatient visits at the ambulatory clinic.[7] Given this marked increase in volume, providing the most efficient and optimal patient care is paramount. The burn surgery service advocates to be consulted immediately upon the patient's presentation to the ED to expedite appropriate patient disposition. When the ED provider places a consult, there is a dedicated burn surgery consult resident to promptly evaluate the patient and determine their ultimate disposition. In the ambulatory level patient in the ED, this involves performing the adequate wound care as well as facilitating the necessary follow-up. The purpose of this study was to assess the relationship between expedited burn surgery evaluation and total length of stay (LOS) in the ED. There have been well-documented problems of ED overcrowding and the need for optimal utilization of resources and patient outcomes, potentially improved with a decreased LOS.


  Methods Top


With internal review board approval, a retrospective chart review was performed of participants who underwent burn surgery consultation while in the ED with complete documentation of their encounter in the electronic medical record (eRecord). Data were collected and analyzed for participants evaluated by the burn surgery team and discharged from the ED between November 1, 2012, and June 30, 2013. Eight months provided sufficient data for our analysis. One hundred and thirty-six patients were identified during this period; however, only 103 had complete data in eRecord. Patients were stratified into two groups based on how soon after arrival the burn surgery service was consulted. It is recommended that all patients presenting with burn injury receive formal burn surgery evaluation. One hundred and three patients were identified who received burn surgery consultation without inpatient admission while in the ED and had documented times of the following events: time of arrival to the ED, ED provider contact, burn surgery consultation, and discharge from the ED. Patients with incomplete available data in the eRecord and those who required inpatient admission were excluded from the study. No patients were excluded based on the demographic makeup, i.e., all races, genders, and ages were included in the study. The “early” and “late” consultation cohorts were determined first by calculating the median arrival-to-burn consultation time (101 min). Patients that were seen within this metric were designated the “early” consultation group, whereas patients seen at 101 min and longer were the “late” consultation group. Demographic data were collected, and tests of statistical significance were performed using t-test within Microsoft Excel, with a significance of P < 0.05.


  Results Top


There were no significant demographic differences between the late and early cohorts. Percentage total body surface area (TBSA%) was similar to not require inpatient admission. There was no difference in consultations to other subspecialties. The average arrival times of patients did not differ between the two groups (early mean: 14:54, late mean: 15:12; P > 0.05) [Table 2]. Burn surgery was consulted and evaluated the early group significantly sooner than the late group (early mean: 63 min, late mean: 191 min; P < 0.001). All there was no significant difference in age (early mean: 26 years, late mean: 32 years; P > 0.05). Total ED LOS (arrival-to-discharge time) was significantly lower for the early burn evaluation group (early mean: 181 min, late mean: 285 min; P < 0.001) with a difference in 104 min.
Table 2: Differences in time to consult and total emergency departments time for early and late consultation groups

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  Discussion Top


Early burn surgery consultation is associated with a significantly reduced total ED LOS for the patient who does not meet admission criteria and is able to be managed safely as an outpatient. On presentation to the ED, the patient is evaluated by a triage nurse, placed in a room, and an ED provider is notified. During the initial ED provider encounter, the decision of whether to consult burn surgery is made. The consult is placed to the dedicated burn surgery consult resident for immediate evaluation. Patients whose first ED provider contact occurs late receive a delayed Burn Surgery evaluation, and thus their definitive management is delayed. Our data argue for immediate burn surgery consultation irrespective of ED provider contact so that patient throughput can be increased and LOS decreased, as evidenced by the statistically significant difference in ultimate LOS (early mean: 181 min, late mean: 285 min; P < 0.001). This has several implications. Financially, there could be impressive savings associated with decreased LOS. To evaluate this hypothesis, we aimed to calculate the net cost per minute and look at the difference between the late and early consult groups. In 2012, the Centers for Disease Control and Prevention estimated that an average ED visit costs approximately 969 dollars.[8] Based on our average LOS of 233 min, it is estimated that each minute spends in the ED costs approximate 4 dollars and 16 cents. The difference in LOS between our two groups, the “late” and “early” consult groups, was 104 min. This value multiplied by the net cost per minute translates into 432 dollars saved per visit if burn surgery is consulted within the designated “early” group. Based on our average annual ED consult volume of 275, it is estimated that consulting burn surgery early can save nearly 120 thousand dollars per year![7] Burns less than 50% TBSA are typically discharged directly from the ED.

There is also room for significant improvement in the patient care realm. There are well-documented problems of overcrowding in EDs, regardless of size or location.[2],[4] The main issue is poorer outcomes from hospitals operating at above capacity. With overcrowding, there may be significant delays in diagnosis and treatment, placing the overall public safety at risk.[9] Longer wait times invariably lead to patient dissatisfaction and may discourage patients from seeking care at an overcrowded ED. Furthermore, many patients may leave without being seen if the wait is too long. Consequently, there is potential for less severe medical issues, such as minor burns, to become more serious and suffer avoidable complications from delay in care. There is also increases in violence, ambulance diversion, and physician productivity with overcrowding in EDs.[9] If total length of time in the ED is reduced improving patient throughput and overcrowding, exclusive of types of patients, the implications are profound. Specifically, there were decreased morbidity and mortality, decreased ED violence, and decreased number of patients who leave without care. Importantly, patient satisfaction is increased as well.[10] While the focus of this paper is not to discuss the specific aspects of the ED, ED provider teams are sizable as patients can be seen by attending physicians (senior), resident physicians (junior), nurse practitioners, or physician assistants. There are no significant identifiable trends in when burn injuries present to the ED.

The ED contains over 75 consultation rooms though not all may be equipped for burn injuries. Severity determines whether a burn injury goes to the trauma bay or is triaged elsewhere in less acute areas of the ED. If a burn injury is deemed severe enough to warrant an overhead hospital-wide page to the “adult burn team” or “pediatric burn team,” it will occur. Otherwise, an ED provider can consult and page a burn surgery provider, typically a resident physician. There is no time recommended for patient evaluation/treatment by triaging ED provider or burn surgeon/resident to assess their patients. Burns seen by the burn surgery team can depend on whether an ED provider deems an in-hospital consult necessary. Alternatively, an ED provider may decide to discharge a patient and have them follow-up in the outpatient burn surgery clinic. The ED team is trained to complete initial care of burn patients (i.e., trauma management); status of advanced burn life support training may vary as at a teaching hospital, there is fluidity of resident physicians.

This study is limited by a relatively small patient cohort as a result of inconsistencies in documentation before November 2012. Moreover, burn volume traditionally fluctuates over the course of a year with a peak in summer months.[11] Our study did not include participants presenting between July and October. Although the medical record provided accurate documentation of pertinent events, further details about possible impediments to discharge were unavailable, such as availability of transportation and ongoing child protective services investigation. Further dissection into the factors that prolong LOS would be a useful future adjunct to the present study. Another future study could look at patients requiring inpatient admission and assess if earlier consultation also reduced the total ED LOS and subsequent cost savings. There are also opportunities to survey patients and assess their satisfaction about their experience, comparing specifically their LOS and outcomes. Furthermore, there can be analysis of ED supply and demand, with the ultimate goal of appropriate allocation of resources and medical personnel.

Although data were collected 2012–2013, the concerns raised by our study are still valid. The lessons learned and suggestions described are still relevant and may assist programs in improving their workflow.


  Conclusions Top


There is an increasing demand for ED resources as well as a concomitant increase in the volume of lower acuity burns presenting to a high volume tertiary burn care center. As such, there is a heightened need for improvements in efficiency and patient throughput. Early burn surgery consultation results in statistically significantly less time spent in the ED, which increases patient throughput. This suggests maximal use of ED opportunity resources with potential financial savings and improved patient satisfaction and outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Soong C, High S, Morgan MW, Ovens H. A novel approach to improving emergency department consultant response times. BMJ Qual Saf 2013;22:299-305.  Back to cited text no. 1
    
2.
Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emerg Med J 2003;20:402-5.  Back to cited text no. 2
    
3.
Kastenmeier A, Faraklas I, Cochran A, Pham TN, Young SR, Gibran NS, et al. The evolution of resource utilization in regional burn centers. J Burn Care Res 2010;31:130-6.  Back to cited text no. 3
    
4.
Taira BR, Singer AJ, Thode HC Jr., Lee C. Burns in the emergency department: A national perspective. J Emerg Med 2010;39:1-5.  Back to cited text no. 4
    
5.
Practice Guidelines for Burn Patient, Ch. 3. Outpatient Management of Burn Patients. J Burn Care Rehabil 2001;21:1.  Back to cited text no. 5
    
6.
Kessler Burn Center. University of Rochester Medical Center. Annual Report (Internal Document); 2014.  Back to cited text no. 6
    
7.
National Center for Health Statistics. Health, United States, 2012: Hyattsville, MD: With Special Feature on Emergency Care; 2013.  Back to cited text no. 7
    
8.
Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: Complex causes and disturbing effects. Ann Emerg Med 2000;35:63-8.  Back to cited text no. 8
    
9.
Lean-driven improvements slash wait times, drive up patient satisfaction scores. ED Manag 2012;24:79-81.  Back to cited text no. 9
    
10.
Hultman CS, Tong WT, Surrusco M, Roden KS, Kiser M, Cairns BA, et al. To everything there is a season: Impact of seasonal change on admissions, acuity of injury, length of stay, throughput, and charges at an accredited, regional burn center. Ann Plast Surg 2012;69:30-4.  Back to cited text no. 10
    
11.
Byrne D, Browne JG, Conway R, Cournane S, O'Riordan D, Silke B, et al. Mortality outcomes and emergency department wait times-the paradox in the capacity limited system. Acute Med 2018;17:130-6.  Back to cited text no. 11
    



 
 
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