Rajiv Arya - Academia.edu (original) (raw)

Papers by Rajiv Arya

Research paper thumbnail of The Amplitude of Outliers

Academic Emergency Medicine, Apr 1, 2012

Research paper thumbnail of Impact of Novice and Advanced Assistants on Clinical Efficiency of Emergency Physicians

Western Journal of Emergency Medicine, 2014

Research paper thumbnail of How Does Emergency Department Crowding, as Measured by National Emergency Department Overcrowding Scale, Affect Medical Student Test Score and Clerkship Evaluation?

Annals of Emergency Medicine, Oct 1, 2013

Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and... more Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and financial resources to selecting and interviewing applicants for residency. Despite the importance of an interview day, factors that the applicants find most valuable are poorly identified. Methods: An anonymous Web-based survey was sent to all applicants interviewed during the 2012-2013 cycle at one EM residency program. The survey assessed activities they found most valuable on the interview day. Results: The survey was sent to 211 applicants, with a response rate of 43%. When evaluating the academic merits of a residency program, factors that the applicants found most helpful included program reputation, the ability to attend the weekly morbidity and mortality conference, and the completion of an away rotation. Additionally, when evaluating social activities on an interview day, 81% of respondents felt that the opportunity to have breakfast with the program leadership improved their experience. Fifty-six percent of respondents reported they preferred an applicant dinner at a resident's home. Additionally, dinner at residents' homes received a higher overall rating than dinner at a restaurant. Conclusions: Residency programs place a lot of effort into recruiting the best candidates for their institution. During interview days, programs work to provide the applicants with information on both the educational aspects and wellness aspects of the program. According to our survey, applicants are interested in participating in rigorous academic activities such as morbidity and mortality conference. These activities give insight into resident and faculty interactions within the program and the educational mission of the program. When learning about the more social aspects of the program, applicants prefer more casual settings such as a casual breakfast with the program leadership or dinner at resident's homes. These activities provide a venue for applicants to determine their comfort level and fit within the membership of the residency program.

Research paper thumbnail of 2080915 Impact of Bedside Ultrasound on Emergency Department Length of Stay in Patients With a Suspected Peritonsillar Abscess: A Case Series

Ultrasound in Medicine and Biology, Apr 1, 2015

Research paper thumbnail of How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

Western Journal of Emergency Medicine, Nov 12, 2015

Research paper thumbnail of Case report Open Access Babesiosis as a rare cause of fever in the immunocompromised patient: a case report

© 2009 Nelson et al; licensee Cases Network Ltd. This is an Open Access article distributed under... more © 2009 Nelson et al; licensee Cases Network Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License

Research paper thumbnail of Impact of Novice and Advanced Assistants on Clinical Efficiency of Emergency Physicians

Western Journal of Emergency Medicine, 2014

Research paper thumbnail of Physiciansʼ Venous Thromboembolism Prophylaxis Decision Patterns During and After Endoscopic Procedure in High and Low-Risk Endoscopic Procedure at a Tertiary Medical Center

American Journal of Gastroenterology, 2016

The American Journal of GASTROENTEROLOGY Abstracts S143 risk. 398 occurred aft er EMA. 150 were h... more The American Journal of GASTROENTEROLOGY Abstracts S143 risk. 398 occurred aft er EMA. 150 were high-risk procedure and 248 were low risk procedure. Excluding those who continued VTE ppx throughout the procedure, the odds of resuming ppx within 24 hours aft er EMA were (OR 2.718; 95% Cl 1.739-4.277; P= < 0.001) among those with high-risk as compared to low-risk procedures, and (OR 1.809; 95% Cl 1.035-3.177; P=0.0379) prior to EMA. From between the time frames of 24 and 48 hours, VTE resumption odds were (OR 2.369; 95% Cl 0.546-10.294; P=0.2326) aft er EMA and (OR 2.207; 95% Cl 0.816-6.153; P=0.1192) prior to EMA. From aft er 48 hours VTE ppx resumption odds were (OR 0.898; 95% Cl 0.408-1.961; P=0.7893) aft er EMA and (OR 0.611; 95% Cl 0.252-1.372; P=0.2498) prior to EMA. Conclusion: VTE development is well-known to be a time-dependent phenomenon as demonstrated in studies in surgical patients. Earlier VTE is likely more important in patients with higher VTE risk. Th e EMA tool increased the odds that a high-risk procedure would receive VTE ppx within 24 hours though no direct comparison could be made with prior to EMA given overlapping confi dence intervals. Th e EMA tool for VTE ppx could potentially improve quality of patient care in patients undergoing inpatient endoscopic procedures.

Research paper thumbnail of Does Institution of an Electronic Medical Alert Tool for Venous Thromboembolism Prophylaxis Improve Venous Thromboembolism Prophylaxis after Endoscopic Procedure?

American Journal of Gastroenterology, 2016

Research paper thumbnail of How Does a Patientʼs Venous Thromboembolism and Bleed Risk Affect Physician Venous Thromboembolism Prophylaxis Patterns During Endoscopic Procedure?

American Journal of Gastroenterology, 2016

Research paper thumbnail of Clinician Behavior Within a Computerized Clinical Decision Support Tool for VTE Prophylaxis: Is It More Than an Inconvenience?

Research paper thumbnail of How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

Western Journal of Emergency Medicine, 2015

The effect of emergency department (ED) crowding has been recognized as a concern for more than 2... more The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. Objective: To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. Methods: We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. Results: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient=-0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar results. When the data were controlled for effect of month of the year, only student test score remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases). Conclusion: ED overcrowding does demonstrate a small but negative association with medical student performance on end-of-rotation examinations. Additional studies are recommended to further evaluate this effect. [West J Emerg Med. 2015;16(6):913-918.] * † 20 years. 1 Previous reports have noted crowding as a risk factor for patients leaving without being seen, increased inpatient mortality, increased frequency of medical errors, and increased

Research paper thumbnail of Semi-Structured Interview Guide

Journal of Health Care for the Poor and Underserved

Research paper thumbnail of 2080915 Impact of Bedside Ultrasound on Emergency Department Length of Stay in Patients With a Suspected Peritonsillar Abscess: A Case Series

Ultrasound in Medicine & Biology, 2015

Research paper thumbnail of Babesiosis as a rare cause of fever in the immunocompromised patient: a case report

Cases journal, Jan 10, 2009

This is the case of a rare and regional disease not often considered in the immunocompromised pat... more This is the case of a rare and regional disease not often considered in the immunocompromised patient presenting with a chief complaint of fever. A 37-year-old immunocompromised Indian woman presented with a chief complaint of fever, in the absence of localizing signs and symptoms, from an area endemic to Babesia microti. Our patient's case is instructive in that Babesiosis and other arthropod born illnesses should be considered in immunocompromised patients presenting with fever in the absence of localizing signs or symptoms. This is especially true when he or she presents from an area with known endemic disease. While the management of fever in immunocompromised patients is largely standardized, considering Babesiosis from the beginning may prompt early investigation of a blood smear, which has the potential to alert the emergency department physician to Babesiosis. In addition, considering the disease from the outset has the potential to accelerate administration of the appro...

Research paper thumbnail of Decision-Making Processes of Patients Who Use the Emergency Department for Primary Care Needs

Journal of Health Care for the Poor and Underserved, 2013

Research paper thumbnail of 390 Divergence in the Distributions of Ventilation/Perfusion Scan Readings in Clinical Practice versus the Original PIOPED Study

Annals of Emergency Medicine, 2012

Research paper thumbnail of How Does Emergency Department Crowding, as Measured by National Emergency Department Overcrowding Scale, Affect Medical Student Test Score and Clerkship Evaluation?

Annals of Emergency Medicine, 2013

Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and... more Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and financial resources to selecting and interviewing applicants for residency. Despite the importance of an interview day, factors that the applicants find most valuable are poorly identified. Methods: An anonymous Web-based survey was sent to all applicants interviewed during the 2012-2013 cycle at one EM residency program. The survey assessed activities they found most valuable on the interview day. Results: The survey was sent to 211 applicants, with a response rate of 43%. When evaluating the academic merits of a residency program, factors that the applicants found most helpful included program reputation, the ability to attend the weekly morbidity and mortality conference, and the completion of an away rotation. Additionally, when evaluating social activities on an interview day, 81% of respondents felt that the opportunity to have breakfast with the program leadership improved their experience. Fifty-six percent of respondents reported they preferred an applicant dinner at a resident's home. Additionally, dinner at residents' homes received a higher overall rating than dinner at a restaurant. Conclusions: Residency programs place a lot of effort into recruiting the best candidates for their institution. During interview days, programs work to provide the applicants with information on both the educational aspects and wellness aspects of the program. According to our survey, applicants are interested in participating in rigorous academic activities such as morbidity and mortality conference. These activities give insight into resident and faculty interactions within the program and the educational mission of the program. When learning about the more social aspects of the program, applicants prefer more casual settings such as a casual breakfast with the program leadership or dinner at resident's homes. These activities provide a venue for applicants to determine their comfort level and fit within the membership of the residency program.

Research paper thumbnail of 228: Cephalgia in Emergency Department Responds to Oxygen Decreasing Time to Relief, Length of Stay, Computed Tomography Utilization, and Need for Pharmacotherapy

Annals of Emergency Medicine, 2009

onset headache and significantly less altered level of consciousness. Patients with d-SAH subtype... more onset headache and significantly less altered level of consciousness. Patients with d-SAH subtype had a higher risk for complications related to SAH with an increased incidence of hydrocephalus (33% vs. 3%, pϽ.01), symptomatic vasospasm (28% vs. 7%, pϭ.04) and secondary stroke (15% vs. 0%, pϭ.07). Ultimately, only 67% of d-SAH patients achieved complete recovery and independent living, compared to 90% of p-SAH patients. Conclusions: Patterns of hemorrhage on the initial CT scan are important prognostic factors for NASAH. The patients that fit strict criteria for perimesencephalic hemorrhage demonstrated a relatively benign course. Patients with a diffuse hemorrhage pattern are at increased risk for hydrocephalus and secondary stroke; they are also less likely to achieve complete recovery and should therefore be cared for with a higher level of surveillance.

Research paper thumbnail of Decreasing Length of Stay in the Emergency Department With a Split Emergency Severity Index 3 Patient Flow Model

Academic Emergency Medicine, 2013

Objectives: There has been a steady increase in emergency department (ED) patient volume and wait... more Objectives: There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients. Methods: This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe. Results: There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%). Conclusions: A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.

Research paper thumbnail of The Amplitude of Outliers

Academic Emergency Medicine, Apr 1, 2012

Research paper thumbnail of Impact of Novice and Advanced Assistants on Clinical Efficiency of Emergency Physicians

Western Journal of Emergency Medicine, 2014

Research paper thumbnail of How Does Emergency Department Crowding, as Measured by National Emergency Department Overcrowding Scale, Affect Medical Student Test Score and Clerkship Evaluation?

Annals of Emergency Medicine, Oct 1, 2013

Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and... more Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and financial resources to selecting and interviewing applicants for residency. Despite the importance of an interview day, factors that the applicants find most valuable are poorly identified. Methods: An anonymous Web-based survey was sent to all applicants interviewed during the 2012-2013 cycle at one EM residency program. The survey assessed activities they found most valuable on the interview day. Results: The survey was sent to 211 applicants, with a response rate of 43%. When evaluating the academic merits of a residency program, factors that the applicants found most helpful included program reputation, the ability to attend the weekly morbidity and mortality conference, and the completion of an away rotation. Additionally, when evaluating social activities on an interview day, 81% of respondents felt that the opportunity to have breakfast with the program leadership improved their experience. Fifty-six percent of respondents reported they preferred an applicant dinner at a resident's home. Additionally, dinner at residents' homes received a higher overall rating than dinner at a restaurant. Conclusions: Residency programs place a lot of effort into recruiting the best candidates for their institution. During interview days, programs work to provide the applicants with information on both the educational aspects and wellness aspects of the program. According to our survey, applicants are interested in participating in rigorous academic activities such as morbidity and mortality conference. These activities give insight into resident and faculty interactions within the program and the educational mission of the program. When learning about the more social aspects of the program, applicants prefer more casual settings such as a casual breakfast with the program leadership or dinner at resident's homes. These activities provide a venue for applicants to determine their comfort level and fit within the membership of the residency program.

Research paper thumbnail of 2080915 Impact of Bedside Ultrasound on Emergency Department Length of Stay in Patients With a Suspected Peritonsillar Abscess: A Case Series

Ultrasound in Medicine and Biology, Apr 1, 2015

Research paper thumbnail of How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

Western Journal of Emergency Medicine, Nov 12, 2015

Research paper thumbnail of Case report Open Access Babesiosis as a rare cause of fever in the immunocompromised patient: a case report

© 2009 Nelson et al; licensee Cases Network Ltd. This is an Open Access article distributed under... more © 2009 Nelson et al; licensee Cases Network Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License

Research paper thumbnail of Impact of Novice and Advanced Assistants on Clinical Efficiency of Emergency Physicians

Western Journal of Emergency Medicine, 2014

Research paper thumbnail of Physiciansʼ Venous Thromboembolism Prophylaxis Decision Patterns During and After Endoscopic Procedure in High and Low-Risk Endoscopic Procedure at a Tertiary Medical Center

American Journal of Gastroenterology, 2016

The American Journal of GASTROENTEROLOGY Abstracts S143 risk. 398 occurred aft er EMA. 150 were h... more The American Journal of GASTROENTEROLOGY Abstracts S143 risk. 398 occurred aft er EMA. 150 were high-risk procedure and 248 were low risk procedure. Excluding those who continued VTE ppx throughout the procedure, the odds of resuming ppx within 24 hours aft er EMA were (OR 2.718; 95% Cl 1.739-4.277; P= < 0.001) among those with high-risk as compared to low-risk procedures, and (OR 1.809; 95% Cl 1.035-3.177; P=0.0379) prior to EMA. From between the time frames of 24 and 48 hours, VTE resumption odds were (OR 2.369; 95% Cl 0.546-10.294; P=0.2326) aft er EMA and (OR 2.207; 95% Cl 0.816-6.153; P=0.1192) prior to EMA. From aft er 48 hours VTE ppx resumption odds were (OR 0.898; 95% Cl 0.408-1.961; P=0.7893) aft er EMA and (OR 0.611; 95% Cl 0.252-1.372; P=0.2498) prior to EMA. Conclusion: VTE development is well-known to be a time-dependent phenomenon as demonstrated in studies in surgical patients. Earlier VTE is likely more important in patients with higher VTE risk. Th e EMA tool increased the odds that a high-risk procedure would receive VTE ppx within 24 hours though no direct comparison could be made with prior to EMA given overlapping confi dence intervals. Th e EMA tool for VTE ppx could potentially improve quality of patient care in patients undergoing inpatient endoscopic procedures.

Research paper thumbnail of Does Institution of an Electronic Medical Alert Tool for Venous Thromboembolism Prophylaxis Improve Venous Thromboembolism Prophylaxis after Endoscopic Procedure?

American Journal of Gastroenterology, 2016

Research paper thumbnail of How Does a Patientʼs Venous Thromboembolism and Bleed Risk Affect Physician Venous Thromboembolism Prophylaxis Patterns During Endoscopic Procedure?

American Journal of Gastroenterology, 2016

Research paper thumbnail of Clinician Behavior Within a Computerized Clinical Decision Support Tool for VTE Prophylaxis: Is It More Than an Inconvenience?

Research paper thumbnail of How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

Western Journal of Emergency Medicine, 2015

The effect of emergency department (ED) crowding has been recognized as a concern for more than 2... more The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. Objective: To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. Methods: We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. Results: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient=-0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar results. When the data were controlled for effect of month of the year, only student test score remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases). Conclusion: ED overcrowding does demonstrate a small but negative association with medical student performance on end-of-rotation examinations. Additional studies are recommended to further evaluate this effect. [West J Emerg Med. 2015;16(6):913-918.] * † 20 years. 1 Previous reports have noted crowding as a risk factor for patients leaving without being seen, increased inpatient mortality, increased frequency of medical errors, and increased

Research paper thumbnail of Semi-Structured Interview Guide

Journal of Health Care for the Poor and Underserved

Research paper thumbnail of 2080915 Impact of Bedside Ultrasound on Emergency Department Length of Stay in Patients With a Suspected Peritonsillar Abscess: A Case Series

Ultrasound in Medicine & Biology, 2015

Research paper thumbnail of Babesiosis as a rare cause of fever in the immunocompromised patient: a case report

Cases journal, Jan 10, 2009

This is the case of a rare and regional disease not often considered in the immunocompromised pat... more This is the case of a rare and regional disease not often considered in the immunocompromised patient presenting with a chief complaint of fever. A 37-year-old immunocompromised Indian woman presented with a chief complaint of fever, in the absence of localizing signs and symptoms, from an area endemic to Babesia microti. Our patient's case is instructive in that Babesiosis and other arthropod born illnesses should be considered in immunocompromised patients presenting with fever in the absence of localizing signs or symptoms. This is especially true when he or she presents from an area with known endemic disease. While the management of fever in immunocompromised patients is largely standardized, considering Babesiosis from the beginning may prompt early investigation of a blood smear, which has the potential to alert the emergency department physician to Babesiosis. In addition, considering the disease from the outset has the potential to accelerate administration of the appro...

Research paper thumbnail of Decision-Making Processes of Patients Who Use the Emergency Department for Primary Care Needs

Journal of Health Care for the Poor and Underserved, 2013

Research paper thumbnail of 390 Divergence in the Distributions of Ventilation/Perfusion Scan Readings in Clinical Practice versus the Original PIOPED Study

Annals of Emergency Medicine, 2012

Research paper thumbnail of How Does Emergency Department Crowding, as Measured by National Emergency Department Overcrowding Scale, Affect Medical Student Test Score and Clerkship Evaluation?

Annals of Emergency Medicine, 2013

Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and... more Study Objectives: Each year, residency programs dedicate a significant amount of time, effort and financial resources to selecting and interviewing applicants for residency. Despite the importance of an interview day, factors that the applicants find most valuable are poorly identified. Methods: An anonymous Web-based survey was sent to all applicants interviewed during the 2012-2013 cycle at one EM residency program. The survey assessed activities they found most valuable on the interview day. Results: The survey was sent to 211 applicants, with a response rate of 43%. When evaluating the academic merits of a residency program, factors that the applicants found most helpful included program reputation, the ability to attend the weekly morbidity and mortality conference, and the completion of an away rotation. Additionally, when evaluating social activities on an interview day, 81% of respondents felt that the opportunity to have breakfast with the program leadership improved their experience. Fifty-six percent of respondents reported they preferred an applicant dinner at a resident's home. Additionally, dinner at residents' homes received a higher overall rating than dinner at a restaurant. Conclusions: Residency programs place a lot of effort into recruiting the best candidates for their institution. During interview days, programs work to provide the applicants with information on both the educational aspects and wellness aspects of the program. According to our survey, applicants are interested in participating in rigorous academic activities such as morbidity and mortality conference. These activities give insight into resident and faculty interactions within the program and the educational mission of the program. When learning about the more social aspects of the program, applicants prefer more casual settings such as a casual breakfast with the program leadership or dinner at resident's homes. These activities provide a venue for applicants to determine their comfort level and fit within the membership of the residency program.

Research paper thumbnail of 228: Cephalgia in Emergency Department Responds to Oxygen Decreasing Time to Relief, Length of Stay, Computed Tomography Utilization, and Need for Pharmacotherapy

Annals of Emergency Medicine, 2009

onset headache and significantly less altered level of consciousness. Patients with d-SAH subtype... more onset headache and significantly less altered level of consciousness. Patients with d-SAH subtype had a higher risk for complications related to SAH with an increased incidence of hydrocephalus (33% vs. 3%, pϽ.01), symptomatic vasospasm (28% vs. 7%, pϭ.04) and secondary stroke (15% vs. 0%, pϭ.07). Ultimately, only 67% of d-SAH patients achieved complete recovery and independent living, compared to 90% of p-SAH patients. Conclusions: Patterns of hemorrhage on the initial CT scan are important prognostic factors for NASAH. The patients that fit strict criteria for perimesencephalic hemorrhage demonstrated a relatively benign course. Patients with a diffuse hemorrhage pattern are at increased risk for hydrocephalus and secondary stroke; they are also less likely to achieve complete recovery and should therefore be cared for with a higher level of surveillance.

Research paper thumbnail of Decreasing Length of Stay in the Emergency Department With a Split Emergency Severity Index 3 Patient Flow Model

Academic Emergency Medicine, 2013

Objectives: There has been a steady increase in emergency department (ED) patient volume and wait... more Objectives: There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients. Methods: This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe. Results: There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%). Conclusions: A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.