Research Forum Abstracts

h) before, after the model change and one year following. Physicians were alsoadministered a survey tool with a ten-point visual analog scale that was validated byqualitative methodology to evaluate level of satisfaction and perceived productivity inthe different practice models.

Results: Physician productivity in a hallway model (Pts/h 1.64�0.37, RVU/h4.69�0.98, Chg/h $481�98) versus centralized model (Pts/h 1.77�0.49, RVU/h4.85�1.16, Chg/h $508�122) showed no statistically significance difference,(p�0.05) as previously reported. One year later the centralized model (Pts/h1.78�0.39, RVU/h 4.77 �1.16, Chg/h $506�116) showed no statistical differenceto the hallway model or the initial centralized model (p�0.05). Physicians rated theirperceived productivity higher in the centralized model 3.55�0.83 versus 1.43�0.93,(p-value of 0.001). The physician satisfaction was also higher in the centralized model3.61�0.90 versus 1.12 �1.03, (p-value 0.001).

Conclusion: With an implementation of a new workflow pattern utilizing thesame number of health care providers and resources leads to higher satisfaction andperceived productivity. While initial implementation shows no degradation inproductivity there is a lack of increased productivity over time. While changes inworkflow patterns can improve perceived productivity and satisfaction they may onlyhave limited effects on actual productivity as measured by standard parameters.Alterations to workflow management need to be assessed by objective criteria in orderto assess for true changes in productivity and workflow impact.

396 Effect of Holidays on the Patient Severity andCensus In the Emergency Department

Leming M, Farley HL, Reed III JF/Christiana Care Health System, Newark, DE

Background: To adequately staff an emergency department (ED) with medicalproviders, it is imperative to be able to correctly estimate the work load. Duringholiday periods work load could be altered from a normal week.

Study Objectives: The purpose of this study is to determine if ED patient census,distribution of Emergency Severity Index (ESI) scores, ED length of stay (LOS),percentage of patients who left without treatment (LWOT) and admission percentageon holidays and the day after holidays are different than during non-holiday periods.

Methods: This was a retrospective observational cohort study conducted over a 4-yearperiod from May, 2005 until May, 2009 at a suburban ED with an annual volume of�100,000 patients. The following holidays were analyzed: New Year’s Day, Easter,Memorial Day, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day.The patient census, percent of patients assigned each ESI score, median ED LOS,percentage of patients who LWOT and admission percentage were calculated on a dailybasis using an automated patient tracking system (Amelior ED tracker, Mission Viejo,CA). Variables were compared between holidays and non-holiday control days, andbetween the day after holidays and non-holiday control days. The data were analyzedusing a one-way analysis of variance and a p value of � 0.05 was considered significant.

Results: There was a significant difference between holidays and non-holidaycontrol days observed for the following variables: ED census (273 � 28 versus 283 �24, p�0.001), percent ESI 4 and 5 patients (32.3 � 4.8 versus 29.0 � 4.3,p�0.001), admission percentage (26.3 � 3.1 versus 27.9 � 3.1, p�0.045),percentage of patients who LWOT (2.3 � 1.3 versus 3.6 � 2.1, p�0.006), andmedian ED LOS in hours (3.9 � 0.4 versus 4.5 � 0.6, p�0.001). In addition, therewas a significant difference between the day after holidays and non-holiday controldays observed for the following variables: patient census (306 � 24 versus 283 � 24,p�0.001), percent ESI 3 patients (45.0 � 4.7 versus 47.1 � 3.7, p�0.001), andpercent ESI 4 and 5 patients (32.0 � 5.9 versus 29.0 � 4.3, p�0.001).

Conclusion: Patient census is significantly higher on the day after holidays whencompared to non-holidays. Administrators may find it helpful to take this observationinto account when attempting to optimize available hospital and ED resources.

397 A Lean-Based Process Redesign: Impact on72-Hour Returns: The SPEED Trial

Mink J, Eanes K, Levine B, Reed JF, Reese IV CL, Sweeney T, Farley HL,Jasani N/Christiana Care Health Services, Newark, DE

Background: Lean principles have been used in manufacturing processes for manyyears and have been associated with improved quality and success. Recently Leanprinciples have been applied to health care and, in particular, emergency departments(ED). These principles in the ED emphasize methods which eliminate over-processing, waste or unnecessary steps in the care delivered to the patient. Weimplemented a Lean-based Synchronized Provider Evaluation and Efficient

Disposition (SPEED) process for a targeted Emergency Severity Index (ESI)-3 patient

S128 Annals of Emergency Medicine

population at a large, academic ED center with annual census in excess of 100K.Some have questioned whether more rapid patient evaluation and treatment results ina higher rate of return visits or misdiagnosis.

Study Objectives: We sought to examine whether 72-hour return rate of patientsincreased in a Lean-based model.

Methods: A prospective study using weekly rapid cycle tests (RCT’s) wasconducted from January through November 2009. Utilizing the SPEED process, asynchronized provider evaluation, treatment and disposition process wasimplemented. Seventy-two hour return rates were calculated for SPEED RCTpatients seen from January to May 2009. This was compared to a control group of allED patients seen from January to May 2009 (control 1) as well as another controlgroup of all ED patients seen from January to May 2008 (control 2). Statisticalanalysis was performed using Pearson’s chi-square.

Results: See Table.

Conclusion: The application of Lean health care principles through the SPEEDredesign process did not result in an increased 72-hour return rate when compared tothe rest of the ED patient population.

398 Are Emergency Physicians More Efficient InRunning a Large Observation Unit?

Pena ME, Takla RB, Dunne RB, Szpunar SM, Kler S/St. John Hospital andMedical Center, Detroit, MI

Study Objective: To compare efficiency when a large observation unit (OU) ismanaged and staffed by emergency physicians versus non-emergency physicians.

Methods: This was an observational, retrospective study of a large 30-bed observationunit in an urban teaching hospital. Data were abstracted from the emergency departmentFirst Net tracking system. Two time periods were compared, November 2007 to August2008 (Period 1) and November 2008 to August 2009 (Period 2). During the first period,the OU was under the management of the department of internal medicine and staffed byprimary care physicians who provided variable staffing. In addition, physician assistantsprovided single coverage on-site staffing 8.5 hours a day Monday through Friday. Duringthe second period, the OU was managed by the department of emergency medicine andstaffed by emergency physicians who provided single coverage on-site staffing twelve hoursa day, seven days a week. Efficiency was evaluated by comparing lengths of stay of patientsdischarged and admitted from the OU between the two periods. In addition, boarderhours per month or the total amount of time in hours observation patients wait in theemergency department (ED) for bed availability in the OU were also compared to look atthe impact on ED crowding. All data were compared using Student’s t-test analysis.

Results: The overall mean ED volume increased from the first time period to thesecond (8091.7 � 348.9 versus 8745.4 � 689.4, p�0.015); however, the percent ofED patients who were admitted to the OU per month did not differ (7.6% � 0.69versus 7.2% � 0.42, p�0.08). Average OU patient volume per month was similar inboth periods (617 � 52.2 versus 626.9 � 66.8, p�0.72). Patient length of stay inthe OU was significantly less in the second period compared to the first for bothdischarged (27.3 � 1.7 hours versus 17.3 � 1.3 hours, p�0.001) and admitted(20.7 � 2.2 hours versus 16.5 � 3.1 hours, p�0.002) patients. Boarder hours alsodecreased significantly in the second period compared to the first (246.5� 54.6 hoursversus 199.3�41 hours, p�0.042).

Conclusion: A large observation unit managed and staffed by emergencyphysicians is more efficient when compared to non-emergency physicians and has a

positive impact on emergency department capacity.

Volume , . : September