Bottom line: Thrombolytic therapy is associated with higher mortality in patients with hemodynamically uncomplicated PE, and therefore not indicated. Thrombolytic therapy in a subgroup of patients with hemodynamic instability or right ventricular dysfunction improves the clinical course and outcome.
Citation: Ibrahim SA, Stone RA, Obrosky S, Geng M, Fine MJ, Aujesky D. Thrombolytic therapy and mortality in patients with acute pulmonary embolism. Arch Intern Med. 2008;168(20):2183-2190.
Hospitalists Improve Patient Flow in the ED
Clinical question: Can active-bed management by hospitalists reduce ED throughput times and diversionary status?
Background: ED overcrowding leads to ambulance diversion, which has been associated with increased mortality. A primary cause of ED crowding is inpatient boarding, which can reduce patient satisfaction and quality of care. Previous studies targeting the ED have had little impact on throughput and ambulance diversion.
Study design: Pre-post case study in a single institution.
Setting: Academic teaching hospital in Baltimore.
Synopsis: ED throughput times and ambulance diversion hours were measured for all adult patients registered in the department from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period). Active-bed management was defined as appointing a hospitalist to assess bed availability in real time and assigning department of medicine admissions to the appropriate clinical setting, as well as the creation of a bed director. Although the ED census was 8.8% higher during the intervention period, throughput time for admitted patients decreased by 98 minutes per patient, to 458 from 360. The time spent under diversionary status for overcrowding or lack of ICU beds decreased by 6% and 27%, respectively. Limitations of this study include the pre-post design and the implementation at a single institution. Additionally, active-bed management is expensive, and in this case required the hiring of three full-time-equivalent faculty. However, this study successfully demonstrates that a quality improvement partnership between hospitalists and the ED can substantially reduce overcrowding.
Bottom line: Active-bed management by hospitalists improves ED throughput by decreasing the length of time admitted patients spend in the ED and reducing ambulance diversion hours.
Citation: Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.