Emergency (2013); 1 (1): ***-*** This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 20 Emergency (2013); 1 (1): 20-23 ORIGINAL RESEARCH Emergency Department Performance Indexes Before and After Establishment of Emergency Medicine Behrooz Hashemi, Alireza Baratloo*, Farhad Rahmati, Mohammad Mehdi Forouzanfar, Maryam Motamedi, Saeed Safari Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Abstract Introduction: Emergency department performance index (EPI) greatly influences the function of other hospital’s units and patient satisfaction. Recently, the Iranian Ministry of Health has defined specific national EPI containing five indexes. In the present study the performance indexes of emergency department (ED) in one educational hospital has been assessed before and after establishment of emergency medicine. Methods: In the present cross- sectional study the ED of Shohadaye Tajrish Hospital, Tehran, Iran was assessed during one-year period from March 2012 to February 2013. The study was divided into two six-month periods of before and after establish- ment of emergency medicine. Five performance indexes including: the percentage of patients were disposed dur- ing 6-hour, leaved the ED in a 12-hour, had unsuccessful cardiopulmonary resuscitations (CPR), discharged against medical advice, and the mean time of triage were calculated using data of department of medical records on daily patients’ files. Then, Mann-Whitney U test was used to make comparisons at P<0.05. Results: The aver- age triage time decreased from 6.04 minutes in the first six months to 1.5 minutes in the second six months (P=0.06). The percentage of patients leaving the ED in a 12-hour decreased from 97.3% to 90.4% (P=0.004). However, the percentage of disposed patients during 6-hour (P=0.2), unsuccessful CPR (P=0.34) and discharged against medical advice (P=0.42) did not differ between the two periods. Conclusion: It seems that establishment of emergency medicine could be able to improve ED performances indexes such as time to triage and leave in a 12-hour period. Key words: Emergency department performance index; emergency medicine; patient discharge; triage Cite this article as: Hashemi B, Baratloo A, Rahmati F, Forouzanfar MM, Motamedi M, Safari S. Emergency department performance indexes before and after establishment of emergency medicine. Emergency. 2013; 1(1):20-3. Introduction:1 mergency department performance index (EPI) greatly influences the function of other hospital’s units and also patient satisfaction. Base on official reports Iran’s emergency departments (ED) admit ap- proximately 30 million critically ill and ambulatory pa- tients all over the country. This great population in- creases the potential of medical errors and the duration of patients’ waiting time in ED (1-3). There are various methods to assess the performance and function in dif- ferent organizations. These methods generally originate from theories, attitudes or situations. They can evaluate the achievement of predetermined goals or aims in an organization. Continuous and correct implementation of these methods improves the function and efficacy of units (4-6). EPI as one of these methods can be used to monitor the performance of EDs (4). Recently, the Ira- *Corresponding Author: Alireza Baratloo; Department of Emergency Medicine, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran. Mobile phone: +989122884364, Fax: +982122721155 Email: alirezabaratloo@yahoo.com Received: 7 September 2013; Accepted: 25 November 2013 nian Ministry of Health has defined specific national EPI containing five indexes for the assessment of EDs’ per- formance. This is measurable and realistic assessment method with definite frameworks and time intervals (7, 8). These five indexes consist of 1: The percentages of patients were disposed during 6-hour of presentation to ED; 2: the percentage of patients leaved the ED in a 12-hour period; 3: percentage of unsuccessful cardio- pulmonary resuscitations (CPR); 4: percentage of dis- charge against medical advice; and 5: the average time of triage (panel 1). Based on the above mentioned, in the present study the performance indexes of ED in one educational hospital has been assessed before and after establishment of emergency medicine. Methods: Study design and setting In the present cross-sectional study the ED of Sho- hadaye Tajrish Hospital (Shahid Beheshti University of Medical sciences, Tehran, Iran) was assessed during one-year period from March 2012 to February 2013. This assessment was carried out based on Iranian na- tional EPI designed by Ministry of Health (panel 1). The E This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 21 Emergency (2013); 1 (1): 20-23 study was divided into two six-month periods of before and after establishment of emergency medicine. Data collection All necessary data, assigned in panel one, were collected using patients’ files at the end of each 24-hour shift by department of medical records’ staffs. Then the data were rechecked by the emergency unit manager and were entered into the database designed for the study. Finally, the five indexes calculated for each day, sepa- rately. Statistical analysis Data were entered into SPSS 21.0 statistical software and reported in means ± standard deviations. Differ- ences between the two periods of the study were evalu- ated by Mann-Whitney U test. Also, since changes made after the establishment of emergency medicine, proba- bly takes time to appear, the difference between the first and last quarters of study period were compared. Statistical significance was defined at P<0.05. Results: The mean of triage time was 6.04 minutes at the first six-month, decreasing to 1.5 minutes during the second half of the study period (P=0.016). The percentage of patients leaving the emergency unit in a 12-hour at the first and second study periods were 97.3% and 90.4%, respectively (p=0.004). There were no significant changes in the percentage of cases disposed in a 6-hour (P=0.2), the percentage of unsuccessful CPRs (P=0.34), and percentage of discharge against medical advice (P=0.42) (Table 1). Evaluation of differences in perfor- mance indexes between the first and last quarters of the study period showed no significant differences between any of the indexes (table 2). Comparing the first and last quarter showed 1.1% decrease in the percentage of pa- tients had been disposed during the first 6-hour, 7.6% in patients leaving the emergency unit in a 12-hour, and 60% in the mean of triage time (p>0.05). The percent- age of unsuccessful CPRs and the percentage of dis- charge against medical advice were not significantly different between two quarters. Discussion: The finding of the present study showed that estab- lishment of emergency medicine results in a more effi- cacious triage. On the other hand, the percentage of pa- tients leaving the emergency unit in the 12-hour period decreased significantly. Although the number of pa- tients discharge against medical advice and the mean of cases disposed in a 6-hour decreased at the end of the study, the differences were not statistically significant. The decrease in triage time can be explained by the fact that in the hospital under study, before establishment of emergency medicine, triage was carried out by general practitioners. This kind of triage had two main disad- vantages: first, the triage duration was long and second; all the triage levels (from level 1 to level 5, based on Emergency Severity Index) were referred to the emer- gency ward. However, after establishment of emergen- cy medicine, triage of patients was carried out by the Panel 1: National emergency department performance index (EPI) Index Data necessary of calculation The method used for calculation The percentages of pa- tients were disposed dur- ing 6-hour the number of patients were disposed in 6 hours; the total number of patients hospitalized tempo- rarily; the time of admission into the emergency ward; the time of disposition the ratio of patients hospitalized temporarily in the emergency ward, whose cases were disposed in 6 hours to the total number of patients hospitalized temporarily in the emergency ward The percentage of patients leaving the ED1 in a 12- hour the number of patients hospitalized temporarily in the emergency ward; the times of admission into and discharge from the emergency ward the ratio of patients hospitalized temporarily in the emergency ward, whose cases were disposed in 12 hours from the admission and discharged to the total number of patients hospitalized temporarily in the emergency ward Unsuccessful CPRs2 The total number of CPRs; the number unsuccessful CPRs the ratio of the number of unsuccessful CPRs to the total number of CPRs at a time interval; successful CPR was defined as cases in which the patient had spontaneous circulation and did not need CPR again for at least 20 minutes Discharge against medical advice the number of patients hospitalized temporarily; the number of patients discharge against medical advice the ratio of patients discharge against medical advice despite the advice of the emergency physician to the total number of patients hospitalized temporarily in the emergency ward Mean time of triage duration of triage; triage level; the total number of the patients in the same triage level the ratio of the total duration of patient triage to the total number of patients in the same triage level 1: Emergency department; 2: Cardiopulmonary resuscitations This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 22 Hashemi et al emergency residents, which resulted in a shorter triage time and referral of level 5 patients to the outpatient clinic. This fact resulted in a change in the pattern of patients referring to the emergency ward, i.e. the num- ber of critically ill patients increased. Since, there were lacking resource regarding number of intensive care unit (ICU) and monitoring room these patients re- mained in the emergency ward. Therefore, during the second half of the study period the percentage of pa- tients who remained in the emergency unit for more than 12-hour, subsequently increased. The previous studies have shown that one of the factors responsible for crowdedness of emergency units is patients’ not leaving the emergency ward due to any causes (9-11). Queuing theory, suggests that an increase in using a service results in an increase in waiting to receive ser- vices (12, 13). Theoretically, when the capacity of a sys- tem remains low, the waiting duration of users for the service will increase (12). Extension of this theory to the emergency unit emphasizes the fact that an increase in the occupation of hospital beds results in an increase in crowdedness of emergency units, subsequently. Bowker and Stewart reported a frequency of 98% for unsuccessful CPR cases (14). Peberdy et al reported a frequency rate of 87% for such cases (15). As shown in Tables 1 and 2, there was an increase in the number of unsuccessful CPRs in the present study. Although the difference was not statistically significant, it was no- ticeable (55.7% vs. 88%). Such a difference was at- tributed to improving and correcting the method used to record unsuccessful CPRs. By definition, a CPR is suc- cessful if the patient has spontaneous circulation after the procedure and does not require repetition of CPR for at least 20 minutes. However, before establishment of emergency medicine, each CPR, which resulted in spontaneous circulation in the patient, was considered a successful CPR (even if CPR was again needed in less than 20 minutes). Therefore, correction of the method used to register the reports resulted in more accurate and reliable statistics. The literature review in the pre- sent study did not bring up a study, which has particu- larly evaluated the performance indexes of emergency units. The majority of studies available have evaluated the management and human resource aspects. For ex- ample, Rahman et al reported that hospitals in which the head of the emergency unit is an emergency medi- cine specialist with experienced personal exhibit better performance in rendering emergency services (16). Movahedina et al evaluated timing indexes in an emer- gency unit and reported that timing indexes in the emergency unit of Firouzgar Hospital were standard, which was attributed to the presence of emergency physicians’ establishment in the unit (17). Other studies are in opposing opinion (18, 19). Limitation The patients referred to ED during two period of study are not necessarily the same. On the other hand, differ- ences may be due to more accurate fulfilling patient’s timetables after nursing educational courses. In addi- tion, our hospital guidelines and resistance of other wards against admission of patients, limit on-time dis- position. Conclusion: It seems that establishment of emergency medicine could be able to improved emergency department per- formances indexes such as time to triage and 12-hour Table 1: Comparison of performance indexes between the first and second halves of the study Index First 6 months Second 6 months p Mean SD1 Mean SD Mean of triage time (minutes) 6.04 7.7 1.5 0.27 0.016 Patients were disposed in 6 hours (%) 94.4 1.6 93.1 1.8 0.2 Patients were disposed during 6 hours, discharged during 12-hour (%) 97.3 0.8 90.4 0.6 0.004 Unsuccessful CPRs (%) 64.9 21.1 74.4 13.2 0.34 Discharge against medical advice (%) 20.7 1.1 19.4 2.0 0.42 1: Standard deviation Table 2: Comparison of performance indexes between the first and last quarters of the study Index First quarter Last quarter p Mean SD1 Mean SD Mean of triage time (minutes) 3.5 0.25 1.4 0.14 0.08 The patients whose cases were disposed in 6 hours (%) 95.0 0.94 93.9 0.17 0.08 The patients discharged from the emer- gency ward in 12 hours (%) 97.5 0.8 89.9 0.47 0.08 Unsuccessful CPRs (%) 55.7 20.1 88.0 14.2 0.13 Discharge against medical advice (%) 20.2 1.4 20.8 1.6 0.56 1: Standard deviation This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 23 Emergency (2013); 1 (1): 20-23 disposition. Acknowledgements: The authors would like to thank all the emergency unit personnel and the staff of the medical statistics center of Shohadaye Tajrish Hospital. Special thanks are also due to Ms. Maryam Nikookalam for her sincere assis- tance in carrying out this research study. Conflict of interest: The authors declare that there are no conflicts of inter- est. Funding: This study was performed based on a dissertation sub- mitted to Shahid Beheshti University of Medical Scienc- es in partial fulfillment of the requirements for an un- dergraduate degree in medicine. No other supports, including financial support, were involved. Authors’ contribution: All authors contribute in drafting/revising the manu- script, study concept or design, analysis or interpreta- tion of data. References: 1. Geelhoed GC, de Klerk NH. 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