title: Impact of operational staging to improve patient throughput in an inner-city emergency department during the novel H1N1 influenza surge: a descriptive study.
abstract: BACKGROUND
  A level 1 pediatric emergency department (ED) in a public hospital of South Bronx rapidly encountered a significant surge in ED patient census over several days as the novel H1N1 influenza outbreak occurred. Our aim was to identify ill patients with influenza-like illness and evaluate and treat them as expeditiously as possible without failing in our responsibility to treat all patients. We describe the ED response to the outbreak during 2009 H1N1-related visits.
  
  
  OBJECTIVE
  The objective of this study was to describe and compare pediatric ED visits during the fall 2009 H1N1 to that in the previous year.
  
  
  METHODS
  The department reorganized patient flow in the ED to maximize the understanding of where to best apportion our resources and to minimize walkout and return visit rates. We developed staging of the flow of patients. This included, but was not limited to, a rapid screening at pretriage stage, early registration before the formal triage, and expanding the service. We compared walkout rates during fall 2009 and fall 2008. Return visits for asthmatic patients within 7 days were also compared.
  
  
  RESULTS
  Over a period of 48 days, 8841 patients visited the pediatric ED. The average number of visits during this outbreak was 184 per day (usual visits per day, 80-110). Overall ED visits increased by 93.6% (95% confidence interval [CI], 78.2%-109.6%; P < 0.001). Fifty-two patients tested positive for H1N1. The walkout rate was 2.9% (95% CI, 1.9%-4.0%) in 2009 compared with the walkout rate of 1.5% (95% CI, 1.0%-2.0%) in 2008. There were no statistically significant differences between walkouts (P = 0.06) and 7-day asthma revisits (P = 0.07) in 2008 and 2009 despite the almost doubling of the ED visits. Admission rates from 2009 did not significantly differ from 2008 (11.2% [990/8841] vs 10.2% [464/4560], P = 0.07).
  
  
  CONCLUSIONS
  Staging of a surge volume allows ED administrators to maintain a strong control of a multipatient event to ensure an effective response and appropriate use of limited resources. The implementation of the reorganized measures during the fall 2009 H1N1-related surge in patient's visits resulted in improved patient flow without significant increase in walkout and 7-day asthma revisit rates. Our strategies accommodated the surge of patients in the ED.
authors.affiliation: Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY 10451, USA. waseemm2001@hotmail.com
authors.forename: Muhammad
authors.initials: M
authors.lastname: Waseem
authors.forename: Joan E
authors.initials: JE
authors.lastname: McInerney
authors.forename: Orlando
authors.initials: O
authors.lastname: Perales
authors.forename: Mark
authors.initials: M
authors.lastname: Leber
mesh_terms: D000293:Adolescent; D001249:Asthma / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D004189:Disaster Planning; D004196:Disease Outbreaks; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006779:Hospitals, Public / Q000458:organization & administration*; D006786:Hospitals, Urban / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000453:epidemiology*; D009519:New York City / Q000453:epidemiology; D010343:Patient Admission / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D010372:Pediatrics; D010559:Personnel Management; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D040841:Resource Allocation; D013997:Time Factors; D014218:Triage / Q000458:organization & administration*; D057188:Workflow; D055815:Young Adult