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Mean wait times were longer in EDs that went on ambulance diversion or boarded admitted patients in hallways and in other spaces. There was no difference in mean wait time for patients needing immediate or emergent care by ambulance diversion status, or by whether the ED boarded admitted patients while waiting for an inpatient bed. Because wait time is highly skewed, that is, a small percentage (5%) of visits have very long wait times (greater than 3 hours), median wait time is less affected by the skewed distribution and provides an alternative way of describing ED wait time. Between 2003 and 2009, median time to see a provider increased 22%, from 27 minutes to 33 minutes. In 2009, 78% of visits occurred in EDs that reported boarding admitted patients in hallways and in other spaces while waiting for an inpatient bed to become available. Mean wait time to see a health care provider increased as annual ED visit volume increased in each ambulance diversion category. The mean wait time in EDs that boarded patients increased as annual ED visit volume increased.
There were no differences in mean wait times for ED patients triaged as immediate or emergent between EDs that went on diversion and EDs that did not go on diversion (Figure 6).
Patients triaged as urgent, semiurgent, or nonurgent, and patients that had no triage, had longer wait times in EDs that went on diversion compared with EDs that did not go on diversion. Patients triaged as urgent, semiurgent, or nonurgent, and patients that had no triage, had longer wait times in EDs that boarded any admitted patients compared with EDs that did not board any admitted patients. In 2009, EDs with any ambulance diversion during the previous year were associated with longer wait times, compared with EDs without ambulance diversions.
The mean wait time in EDs with unknown ambulance diversion status was similar to the wait time in EDs that went on ambulance diversion. There was no difference in mean wait time for patients triaged as immediate or emergent between EDs that went on diversion compared with EDs that did not go on diversion. This analysis indicates that EDs are continuing to experience pressure to treat more patients with fewer EDs and with fewer hospital beds. Emergency department crowding: An ED is considered crowded when inadequate resources to meet patient care demands lead to a reduction in the quality of care (8). Ambulance diversion: An ambulance is diverted when hospitals request that ambulances bypass their ED and transport patients to other medical facilities (4). All estimates are from the National Hospital Ambulatory Medical Care Survey (NHAMCS), an annual nationally representative survey of visits to nonfederal, general, and short-stay hospital emergency and outpatient departments. In 2009, ED wait time data were reported for visits seen by a physician, physician assistant, or nurse practitioner (n = 30,904).
Esther Hing and Farida Bhuiya are with the Centers for Disease Control and Prevention's National Center for Health Statistics, Division of Health Care Statistics.
Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. Patients involved in high energy trauma, should be assessed by Advanced Trauma Life Support (ATLS) principles.
Avascular necrosis (AVN, also called osteonecrosis) of the femoral head - this is the most common complication following a NOF fracture.


Coxa vara (neck shaft angle <120 degrees) - this is the second most common complication and has been reported to occur in up to 30% of cases.
Thyrotoxic periodic paralysis (TPP) attacks are characterized as recurrent, transient episodes of muscle weakness that range from mild weakness to complete flaccid paralysis.
In this case, we report the presence of 3 distinct arrhythmias in a single patient as his potassium levelchanged during an episode of acute TPP. A 29-year-old Asian male presented to the emergency department (ED) with symmetric paralysis of his lower extremities and weakness of his upper extremities that developed overnight.
On further history, it was discovered that over the preceding 4 months the patient had clinical features of TPP that had been subtle, with reports of transient lower extremity weakness occurring that resolved without medical intervention. On physical exam, the patient had symmetrical weakness and was unable to move his legs, but able to move his upper body, with sensation still intact. The development of this 2:1 AV block coincided with increased weakness of more proximal muscles and decrease in reflexes. Our patient exhibited numerous ECG changes due to hypokalemia secondary to thyrotoxicosis, with associated thyrotoxic periodic paralysis. Address for Correspondence: Sarah Lopez, MD, MBA, LAC+USC Medical Center, Department of Emergency Medicine, 1200 N. Our PhilosophyEmergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. In some hospitals, increased ED visit volume has resulted in ED crowding and increased wait times for minor and sometimes serious problems, such as myocardial infarction (3a€“7). In 2009, emergency department wait time referred to wait time to see a physician, physician assistant, or nurse practitioner; prior to 2009, emergency department wait time referred to wait time to see a physician.
The difference in mean wait time by hospital location among EDs that did not board was not statistically significant. Among EDs that did not board patients, EDs with less than 20,000 annual visits had shorter wait times than those with more than 20,000 annual visits; but there was no difference in wait times for EDs with 20,000a€“49,999 visits and those with 50,000 or more visits. Similarly, there were no differences in wait times for ED patients triaged as immediate or emergent by whether the ED boarded any admitted patients. Consistent with previous research, longer wait time for treatment was associated with urban ED locations (inside metropolitan statistical areas) and with increased annual ED visit volume (6).
EDs that boarded admitted patients inside the ED, in observation units, or outside the ED (in hallways) were also associated with longer wait times compared with EDs that did not board. The mean wait time in EDs for which boarding was unknown was also similar to the mean wait time in EDs that boarded patients inside or outside the ED. There was also no difference in wait time for patients triaged as immediate or emergent by whether the ED boarded patients. Differences in average wait times for treatment by ED and patient visit characteristics were examined using t tests for differences at the 0.05 level. National Hospital Ambulatory Medical Care Survey: 2009 emergency department summary tables. Episodes of weakness are accompanied by hypokalemia, which left untreated can lead to life-threatening arrhythmias (6). He had been recently diagnosed with hyperthyroidism 10 days prior, after presenting with 4 months of palpitations, muscle pain, cramping, and stiffness.


However, the patient’s airway was never compromised because his respiratory muscles were always intact. Symptoms resolved, along with the seen ECG changes, with cautious potassium repletion and control of the underlying thyrotoxicosis. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response.
Poisoning can occur if you eat the leaves of this plant. This is for information only and not for use in the treatment or management of an actual poison exposure. This report describes the recent trend in wait times for treatment in EDs, and focuses on how wait times for treatment varied by two ED crowding measures: ambulance diversions and boarding of admitted patients. In this analysis, mean wait times for treatment did not differ among urban EDs that went on ambulance diversion during the previous year, but mean wait times were longer among urban EDs and nonurban EDs with no ambulance diversions and with unknown ambulance diversion status.
Figures 3 and 4 further indicate that ED visits missing information on ambulance diversions were all located in urban EDs and in EDs with annual visit volumes of 20,000 or more. Hospital emergency departments: Crowding continues to occur, and some patients wait longer than recommended time frames.
In this case study, we followed a patient’s potassium levels analyzing how they correlate with electrocardiogram changes seen while treating his hypokalemia and ultimately his paralysis.
The paralytic attack was aborted with a combination of cautious potassium replacement, methimazole and parenteral propranolol.
This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. Among EDs that boarded admitted patients (either inside or outside ED spaces), mean wait times were longer in EDs with annual visit volumes of 20,000 or more. The long mean wait times for visits in EDs missing information on ambulance diversions, as well as the high percentage (71%) that also reported boarding admitted patients, suggest that these EDs may have been on ambulance diversion.
The median wait time to see a physician (33 minutes) was also not affected by the wording change in NHAMCS. After resolution of his original symptoms, he stopped taking the medications and presented to the ED with complete paralysis of his lower extremities. The initial electrocardiogram (ECG) showed 1st degree heart block with prominent U waves (Figure 1). The patient received initial doses of potassium chloride 10 mEq intravenously and 40 mEq orally. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health. In this report, wait times were not presented for visits not seen by a physician, physician assistant, or nurse practitioner (4.1%). Subsequently, the PR interval was noted to shorten and the rhythm returned to normal sinus (Figure 3).



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