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Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine: a health records review
  1. Valerie Charbonneau1,
  2. Edmund Kwok1,
  3. Loree Boyle2,
  4. Ian G Stiell1,3
  1. 1 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
  2. 2 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  3. 3 Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Dr Valerie Charbonneau, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, Ontario K1Y 4E9, Canada; vcharbonneau{at}


Background The goal of this study was to determine if ED surge and end-of-shift assessment of patients affect the extent of diagnostic tests, therapeutic interventions and accuracy of diagnosis prior to referral to internal medicine.

Methods This study was a health records review of consecutive patients referred to the internal medicine service with an ED diagnosis of heart failure, chronic obstructive pulmonary disease (COPD) or sepsis starting 1 December 2013 until 100 cases for each condition had been obtained. We developed a scoring system in consultation with emergency and internal medicine physicians to uniformly assess the completeness of treatments and investigations performed. These scores, expressed as percentage of possible points, were compared at high and low surge levels and at middle and end of shift at time of patient referral. End of shift was defined as 7:30–8:30, 15:30–16:30 and 23:30–00:30 as our shift changes occur at 8:00, 16:00 and 24:00. Rate of admission, diversion to other services and diagnosis disagreements were also assessed.

Results We included 308 patients (101 heart failure, 101 COPD, 106 sepsis) with a mean age of 74.7. Comparing middle of shift to end of shift, the mean scores were 91.9% versus 91.8% (difference 0.1% (95% CI −2.4 to 3.0)) for investigations and 73.0% versus 70.4% (difference 2.6% (95% CI −1.8 to 7.4)) for treatments. Comparing low to high surge times, the mean scores were 92.1% versus 91.7% (difference 0.4% (95% CI −1.2 to 2.4)) for investigations and 71.4% versus 73.6% (difference −2.2% (95% CI −5.6 to 1.3)) for treatments. We found low rates of diversion to alternate services (8.9% heart failure, 0% COPD, 6.6% sepsis) and low rates of diagnosis disagreement (4.0% heart failure, 10.9% COPD, 8.5% sepsis).

Conclusions We found no evidence that surge levels and end of shift impact the extent of investigations and treatments provided to patients diagnosed in the ED with heart failure, COPD or sepsis and referred to internal medicine.

  • emergency department
  • crowding
  • heart failure
  • COPD
  • sepsis

Statistics from


  • Contributors EK and VC conceived the idea. IGS designed the study and oversaw statistical analysis and management of data. LB assisted in the design of the study. VC performed data collection and analysis. All authors supervised the conduct of the trial and data collection, drafted the manuscript and/or contributed to its revision, and approved the final version. IGS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding We acknowledge funding from the Department of Emergency Medicine.

  • Competing interests IGS holds a Distinguished Professorship and University Health Research Chair from the University of Ottawa.

  • Patient consent Not required.

  • Ethics approval Ottawa Health Sciences Network Ethics Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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