Public health and clinical impact of increasing emergency department-based HIV testing: perspectives from the 2007 conference of the National Emergency Department HIV Testing Consortium.

PubMed

Kecojevic, Aleksandar; Lindsell, Christopher J; Lyons, Michael S; Holtgrave, David; Torres, Gretchen; Heffelfinger, James; Brown, Jeremy; Couture, Eileen; Jung, Julianna; Connell, Samantha; Rothman, Richard E

2011-07-01

Understanding perceived benefits and disadvantages of HIV testing in emergency departments (EDs) is imperative to overcoming barriers to implementation. We codify those domains of public health and clinical care most affected by implementing HIV testing in EDs, as determined by expert opinion. Opinions were systematically collected from attendees of the 2007 National ED HIV Testing Consortium meeting. Structured evaluation of strengths, weaknesses, opportunities, and threats analysis was conducted to assess the impact of ED-based HIV testing on public health. A modified Delphi method was used to assess the impact of ED-based HIV testing on clinical care from both individual patient and individual provider perspectives. Opinions were provided by 98 experts representing 42 academic and nonacademic institutions. Factors most frequently perceived to affect public health were (strengths) high volume of ED visits and high prevalence of HIV, (weaknesses) undue burden on EDs, (opportunities) reduction of HIV stigma, and (threats) lack of resources in EDs. Diagnostic testing and screening for HIV were considered to have a favorable impact on ED clinical care from both individual patient and individual provider perspectives; however, negative test results were not perceived to have any benefit from the provider's perspective. The need for HIV counseling in the ED was considered to have a negative impact on clinical care from the provider's perspective. Experts in ED-based HIV testing perceived expanded ED HIV testing to have beneficial impacts for both the public health and individual clinical care; however, limited resources were frequently cited as a possible impediment. Many issues must be resolved through further study, education, and policy changes if the full potential of HIV testing in EDs is to be realized. Copyright © 2011. Published by Mosby, Inc.

Utilization of Failure Mode and Effects Analysis (FMEA) Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study.

PubMed

Shahrami, Ali; Rahmati, Farhad; Kariman, Hamid; Hashemi, Behrooz; Rahmati, Majid; Baratloo, Alireza; Forouzanfar, Mohammad Mehdi; Safari, Saeed

2013-01-01

The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (p<0.001). 111.0% increase in the ED revenue after solving of first priority problems revealed that they were extremely indispensable in decreasing the revenue (p<0.0001). The findings of the present study revealed that FMEA could be considered as an efficient model for increasing the revenue of emergency department. According to this model, not recording the services by the nursing unit, and lack of specific identifying code for the patients moving from ED to any other department, were the two first priority problems in decreasing our ED revenue.

Validation of a Syndromic Case Definition for Detecting Emergency Department Visits Potentially Related to Marijuana.

PubMed

DeYoung, Kathryn; Chen, Yushiuan; Beum, Robert; Askenazi, Michele; Zimmerman, Cali; Davidson, Arthur J

Reliable methods are needed to monitor the public health impact of changing laws and perceptions about marijuana. Structured and free-text emergency department (ED) visit data offer an opportunity to monitor the impact of these changes in near-real time. Our objectives were to (1) generate and validate a syndromic case definition for ED visits potentially related to marijuana and (2) describe a method for doing so that was less resource intensive than traditional methods. We developed a syndromic case definition for ED visits potentially related to marijuana, applied it to BioSense 2.0 data from 15 hospitals in the Denver, Colorado, metropolitan area for the period September through October 2015, and manually reviewed each case to determine true positives and false positives. We used the number of visits identified by and the positive predictive value (PPV) for each search term and field to refine the definition for the second round of validation on data from February through March 2016. Of 126 646 ED visits during the first period, terms in 524 ED visit records matched ≥1 search term in the initial case definition (PPV, 92.7%). Of 140 932 ED visits during the second period, terms in 698 ED visit records matched ≥1 search term in the revised case definition (PPV, 95.7%). After another revision, the final case definition contained 6 keywords for marijuana or derivatives and 5 diagnosis codes for cannabis use, abuse, dependence, poisoning, and lung disease. Our syndromic case definition and validation method for ED visits potentially related to marijuana could be used by other public health jurisdictions to monitor local trends and for other emerging concerns.

Frequent methamphetamine injection predicts emergency department utilization among street-involved youth

PubMed Central

Marshall, B.D.L.; Grafstein, E.; Buxton, J.A.; Qi, J.; Wood, E.; Shoveller, J.A.; Kerr, T.

2011-01-01

SUMMARY Objectives Methamphetamine (MA) use has been associated with health problems that commonly present in the emergency department (ED). This study sought to determine whether frequent MA injection was a risk factor for ED utilization among street-involved youth. Study design Prospective cohort study. Methods Data were derived from a street-involved youth cohort known as the ‘At Risk Youth Study’. Behavioural data including MA use were linked to ED records at a major inner-city hospital. Kaplan-Meier and Cox proportional hazards methods were used to determine the risk factors for ED utilization. Results Between September 2005 and January 2007, 427 eligible participants were enrolled, among whom the median age was 21 (interquartile range 19–23) years and 154 (36.1%) were female. Within 1 year, 163 (38.2%) visited the ED, resulting in an incidence density of 53.7 per 100 person-years. ED utilization was significantly higher among frequent (i.e. ≥daily) MA injectors (log-rank P=0.004). In multivariate analysis, frequent MA injection was associated with an increased hazard of ED utilization (adjusted hazard ratio=1.84, 95% confidence interval 1.04–3.25; P=0.036). Conclusions Street-involved youth who frequently inject MA appear to be at increased risk of ED utilization. The integration of MA-specific addiction treatment services within emergency care settings for high-risk youth is recommended. PMID:22133669

Child, Caregiver, and Family Characteristics Associated with Emergency Department Use by Children Who Remain at Home after a Child Protective Services Investigation

ERIC Educational Resources Information Center

Schneiderman, Janet U.; Hurlburt, Michael S.; Leslie, Laurel K.; Zhang, Jinjin; Horwitz, Sarah McCue

2012-01-01

Objectives: To examine emergency department (ED) use among children involved with child protective services (CPS) in the US but who remain at home, and to determine if ED use is related to child, caregiver and family characteristics as well as receipt of CPS services. Method: We analyzed data on 4,001 children in the National Survey of Child and…

Forecasting daily patient volumes in the emergency department.

PubMed

Jones, Spencer S; Thomas, Alun; Evans, R Scott; Welch, Shari J; Haug, Peter J; Snow, Gregory L

2008-02-01

Shifts in the supply of and demand for emergency department (ED) resources make the efficient allocation of ED resources increasingly important. Forecasting is a vital activity that guides decision-making in many areas of economic, industrial, and scientific planning, but has gained little traction in the health care industry. There are few studies that explore the use of forecasting methods to predict patient volumes in the ED. The goals of this study are to explore and evaluate the use of several statistical forecasting methods to predict daily ED patient volumes at three diverse hospital EDs and to compare the accuracy of these methods to the accuracy of a previously proposed forecasting method. Daily patient arrivals at three hospital EDs were collected for the period January 1, 2005, through March 31, 2007. The authors evaluated the use of seasonal autoregressive integrated moving average, time series regression, exponential smoothing, and artificial neural network models to forecast daily patient volumes at each facility. Forecasts were made for horizons ranging from 1 to 30 days in advance. The forecast accuracy achieved by the various forecasting methods was compared to the forecast accuracy achieved when using a benchmark forecasting method already available in the emergency medicine literature. All time series methods considered in this analysis provided improved in-sample model goodness of fit. However, post-sample analysis revealed that time series regression models that augment linear regression models by accounting for serial autocorrelation offered only small improvements in terms of post-sample forecast accuracy, relative to multiple linear regression models, while seasonal autoregressive integrated moving average, exponential smoothing, and artificial neural network forecasting models did not provide consistently accurate forecasts of daily ED volumes. This study confirms the widely held belief that daily demand for ED services is characterized by seasonal and weekly patterns. The authors compared several time series forecasting methods to a benchmark multiple linear regression model. The results suggest that the existing methodology proposed in the literature, multiple linear regression based on calendar variables, is a reasonable approach to forecasting daily patient volumes in the ED. However, the authors conclude that regression-based models that incorporate calendar variables, account for site-specific special-day effects, and allow for residual autocorrelation provide a more appropriate, informative, and consistently accurate approach to forecasting daily ED patient volumes.

Methods for calculating dietary energy density in a nationally representative sample

PubMed Central

Vernarelli, Jacqueline A.; Mitchell, Diane C.; Rolls, Barbara J.; Hartman, Terryl J.

2013-01-01

There has been a growing interest in examining dietary energy density (ED, kcal/g) as it relates to various health outcomes. Consuming a diet low in ED has been recommended in the 2010 Dietary Guidelines, as well as by other agencies, as a dietary approach for disease prevention. Translating this recommendation into practice; however, is difficult. Currently there is no standardized method for calculating dietary ED; as dietary ED can be calculated with foods alone, or with a combination of foods and beverages. Certain items may be defined as either a food or a beverage (e.g., meal replacement shakes) and require special attention. National survey data are an excellent resource for evaluating factors that are important to dietary ED calculation. The National Health and Nutrition Examination Survey (NHANES) nutrient and food database does not include an ED variable, thus researchers must independently calculate ED. The objective of this study was to provide information that will inform the selection of a standardized ED calculation method by comparing and contrasting methods for ED calculation. The present study evaluates all consumed items and defines foods and beverages based on both USDA food codes and how the item was consumed. Results are presented as mean EDs for the different calculation methods stratified by population demographics (e.g. age, sex). Using United State Department of Agriculture (USDA) food codes in the 2005–2008 NHANES, a standardized method for calculating dietary ED can be derived. This method can then be adapted by other researchers for consistency across studies. PMID:24432201

Effects of emergency department expansion on emergency department patient flow.

PubMed

Mumma, Bryn E; McCue, James Y; Li, Chin-Shang; Holmes, James F

2014-05-01

Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. The mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding. © 2014 by the Society for Academic Emergency Medicine.

Emergency Department Length of Stay: Accuracy of Patient Estimates

PubMed Central

Parker, Brendan T.; Marco, Catherine

2014-01-01

Introduction Managing a patient’s expectations in the emergency department (ED) environment is challenging. Previous studies have identified several factors associated with ED patient satisfaction. Lengthy wait times have shown to be associated with dissatisfaction with ED care. Understanding that patients are inaccurate at their estimation of wait time, which could lead to lower satisfaction, provides administrators possible points of intervention to help improve accuracy of estimation and possibly satisfaction with the ED. This study was undertaken to examine the accuracy of patient estimates of time periods in an ED and identify factors associated with accuracy. Method In this prospective convenience sample survey at UTMC ED, we collected data between March and July 2012. Outcome measures included duration of each phase of ED care and patient estimates of these time periods. Results Among 309 participants, the majority underestimated the total length of stay (LOS) in the ED (median difference −7 minutes (IQR −29-12)). There was significant variability in ED LOS (median 155 minutes (IQR 75–240)). No significant associations were identified between accuracy of time estimates and gender, age, race, or insurance status. Participants with longer ED LOS demonstrated lower patient satisfaction scores (p<0.001). Conclusion Patients demonstrated inaccurate time estimates of ED treatment times, including total LOS. Patients with longer ED LOS had lower patient satisfaction scores. PMID:24672606

Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department.

PubMed

Crisp, Jonathan G; Lovato, Luis M; Jang, Timothy B

2010-12-01

Compression ultrasonography of the lower extremity is an established method of detecting proximal lower extremity deep venous thrombosis when performed by a certified operator in a vascular laboratory. Our objective is to determine the sensitivity and specificity of bedside 2-point compression ultrasonography performed in the emergency department (ED) with portable vascular ultrasonography for the detection of proximal lower extremity deep venous thrombosis. We did this by directly comparing emergency physician-performed ultrasonography to lower extremity duplex ultrasonography performed by the Department of Radiology. This was a prospective, cross-sectional study and diagnostic test assessment of a convenience sample of ED patients with a suspected lower extremity deep venous thrombosis, conducted at a single-center, urban, academic ED. All physicians had a 10-minute training session before enrolling patients. ED compression ultrasonography occurred before Department of Radiology ultrasonography and involved identification of 2 specific points: the common femoral and popliteal vessels, with subsequent compression of the common femoral and popliteal veins. The study result was considered positive for proximal lower extremity deep venous thrombosis if either vein was incompressible or a thrombus was visualized. Sensitivity and specificity were calculated with the final radiologist interpretation of the Department of Radiology ultrasonography as the criterion standard. A total of 47 physicians performed 199 2-point compression ultrasonographic examinations in the ED. Median number of examinations per physician was 2 (range 1 to 29 examinations; interquartile range 1 to 5 examinations). There were 45 proximal lower extremity deep venous thromboses observed on Department of Radiology evaluation, all correctly identified by ED 2-point compression ultrasonography. The 153 patients without proximal lower extremity deep venous thrombosis all had a negative ED compression ultrasonographic result. One patient with a negative Department of Radiology ultrasonographic result was found to have decreased compression of the popliteal vein on ED compression ultrasonography, giving a single false-positive result, yet repeated ultrasonography by the Department of Radiology 1 week later showed a popliteal deep venous thrombosis. The sensitivity and specificity of ED 2-point compression ultrasonography for deep venous thrombosis were 100% (95% confidence interval 92% to 100%) and 99% (95% confidence interval 96% to 100%), respectively. Emergency physician-performed 2-point compression ultrasonography of the lower extremity with a portable vascular ultrasonographic machine, conducted in the ED by this physician group and in this patient sample, accurately identified the presence and absence of proximal lower extremity deep venous thrombosis. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Load Balancing at Emergency Departments using ‘Crowdinforming’

PubMed Central

Friesen, Marcia R; Strome, Trevor; Mukhi, Shamir; McLoed, Robert

2011-01-01

Background: Emergency Department (ED) overcrowding is an important healthcare issue facing increasing public and regulatory scrutiny in Canada and around the world. Many approaches to alleviate excessive waiting times and lengths of stay have been studied. In theory, optimal ED patient flow may be assisted via balancing patient loads between EDs (in essence spreading patients more evenly throughout this system). This investigation utilizes simulation to explore “Crowdinforming” as a basis for a process control strategy aimed to balance patient loads between six EDs within a mid-sized Canadian city. Methods: Anonymous patient visit data comprising 120,000 ED patient visits over six months to six ED facilities were obtained from the region’s Emergency Department Information System (EDIS) to (1) determine trends in ED visits and interactions between parameters; (2) to develop a process control strategy integrating crowdinforming; and, (3) apply and evaluate the model in a simulated environment to explore the potential impact on patient self-redirection and load balancing between EDs. Results: As in reality, the data available and subsequent model demonstrated that there are many factors that impact ED patient flow. Initial results suggest that for this particular data set used, ED arrival rates were the most useful metric for ED ‘busyness’ in a process control strategy, and that Emergency Department performance may benefit from load balancing efforts. Conclusions: The simulation supports the use of crowdinforming as a potential tool when used in a process control strategy to balance the patient loads between EDs. The work also revealed that the value of several parameters intuitively expected to be meaningful metrics of ED ‘busyness’ was not evident, highlighting the importance of finding parameters meaningful within one’s particular data set. The information provided in the crowdinforming model is already available in a local context at some ED sites. The extension to a wider dissemination of information via an Internet web service accessible by smart phones is readily achievable and not a technological obstacle. Similarly, the system could be extended to help direct patients by including future estimates or predictions in the crowdinformed data. The contribution of the simulation is to allow for effective policy evaluation to better inform the public of ED ‘busyness’ as part of their decision making process in attending an emergency department. In effect, this is a means of providing additional decision support insights garnered from a simulation, prior to a real world implementation. PMID:23569610

Variable Access to Immediate Bedside Ultrasound in the Emergency Department

PubMed Central

Talley, Brad E.; Ginde, Adit A.; Raja, Ali S.; Sullivan, Ashley F.; Espinola, Janice A.; Camargo, Carlos A.

2011-01-01

Objective: Use of bedside emergency department (ED) ultrasound has become increasingly important for the clinical practice of emergency medicine (EM). We sought to evaluate differences in the availability of immediate bedside ultrasound based on basic ED characteristics and physician staffing. Methods: We surveyed ED directors in all 351 EDs in Colorado, Georgia, Massachusetts, and Oregon between January and April 2009. We assessed access to bedside ED ultrasound by the question: “Is bedside ultrasound available immediately in the ED?” ED characteristics included location, visit volume, admission rate, percent uninsured, total emergency physician full-time equivalents and proportion of EM board-certified (BC) or EM board-eligible (BE) physicians. Data analysis used chi-square tests and multivariable logistical regression to compare differences in access to bedside ED ultrasound by ED characteristics and staffing. Results: We received complete responses from 298 (85%) EDs. Immediate access to bedside ultrasound was available in 175 (59%) EDs. ED characteristics associated with access to bedside ultrasound were: location (39% for rural vs. 71% for urban, P<0.001); visit volume (34% for EDs with low volume [<1 patient/hour] vs. 79% for EDs with high volume [≥3 patients/hour], P<0.001); admission rate (39% for EDs with low [0–10%] admission rates vs. 84% for EDs with high [>20%] rates, P<0.001); and EM BC/BE physicians (26% for EDs with a low percentage [0–20%] vs.74% for EDs with a high percentage [≥80%], P<0.001). Conclusion: U.S. EDs differ significantly in their access to immediate bedside ultrasound. Smaller, rural EDs and those staffed by fewer EM BC/BE physicians more frequently lacked access to immediate bedside ultrasound in the ED. PMID:21691479

Patient flow within UK emergency departments: a systematic review of the use of computer simulation modelling methods

PubMed Central

Mohiuddin, Syed; Busby, John; Savović, Jelena; Richards, Alison; Northstone, Kate; Hollingworth, William; Donovan, Jenny L; Vasilakis, Christos

2017-01-01

Objectives Overcrowding in the emergency department (ED) is common in the UK as in other countries worldwide. Computer simulation is one approach used for understanding the causes of ED overcrowding and assessing the likely impact of changes to the delivery of emergency care. However, little is known about the usefulness of computer simulation for analysis of ED patient flow. We undertook a systematic review to investigate the different computer simulation methods and their contribution for analysis of patient flow within EDs in the UK. Methods We searched eight bibliographic databases (MEDLINE, EMBASE, COCHRANE, WEB OF SCIENCE, CINAHL, INSPEC, MATHSCINET and ACM DIGITAL LIBRARY) from date of inception until 31 March 2016. Studies were included if they used a computer simulation method to capture patient progression within the ED of an established UK National Health Service hospital. Studies were summarised in terms of simulation method, key assumptions, input and output data, conclusions drawn and implementation of results. Results Twenty-one studies met the inclusion criteria. Of these, 19 used discrete event simulation and 2 used system dynamics models. The purpose of many of these studies (n=16; 76%) centred on service redesign. Seven studies (33%) provided no details about the ED being investigated. Most studies (n=18; 86%) used specific hospital models of ED patient flow. Overall, the reporting of underlying modelling assumptions was poor. Nineteen studies (90%) considered patient waiting or throughput times as the key outcome measure. Twelve studies (57%) reported some involvement of stakeholders in the simulation study. However, only three studies (14%) reported on the implementation of changes supported by the simulation. Conclusions We found that computer simulation can provide a means to pretest changes to ED care delivery before implementation in a safe and efficient manner. However, the evidence base is small and poorly developed. There are some methodological, data, stakeholder, implementation and reporting issues, which must be addressed by future studies. PMID:28487459

Emergency Department Overcrowding and Ambulance Turnaround Time

PubMed Central

Lee, Yu Jin; Shin, Sang Do; Lee, Eui Jung; Cho, Jin Seong; Cha, Won Chul

2015-01-01

Objective The aims of this study were to describe overcrowding in regional emergency departments in Seoul, Korea and evaluate the effect of crowdedness on ambulance turnaround time. Methods This study was conducted between January 2010 and December 2010. Patients who were transported by 119-responding ambulances to 28 emergency centers within Seoul were eligible for enrollment. Overcrowding was defined as the average occupancy rate, which was equal to the average number of patients staying in an emergency department (ED) for 4 hours divided by the number of beds in the ED. After selecting groups for final analysis, multi-level regression modeling (MLM) was performed with random-effects for EDs, to evaluate associations between occupancy rate and turnaround time. Results Between January 2010 and December 2010, 163,659 patients transported to 28 EDs were enrolled. The median occupancy rate was 0.42 (range: 0.10-1.94; interquartile range (IQR): 0.20-0.76). Overcrowded EDs were more likely to have older patients, those with normal mentality, and non-trauma patients. Overcrowded EDs were more likely to have longer turnaround intervals and traveling distances. The MLM analysis showed that an increase of 1% in occupancy rate was associated with 0.02-minute decrease in turnaround interval (95% CI: 0.01 to 0.03). In subgroup analyses limited to EDs with occupancy rates over 100%, we also observed a 0.03 minute decrease in turnaround interval per 1% increase in occupancy rate (95% CI: 0.01 to 0.05). Conclusions In this study, we found wide variation in emergency department crowding in a metropolitan Korean city. Our data indicate that ED overcrowding is negatively associated with turnaround interval with very small practical significance. PMID:26115183

Evaluating the Relationship between Productivity and Quality in Emergency Departments

PubMed Central

Bastian, Nathaniel D.; Riordan, John P.

2017-01-01

Background In the United States, emergency departments (EDs) are constantly pressured to improve operational efficiency and quality in order to gain financial benefits and maintain a positive reputation. Objectives The first objective is to evaluate how efficiently EDs transform their input resources into quality outputs. The second objective is to investigate the relationship between the efficiency and quality performance of EDs and the factors affecting this relationship. Methods Using two data sources, we develop a data envelopment analysis (DEA) model to evaluate the relative efficiency of EDs. Based on the DEA result, we performed multinomial logistic regression to investigate the relationship between ED efficiency and quality performance. Results The DEA results indicated that the main source of inefficiencies was working hours of technicians. The multinomial logistic regression result indicated that the number of electrocardiograms and X-ray procedures conducted in the ED and the length of stay were significantly associated with the trade-offs between relative efficiency and quality. Structural ED characteristics did not influence the relationship between efficiency and quality. Conclusions Depending on the structural and operational characteristics of EDs, different factors can affect the relationship between efficiency and quality. PMID:29065673

When Health Insurance Is Not a Factor: National Comparison of Homeless and Nonhomeless US Veterans Who Use Veterans Affairs Emergency Departments

PubMed Central

Doran, Kelly M.; Rosenheck, Robert A.

2013-01-01

Objectives. We examined the proportion of homeless veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally. Methods. We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n = 64 091) and nonhomeless (n = 866 621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics. Results. Homeless veterans had 4 times the odds of using EDs than nonhomeless veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.97, 4.27), alcohol use disorder (OR = 3.67; 95% CI = 3.55, 3.79), or schizophrenia (OR = 3.44; 95% CI = 3.25, 3.64) in the past year. Conclusions. In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or “in” reach) services to address mental health and addictive disorders. PMID:24148061

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data.

PubMed

Kim, Hyunjee; McConnell, K John; Sun, Benjamin C

2017-08-01

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.

Emergency Department Crowding and Outcomes After Emergency Department Discharge

PubMed Central

Gabayan, Gelareh Z.; Derose, Stephen F.; Chiu, Vicki Y.; Yiu, Sau C.; Sarkisian, Catherine A.; Jones, Jason P.; Sun, Benjamin C.

2015-01-01

Study objective We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge. Methods We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure. Results The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes. Conclusion Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients. PMID:26003004

Overcoming Barriers to the Use of Osteopathic Manipulation Techniques in the Emergency Department

PubMed Central

Roberge, Raymond J.; Roberge, Marc R.

2009-01-01

Background: Osteopathic Manipulation Techniques (OMT) have been shown to be effective therapeutic modalities in various clinical settings, but appear to be underutilized in the emergency department (ED) setting. Objective: To examine barriers to the use of OMT in the ED and provide suggestions to ameliorate these barriers. Methods: Literature review Results: While the medical literature cites numerous obstacles to the use of OMT in the ED setting, most can be positively addressed through education, careful planning, and ongoing research into use of these techniques. Recent prospective clinical trials of OMT have demonstrated the utility of these modalities. Conclusion: Osteopathic Manipulation Techniques are useful therapeutic modalities that could be utilized to a greater degree in the ED. As the number of osteopathic emergency physicians increases, the opportunity to employ these techniques should increase. PMID:19718381

Observational studies of patients in the emergency department: a comparison of 4 sampling methods.

PubMed

Valley, Morgan A; Heard, Kennon J; Ginde, Adit A; Lezotte, Dennis C; Lowenstein, Steven R

2012-08-01

We evaluate the ability of 4 sampling methods to generate representative samples of the emergency department (ED) population. We analyzed the electronic records of 21,662 consecutive patient visits at an urban, academic ED. From this population, we simulated different models of study recruitment in the ED by using 2 sample sizes (n=200 and n=400) and 4 sampling methods: true random, random 4-hour time blocks by exact sample size, random 4-hour time blocks by a predetermined number of blocks, and convenience or "business hours." For each method and sample size, we obtained 1,000 samples from the population. Using χ(2) tests, we measured the number of statistically significant differences between the sample and the population for 8 variables (age, sex, race/ethnicity, language, triage acuity, arrival mode, disposition, and payer source). Then, for each variable, method, and sample size, we compared the proportion of the 1,000 samples that differed from the overall ED population to the expected proportion (5%). Only the true random samples represented the population with respect to sex, race/ethnicity, triage acuity, mode of arrival, language, and payer source in at least 95% of the samples. Patient samples obtained using random 4-hour time blocks and business hours sampling systematically differed from the overall ED patient population for several important demographic and clinical variables. However, the magnitude of these differences was not large. Common sampling strategies selected for ED-based studies may affect parameter estimates for several representative population variables. However, the potential for bias for these variables appears small. Copyright © 2012. Published by Mosby, Inc.

Summertime Acute Heat Illness in U.S. Emergency Departments from 2006 through 2010: Analysis of a Nationally Representative Sample

PubMed Central

Saha, Shubhayu; Luber, George

2014-01-01

Background: Patients with acute heat illness present primarily to emergency departments (EDs), yet little is known regarding these visits. Objective: We aimed to describe acute heat illness visits to U.S. EDs from 2006 through 2010 and identify factors associated with hospital admission or with death in the ED. Methods: We extracted ED case-level data from the Nationwide Emergency Department Sample (NEDS) for 2006–2010, defining cases as ED visits from May through September with any heat illness diagnosis (ICD-9-CM 992.0–992.9). We correlated visit rates and temperature anomalies, analyzed demographics and ED disposition, identified risk factors for adverse outcomes, and examined ED case fatality rates (CFR). Results: There were 326,497 (95% CI: 308,372, 344,658) cases, with 287,875 (88.2%) treated and released, 38,392 (11.8%) admitted, and 230 (0.07%) died in the ED. Heat illness diagnoses were first-listed in 68%. 74.7% had heat exhaustion, 5.4% heat stroke. Visit rates were highly correlated with annual temperature anomalies (Pearson correlation coefficient 0.882, p = 0.005). Treat-and-release rates were highest for younger adults (26.2/100,000/year), whereas hospitalization and death-in-the-ED rates were highest for older adults (6.7 and 0.03/100,000/year, respectively); all rates were highest in rural areas. Heat stroke had an ED CFR of 99.4/10,000 (95% CI: 78.7, 120.1) visits and was diagnosed in 77.0% of deaths. Adjusted odds of hospital admission or death in the ED were higher among elders, males, urban and low-income residents, and those with chronic conditions. Conclusions: Heat illness presented to the ED frequently, with highest rates in rural areas. Case definitions should include all diagnoses. Visit rates were correlated with temperature anomalies. Heat stroke had a high ED CFR. Males, elders, and the chronically ill were at greatest risk of admission or death in the ED. Chronic disease burden exponentially increased this risk. Citation: Hess JJ, Saha S, Luber G. 2014. Summertime acute heat illness in U.S. emergency departments from 2006 through 2010: analysis of a nationally representative sample. Environ Health Perspect 122:1209–1215; http://dx.doi.org/10.1289/ehp.1306796 PMID:24937159

System Level Health Disparities in California Emergency Departments: Minorities and Medicaid Patients are at Higher Risk of Losing Their EDs

PubMed Central

Hsia, Renee Y.; Srebotnjak, Tanja; Kanzaria, Hemal K.; McCulloch, Charles; Auerbach, Andrew D.

2015-01-01

Study Objective Emergency Department (ED) closures threaten community access to emergency services, but few data exist to describe factors associated with closure. We evaluated factors associated with ED closure in California and sought to determine if hospitals serving more vulnerable populations have a higher rate of ED closure. Methods Retrospective cohort study of California hospital EDs between 1998 and 2008, using hospital and patient level data from the California Office of Statewide Planning and Development (OSHPD), as well as OSHPD Patient Discharge Data. We examined the effects of hospital and patient factors on the hospital's likelihood of ED closure using Cox proportional hazards models. Results In 4,411 hospital-years of observation, 29 of 401 (7.2%) EDs closed. In a model adjusted for total ED visits, hospital discharges, trauma center and teaching status, ownership, operating margin, and urbanicity, hospitals with more black patients (OR 1.41 per increase in proportion of blacks by 0.1, 95% CI 1.16-1.72) and Medi-Cal recipients (OR 1.17 per increase in proportion insured by Medi-Cal by 0.1, 95% CI 1.02-1.34) had higher odds for ED closure, as did for-profit institutions (OR 1.65, 95% CI 1.13-2.41). Conclusion The population served by EDs and hospitals’ profit model are associated with ED closure. Whether our findings are a manifestation of poorer reimbursement in at-risk EDs is unclear. PMID:22093435

Emergency department utilization and subsequent prescription drug overdose death

PubMed Central

Brady, Joanne E.; DiMaggio, Charles J.; Keyes, Katherine M.; Doyle, John J.; Richardson, Lynne D.; Li, Guohua

2015-01-01

Purpose Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. Methods Using data from the New York Statewide Planning and Research Cooperative System for 2006–2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18–64 years and subsequent PDO death. Results The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50–5.34) for those with two ED visits, 16.61 (95% CI: 14.72–18.75) for those with three ED visits, and 48.24 (95% CI: 43.23–53.83) for those with four ED visits or more. Conclusions Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality. PMID:25935710

LQAS usefulness in an emergency department.

PubMed

de la Orden, Susana Granado; Rodríguez-Rieiro, Cristina; Sánchez-Gómez, Amaya; García, Ana Chacón; Hernández-Fernández, Tomás; Revilla, Angel Abad; Escribano, Dolores Vigil; Pérez, Paz Rodríguez

2008-01-01

This paper aims to explore lot quality assurance sampling (LQAS) applicability and usefulness in the evaluation of quality indicators in a hospital emergency department (ED) and to determine the degree of compliance with quality standards according to this sampling method. Descriptive observational research in the Hospital General Universitario Gregorio Marañón (HGUGM) emergency department (ED). Patients older than 15 years, diagnosed with dyspnoea, chest pain, urinary tract colic or bronchial asthma attending the HGUGM ED from December 2005 to May 2006, and patients admitted during 2005 with exacerbation of chronic obstructive pulmonary disease or acute meningitis were included in the study. Sample sizes were calculated using LQAS. Different quality indicators, one for each process, were selected. The upper (acceptable quality level (AQL)) and lower thresholds (rejectable quality level (RQL)) were established considering risk alpha = 5 per cent and beta = 20 per cent, and the minimum number of observations required was calculated. It was impossible to reach the necessary sample size for bronchial asthma and urinary tract colic patients. For chest pain, acute exacerbation of chronic obstructive pulmonary disease, and acute meningitis, quality problems were detected. The lot was accepted only for the dyspnoea indicator. The usefulness of LQAS to detect quality problems in the management of health processes in one hospital's ED. The LQAS could complement traditional sampling methods.

Low Caregiver Health Literacy is Associated with Higher Pediatric Emergency Department Use and Non-urgent Visits

PubMed Central

Morrison, Andrea K.; Schapira, Marilyn M.; Gorelick, Marc H.; Hoffmann, Raymond G.; Brousseau, David C.

2014-01-01

Objective We sought to determine the association between low caregiver health literacy and child emergency department (ED) use, both the number and urgency of ED visits. Methods This year long cross-sectional study utilized the Newest Vital Sign to measure the health literacy of caregivers accompanying children to a pediatric ED. Prior ED visits were extracted from a regional database. ED visit urgency was classified by resources utilized during the index ED visit. Regression analyses were used to model the outcomes: 1) prior ED visits and 2) ED visit urgency, stratified by chronic illness. Analyses were weighted by triage level. Results Overall, 503 caregivers completed the study; 55% demonstrated low health literacy. Children of caregivers with low health literacy had more prior ED visits (aIRR 1.5; 95% C.I.1.2, 1.8) and increased odds of a non-urgent index ED visit (AOR 2.4; 1.3, 4.4). Among children without chronic illness, low caregiver health literacy was associated with an increased proportion of non-urgent index ED visits (48% vs 22%; AOR 3.2; 1.8, 5.7). Conclusions Over half of caregivers presenting with their children to the ED have low health literacy. Low caregiver health literacy is an independent predictor of higher ED use and use of the ED for non-urgent conditions. In children without a chronic illness, low health literate caregivers had more than three times great odds of presenting for a non-urgent condition than those with adequate health literacy. PMID:24767784

Impact of clinical pharmacy services in a short stay unit of a hospital emergency department in Qatar.

PubMed

Abdelaziz, Hani; Al Anany, Rasha; Elmalik, Ashraf; Saad, Mohammad; Prabhu, Kirti; Al-Tamimi, Haleema; Salah, Salem Abu; Cameron, Peter

2016-08-01

Background The presence of a clinical pharmacist in a hospital's Emergency Department (ED) is important to decrease the potential for medication errors. To our knowledge, no previous studies have been conducted to evaluate the impact of implementing clinical pharmacy services in the ED in Qatar. Objective To characterize the contributions of clinical pharmacists in a short stay unit of ED in order to implement and scale-up the service to all ED areas in the future. Methods A retrospective study conducted for 7 months in the ED of Hamad General Hospital, Qatar. The intervention recommendations were made by clinical pharmacists to the physician in charge during medical rounds. Results A total of 824 documented pharmacist recommendations were analyzed. The interventions included the following: Providing information to the physician (24.4 %) and recommending medication discontinuation (22.0 %), dose adjustment (19.3 %), medication addition (16.0 %), changes in frequency of medications (7.6 %), medication resumption (5.7 %), and patient education (5.0 %). Conclusion Clinical pharmacists in the ED studied play an important role in patient care.

Epidemiology of Mental Health Attendances at Emergency Departments: Systematic Review and Meta-Analysis

PubMed Central

Rojas-García, Antonio; Clarke, Katherine; Moore, Anna; Whittington, Craig; Stockton, Sarah; Thomas, James; Pilling, Stephen; Raine, Rosalind

2016-01-01

Background The characteristics of Emergency Department (ED) attendances due to mental or behavioural health disorders need to be described to enable appropriate development of services. We aimed to describe the epidemiology of mental health-related ED attendances within health care systems free at the point of access, including clinical reason for presentation, previous service use, and patient sociodemographic characteristics. Method Systematic review and meta-analysis of observational studies describing ED attendances by patients with common mental health conditions. Findings 18 studies from seven countries met eligibility criteria. Patients attending due to mental or behavioural health disorders accounted for 4% of ED attendances; a third were due to self-harm or suicidal ideation. 58.1% of attendees had a history of psychiatric illness and up to 58% were admitted. The majority of studies were single site and of low quality so results must be interpreted cautiously. Conclusions Prevalence studies of mental health-related ED attendances are required to enable the development of services to meet specific needs. PMID:27120350

A multivariate time series approach to modeling and forecasting demand in the emergency department.

PubMed

Jones, Spencer S; Evans, R Scott; Allen, Todd L; Thomas, Alun; Haug, Peter J; Welch, Shari J; Snow, Gregory L

2009-02-01

The goals of this investigation were to study the temporal relationships between the demands for key resources in the emergency department (ED) and the inpatient hospital, and to develop multivariate forecasting models. Hourly data were collected from three diverse hospitals for the year 2006. Descriptive analysis and model fitting were carried out using graphical and multivariate time series methods. Multivariate models were compared to a univariate benchmark model in terms of their ability to provide out-of-sample forecasts of ED census and the demands for diagnostic resources. Descriptive analyses revealed little temporal interaction between the demand for inpatient resources and the demand for ED resources at the facilities considered. Multivariate models provided more accurate forecasts of ED census and of the demands for diagnostic resources. Our results suggest that multivariate time series models can be used to reliably forecast ED patient census; however, forecasts of the demands for diagnostic resources were not sufficiently reliable to be useful in the clinical setting.

Availability of mobile phones for discharge follow-up of pediatric Emergency Department patients in western Kenya

PubMed Central

Cheptinga, Philip; Rusyniak, Daniel E.

2015-01-01

Objective. Mobile phones have been successfully used for Emergency Department (ED) patient follow-up in developed countries. Mobile phones are widely available in developing countries and may offer a similar potential for follow-up and continued care of ED patients in low and middle-income countries. The goal of this study was to determine the percentage of families with mobile phones presenting to a pediatric ED in western Kenya and rate of response to a follow-up phone call after discharge. Methods. A prospective, cross-sectional observational study of children presenting to the emergency department of a government referral hospital in Eldoret, Kenya was performed. Documentation of mobile phone access, including phone number, was recorded. If families had access, consent was obtained and families were contacted 7 days after discharge for follow-up. Results. Of 788 families, 704 (89.3%) had mobile phone access. Of those families discharged from the ED, successful follow-up was made in 83.6% of cases. Conclusions. Mobile phones are an available technology for follow-up of patients discharged from a pediatric emergency department in resource-limited western Kenya. PMID:25780757

Availability of mobile phones for discharge follow-up of pediatric Emergency Department patients in western Kenya.

PubMed

House, Darlene R; Cheptinga, Philip; Rusyniak, Daniel E

2015-01-01

Objective. Mobile phones have been successfully used for Emergency Department (ED) patient follow-up in developed countries. Mobile phones are widely available in developing countries and may offer a similar potential for follow-up and continued care of ED patients in low and middle-income countries. The goal of this study was to determine the percentage of families with mobile phones presenting to a pediatric ED in western Kenya and rate of response to a follow-up phone call after discharge. Methods. A prospective, cross-sectional observational study of children presenting to the emergency department of a government referral hospital in Eldoret, Kenya was performed. Documentation of mobile phone access, including phone number, was recorded. If families had access, consent was obtained and families were contacted 7 days after discharge for follow-up. Results. Of 788 families, 704 (89.3%) had mobile phone access. Of those families discharged from the ED, successful follow-up was made in 83.6% of cases. Conclusions. Mobile phones are an available technology for follow-up of patients discharged from a pediatric emergency department in resource-limited western Kenya.

Assessing the Burden of Diabetes Mellitus in Emergency Departments in the United States: The National Hospital Ambulatory Medical Care Survey (NHAMCS)

PubMed Central

Asao, Keiko; Kaminski, James; McEwen, Laura N.; Wu, Xiejian; Lee, Joyce M.; Herman, William H.

2014-01-01

Objective To evaluate the performance of three alternative methods to identify diabetes in patients visiting Emergency Departments (EDs), and to describe the characteristics of patients with diabetes who are not identified when the alternative methods are used. Research Design and Methods We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2009 and 2010. We assessed the sensitivity and specificity of using providers’ diagnoses and diabetes medications (both excluding and including biguanides) to identify diabetes compared to using the checkbox for diabetes as the gold standard. We examined the characteristics of patients whose diabetes was missed using multivariate Poisson regression models. Results The checkbox identified 5,567 ED visits by adult patients with diabetes. Compared to the checkbox, the sensitivity was 12.5% for providers’ diagnoses alone, 20.5% for providers’ diagnoses and diabetes medications excluding biguanides, and 21.5% for providers’ diagnoses and diabetes medications including biguanides. The specificity of all three of the alternative methods was >99%. Older patients were more likely to have diabetes not identified. Patients with self-payment, those who had glucose measured or received IV fluids in the ED, and those with more diagnosis codes and medications, were more likely to have diabetes identified. Conclusions NHAMCS's providers’ diagnosis codes and medication lists do not identify the majority of patients with diabetes visiting EDs. The newly introduced checkbox is helpful in measuring ED resource utilization by patients with diabetes. PMID:24680472

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool.

PubMed

Hasemann, Wolfgang; Grossmann, Florian F; Stadler, Rahel; Bingisser, Roland; Breil, Dieter; Hafner, Martina; Kressig, Reto W; Nickel, Christian H

2017-12-30

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q 1  = 72.15; Q 3  = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

Engaging stakeholders to design a comparative effectiveness trial in children with uncontrolled asthma

PubMed Central

Erwin, Kim; Martin, Molly A; Flippin, Tara; Norell, Sarah; Shadlyn, Ariana; Yang, Jie; Falco, Paula; Rivera, Jaime; Ignoffo, Stacy; Kumar, Rajesh; Margellos-Anast, Helen; McDermott, Michael; McMahon, Kate; Mosnaim, Giselle; Nyenhuis, Sharmilee M; Press, Valerie G; Ramsay, Jessica E; Soyemi, Kenneth; Thompson, Trevonne M; Krishnan, Jerry A

2016-01-01

Aim: To present the methods and outcomes of stakeholder engagement in the development of interventions for children presenting to the emergency department (ED) for uncontrolled asthma. Methods: We engaged stakeholders (caregivers, physicians, nurses, administrators) from six EDs in a three-phase process to: define design requirements; prototype and refine; and evaluate. Results: Interviews among 28 stakeholders yielded themes regarding in-home asthma management practices and ED discharge experiences. Quantitative and qualitative evaluation showed strong preference for the new discharge tool over current tools. Conclusion: Engaging end-users in contextual inquiry resulted in CAPE (CHICAGO Action Plan after ED discharge), a new stakeholder-balanced discharge tool, which is being tested in a multicenter comparative effectiveness trial. PMID:26690579

Improving Emergency Department radiology transportation time: a successful implementation of lean methodology.

PubMed

Hitti, Eveline A; El-Eid, Ghada R; Tamim, Hani; Saleh, Rana; Saliba, Miriam; Naffaa, Lena

2017-09-05

Emergency Department overcrowding has become a global problem and a growing safety and quality concern. Radiology and laboratory turnaround time, ED boarding and increased ED visits are some of the factors that contribute to ED overcrowding. Lean methods have been used in the ED to address multiple flow challenges from improving door-to-doctor time to reducing length of stay. The objective of this study is to determine the effectiveness of using Lean management methods on improving Emergency Department transportation times for plain radiography. We performed a before and after study at an academic urban Emergency Department with 49,000 annual visits after implementing a Lean driven intervention. The primary outcome was mean radiology transportation turnaround time (TAT). Secondary outcomes included overall study turnaround time from order processing to preliminary report time as well as ED length of stay. All ED patients undergoing plain radiography 6 months pre-intervention were compared to all ED patients undergoing plain radiography 6 months post-intervention after a 1 month washout period. Post intervention there was a statistically significant decrease in the mean transportation TAT (mean ± SD: 9.87 min ± 15.05 versus 22.89 min ± 22.05, respectively, p-value <0.0001). In addition, it was found that 71.6% of patients in the post-intervention had transportation TAT ≤ 10 min, as compared to 32.3% in the pre-intervention period, p-value <0.0001, with narrower interquartile ranges in the post-intervention period. Similarly, the "study processing to preliminary report time" and the length of stay were lower in the post-intervention as compared to the pre-intervention, (52.50 min ± 35.43 versus 54.04 min ± 34.72, p-value = 0.02 and 3.65 h ± 5.17 versus 4.57 h ± 10.43, p < 0.0001, respectively), in spite of an increase in the time it took to elease a preliminary report in the post-intervention period. Using Lean change management techniques can be effective in reducing transportation time to plain radiography in the Emergency Department as well as improving process reliability.

Outpatient Care of Young People after Emergency Treatment of Deliberate Self-Harm

ERIC Educational Resources Information Center

Bridge, Jeffrey A.; Marcus, Steven C.; Olfson, Mark

2012-01-01

Objective: Little is known about the mental health care received by young people after an episode of deliberate self-harm. This study examined predictors of emergency department (ED) discharge, mental health assessments in the ED, and follow-up outpatient mental health care for Medicaid-covered youth with deliberate self-harm. Method: A…

Time-trends, Predictors and Outcome of Emergency Department Utilization for Gout: A Nationwide U.S. Study

PubMed Central

Singh, Jasvinder A.; Yu, Shaohua

2016-01-01

Objective To assess gout-related emergency department (ED) utilization/charges and discharge disposition. Methods We used the U.S. National ED Sample (NEDS) data to examine the time-trends in total ED visits and charges and ED-related hospitalizations with gout as the primary diagnosis. We assessed multivariable-adjusted predictors of ED charges and hospitalization for gout-related visits using the 2012 NEDS data. Results There were 180,789, 201,044 and 205,152 ED visits in years 2009, 2010 and 2012 with gout as the primary diagnosis, with total ED charges of $195, $239 and $287 million, respectively; these accounted for 0.14-0.16% of all ED visits. Mean/median 2012 ED charges/visit were $1,398/$956. Of all gout-related ED visits, 7.7% were admitted to the hospital in 2012. Mean/median length of hospital stay was 3.9/2.6 days and mean/median inpatient charge/admission was $22,066/$15,912 in 2012. In multivariable-adjusted analyses, older age, female gender, highest income quartile, being uninsured, metropolitan residence, Western U.S. hospital location, heart disease, renal failure, congestive heart failure (CHF), hypertension, diabetes, osteoarthritis and chronic obstructive pulmonary disease (COPD) were associated with higher ED charges. Older age, Northeast location, Metropolitan teaching hospital, higher income quartile, heart disease, renal failure, CHF, hyperlipidemia, hypertension, diabetes, COPD, and osteoarthritis were associated with higher odds where as self-pay insurance status was associated with lower odds of hospitalization following an ED visit for gout. Conclusions Absolute ED utilization and charges for gout increased over time, but relative utilization remained stable. Modifiable comorbidity factors associated with higher gout-related utilization should be targeted to reduce morbidity and healthcare utilization. PMID:27134260

Language affects length of stay in emergency departments in Queensland public hospitals

PubMed Central

Mahmoud, Ibrahim; Hou, Xiang-yu; Chu, Kevin; Clark, Michele

2013-01-01

BACKGROUND: A long length of stay (LOS) in the emergency department (ED) associated with overcrowding has been found to adversely affect the quality of ED care. The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home. METHODS: A secondary data analysis of a Queensland state-wide hospital EDs dataset (Emergency Department Information System) was conducted for the period, 1 January 2008 to 31 December 2010. RESULTS: The interpreter requirement was the highest among Vietnamese speakers (23.1%) followed by Chinese (19.8%) and Arabic speakers (18.7%). There were significant differences in the distributions of the departure statuses among the language groups (Chi-squared=3236.88, P<0.001). Compared with English speakers, the Beta coefficient for the LOS in the EDs measured in minutes was among Vietnamese, 26.3 (95%CI: 22.1–30.5); Arabic, 10.3 (95%CI: 7.3–13.2); Spanish, 9.4 (95%CI: 7.1–11.7); Chinese, 8.6 (95%CI: 2.6–14.6); Hindi, 4.0 (95%CI: 2.2–5.7); Italian, 3.5 (95%CI: 1.6–5.4); and German, 2.7 (95%CI: 1.0–4.4). The final regression model explained 17% of the variability in LOS. CONCLUSION: There is a close relationship between the language spoken at home and the LOS at EDs, indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland’s public hospitals. PMID:25215085

Emergency Department Use and Risk Factors among Deaf American Sign Language Users

PubMed Central

McKee, Michael M.; Winters, Paul C.; Sen, Ananda; Zazove, Philip; Fiscella, Kevin

2015-01-01

Background Deaf American Sign Language (ASL) users comprise a linguistic minority population with poor health care access due to communication barriers and low health literacy. Potentially, these health care barriers could increase Emergency Department (ED) use. Objective To compare ED use between deaf and non-deaf patients. Method A retrospective cohort from medical records. The sample was derived from 400 randomly selected charts (200 deaf ASL users and 200 hearing English speakers) from an outpatient primary care health center with a high volume of deaf patients. Abstracted data included patient demographics, insurance, health behavior, and ED use in the past 36 months. Results Deaf patients were more likely to be never smokers and be insured through Medicaid. In an adjusted analysis, deaf individuals were significantly more likely to use the ED (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.11–3.51) over the prior 36 months. Conclusion Deaf American Sign Language users appear to be at greater odds for elevated ED utilization when compared to the general hearing population. Efforts to further understand the drivers for increased ED utilization among deaf ASL users are much needed. PMID:26166160

A descriptive study of access to services in a random sample of Canadian rural emergency departments.

PubMed

Fleet, Richard; Poitras, Julien; Maltais-Giguère, Julie; Villa, Julie; Archambault, Patrick

2013-11-27

To examine 24/7 access to services and consultants in a sample of Canadian rural emergency departments (EDs). Cross-sectional study-mixed methods (structured interview, survey and government data bases) with random sampling of hospitals. Canadian rural EDs (rural small town (RST) definition-Statistics Canada). 28% (95/336) of Canadian rural EDs providing 24/7 physician coverage located in hospitals with acute care hospitalisation beds. General characteristics of the rural EDs, information about 24/7 access to consultants, equipment and services, and the proportion of rural hospitals more than 300 km from levels 1 and 2 trauma centres. Of the 336 rural EDs identified, 122 (36%) were randomly selected and contacted. Overall, 95 EDs participated in the study (participation rate, 78%). Hospitals had, on an average, 23 acute care beds, 7 ED stretchers and 13 500 annual ED visits. The proportion of rural hospitals with local access to the following 24/7 services was paediatrician, 5%; obstetrician, 10%; psychiatrist, 11%; internist, 12%; intensive care unit, 17%; CT scanner, 20%; surgeon, 26%; ultrasound, 28%; basic X-ray, 97% and laboratory services, 99%. Forty-four per cent and 54% of the RST EDs were more than 300 km from a level 1 and level 2 trauma centre, respectively. This is the first study describing the services available in Canadian rural EDs. Apart from basic laboratory and X-ray services, most rural EDs have limited access to consultants, advanced imaging and critical care services. A detailed study is needed to evaluate the impact of these limited services on patient outcomes, costs and interfacility transport demands.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

PubMed Central

Schumacher, Jessica R.; Lutz, Barbara J.; Hall, Allyson G.; Pines, Jesse M.; Jones, Andrea L.; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L.

2017-01-01

Introduction Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions. Methods We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients’ reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. Results PAM scores fell in both groups after the ED visit but fell significantly more in “usual care” (average decline −4.64) than “intervention” participants (average decline −2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. Conclusion The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare. PMID:28611897

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions

PubMed Central

Campbell, Ronna L.; Bellolio, M. Fernanda; Motosue, Megan S.; Sunga, Kharmene L.; Lohse, Christine M.; Rudis, Maria I.

2016-01-01

Introduction Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery. Methods This observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by healthcare providers at an academic ED. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED healthcare providers. Results Of 217 ED healthcare providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably for time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (p<0.001 for all comparisons). However, manual injection use was rated more favorably for risk of provider self-injury and patient cost (p<0.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector. Conclusion ED healthcare providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED. PMID:27833688

Use of emergency department electronic medical records for automated epidemiological surveillance of suicide attempts: a French pilot study.

PubMed

Metzger, Marie-Hélène; Tvardik, Nastassia; Gicquel, Quentin; Bouvry, Côme; Poulet, Emmanuel; Potinet-Pagliaroli, Véronique

2017-06-01

The aim of this study was to determine whether an expert system based on automated processing of electronic health records (EHRs) could provide a more accurate estimate of the annual rate of emergency department (ED) visits for suicide attempts in France, as compared to the current national surveillance system based on manual coding by emergency practitioners. A feasibility study was conducted at Lyon University Hospital, using data for all ED patient visits in 2012. After automatic data extraction and pre-processing, including automatic coding of medical free-text through use of the Unified Medical Language System, seven different machine-learning methods were used to classify the reasons for ED visits into "suicide attempts" versus "other reasons". The performance of these different methods was compared by using the F-measure. In a test sample of 444 patients admitted to the ED in 2012 (98 suicide attempts, 48 cases of suicidal ideation, and 292 controls with no recorded non-fatal suicidal behaviour), the F-measure for automatic detection of suicide attempts ranged from 70.4% to 95.3%. The random forest and naïve Bayes methods performed best. This study demonstrates that machine-learning methods can improve the quality of epidemiological indicators as compared to current national surveillance of suicide attempts. Copyright © 2016 John Wiley & Sons, Ltd.

Psychiatric patients turnaround times in the emergency department

PubMed Central

2005-01-01

Background To analyze the turnaround times of psychiatric patients within the Emergency Department (ED) from registration to discharge or hospitalization in a University Hospital in 2002. Methods Data from a one-year period of psychiatric admissions to the emergency service at a University Hospital were monitored and analyzed focused on turnaround times within the ED. Information on patients variables such as age, sex, diagnosis, consultations and diagnostic procedures were extracted from the patients' charts. Results From 34.058 patients seen in the ED in 2002, 2632 patients were examined by psychiatrists on duty. Mean turnaround time in the ED was 123 (SD 97) minutes (median 95). Patients to be hospitalized on a psychiatric ward stayed shorter within the ED, patients who later were admitted to another faculty, were treated longer in the ED. Patients with cognitive or substance related disorders stayed longer in the ED than patients with other psychiatric diagnoses. The number of diagnostic procedures and consultations increased the treatment time significantly. Conclusion As the number of patients within the examined ED increases every year, the relevant variables responsible for longer or complicated treatments were assessed in order to appropriately change routine procedures without loss of medical standards. Using this basic data, comparisons with the following years and other hospitals will help to define where the benchmark of turnaround times for psychiatric emergency services might be. PMID:16351721

Trends and correlates of cannabis-involved emergency department visits: 2004 to 2011

PubMed Central

Zhu, He; Wu, Li-Tzy

2016-01-01

Objectives To examine trends and correlates of cannabis-involved emergency department (ED) visits in the United States from 2004 to 2011. Methods Data were obtained from the 2004-2011 Drug Abuse Warning Network. We analyzed trend in cannabis-involved ED visits for persons aged ≥12 years and stratified by type of cannabis involvement (cannabis-only, cannabis-polydrug). We used logistic regressions to determine correlates of cannabis-involved hospitalization versus cannabis-involved ED visits only. Results Between 2004 and 2011, the ED visit rate increased from 51 to 73 visits per 100,000 population aged ≥ 12 years for cannabis-only use (P-value for trend=0.004) and from 63 to 100 for cannabis-polydrug use (P-value for trend<0.001). Adolescents aged 12-17 years showed the largest increase in the cannabis-only-involved ED visit rate (Rate difference=80 per 100,000 adolescents). Across racial/ethnic groups, the most prevalent ED visits were noted among non-Hispanic blacks. Among cannabis-involved visits, the odds of hospitalization (versus ED visits only) increased with age strata compared with aged 12-17 years. Conclusions These findings suggest a notable increase in the ED visit numbers and rates for both the use of cannabis-only and cannabis-polydrug during the studied period, particularly among young people and non-Hispanic blacks. PMID:27574753

Clinical Pharmacy Services in Canadian Emergency Departments: A National Survey

PubMed Central

Wanbon, Richard; Lyder, Catherine; Villeneuve, Eric; Shalansky, Stephen; Manuel, Leslie; Harding, Melanie

2015-01-01

Background: Providing clinical pharmacy services in emergency departments (EDs) is important because adverse drug events commonly occur before, during, and after ED encounters. Survey studies in the United States have indicated a relatively low presence of clinical pharmacy services in the ED setting, but a descriptive survey specific to Canada has not yet been performed. Objectives: To describe the current status of pharmacy services in Canadian EDs and potential barriers to implementing pharmacy services in this setting. Methods: All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least 0.5 full-time equivalent [FTE] position). Three different electronic surveys were then distributed by e-mail to ED pharmacy team members (if available), pharmacy managers (at hospitals without an ED pharmacy team), and ED managers (all hospitals). The surveys were completed between July and September 2013. Results: Of the 243 hospitals identified, 95 (39%) had at least 0.5 FTE clinical pharmacy services in the ED (based on initial telephone screening). Of the 60 ED pharmacy teams that responded to the survey, 56 had pharmacists (27 of which also had ED pharmacy technicians) and 4 had pharmacy technicians (without pharmacists). Forty-four (79%) of the 56 ED pharmacist services had been established within the preceding 10 years. Order clarification, troubleshooting, medication reconciliation, and assessment of renal dosing were the services most commonly provided. The large majority of pharmacy managers and ED managers identified the need for ED pharmacy services where such services do not yet exist. Inadequate funding, competing priorities, and lack of training were the most commonly reported barriers to providing this service. Conclusions: Although the establishment of ward-based pharmacy services in Canadian EDs has increased over the past 10 years, lack of funding and a lack of ED training for pharmacists were reported as significant barriers to the expansion of this role in most hospitals. PMID:26157180

Oiling the gate: a mobile application to improve the admissions process from the emergency department to an academic community hospital inpatient medicine service.

PubMed

Fung, Russell; Hyde, Jensen Hart; Davis, Mike

2018-01-01

The process of admitting patients from the emergency department (ED) to an academic internal medicine (AIM) service in a community teaching hospital is one fraught with variability and disorder. This results in an inconsistent volume of patients admitted to academic versus private hospitalist services and results in frustration of both ED and AIM clinicians. We postulated that implementation of a mobile application (app) would improve provider satisfaction and increase admissions to the academic service. The app was designed and implemented to be easily accessible to ED physicians, regularly updated by academic residents on call, and a real-time source of the number of open AIM admission spots. We found a significant improvement in ED and AIM provider satisfaction with the admission process. There was also a significant increase in admissions to the AIM service after implementation of the app. We submit that the implementation of a mobile app is a viable, cost-efficient, and effective method to streamline the admission process from the ED to AIM services at community-based hospitals.

An Assessment of the Department of Education's Approach and Model for Analyzing Lender Profitability.

ERIC Educational Resources Information Center

Jenkins, Sarah; And Others

An assessment was done of the Department of Education's (ED) approach to determining lender profitability for Guaranteed Student Loans. The assessment described the current net present value (NPV) method as well as discussing its strengths and weaknesses. The NPV method has been widely accepted for determining the profitability of different…

Can near real-time monitoring of emergency department diagnoses facilitate early response to sporadic meningococcal infection? - prospective and retrospective evaluations

PubMed Central

2010-01-01

Background Meningococcal infection causes severe, rapidly progressing illness and reporting of cases is mandatory in New South Wales (NSW), Australia. The NSW Department of Health operates near real-time Emergency Department (ED) surveillance that includes capture and statistical analysis of clinical preliminary diagnoses. The system can provide alerts in response to specific diagnoses entered in the ED computer system. This study assessed whether once daily reporting of clinical diagnoses of meningococcal infection using the ED surveillance system provides an opportunity for timelier public health response for this disease. Methods The study involved a prospective and retrospective component. First, reporting of ED diagnoses of meningococcal infection from the ED surveillance system prospectively operated in parallel with conventional surveillance which requires direct telephone reporting of this scheduled medical condition to local public health authorities by hospitals and laboratories when a meningococcal infection diagnosis is made. Follow-up of the ED diagnoses determined whether meningococcal infection was confirmed, and the time difference between ED surveillance report and notification by conventional means. Second, cases of meningococcal infection reported by conventional surveillance during 2004 were retrospectively matched to ED visits to determine the sensitivity and positive predictive value (PPV) of ED surveillance. Results During the prospective evaluation, 31 patients were diagnosed with meningococcal infection in participating EDs. Of these, 12 had confirmed meningococcal disease, resulting in a PPV of 38.7%. All confirmed cases were notified earlier to public health authorities by conventional reporting. Of 149 cases of notified meningococcal disease identified retrospectively, 130 were linked to an ED visit. The sensitivity and PPV of the ED diagnosis for meningococcal infection was 36.2% and 36.7%, respectively. Conclusions Based on prospective evaluation, it is reassuring that existing mechanisms for reporting meningococcal infection perform well and are timely. The retrospective evaluation found low sensitivity and PPV of ED diagnoses for meningococcal disease. Even if more rapid forwarding of ED meningococcal diagnoses to public health authorities were possible, the low sensitivity and PPV do not justify this. In this study, use of an ED surveillance system to augment conventional surveillance of this scheduled medical condition did not demonstrate a benefit. PMID:20979656

Communication and Influencing for ED Professionals: A training programme developed in the emergency department for the emergency department.

PubMed

Rixon, Andrew; Rixon, Sascha; Addae-Bosomprah, Hansel; Ding, Mingshuang; Bell, Anthony

2016-08-01

The objective of the present study is to develop and pilot a communication and influencing skills training programme that meets ED health professionals' needs at an urban district hospital. Qualitative methods within a participatory action research framework were utilised. An interdisciplinary team guided the programme's design and development. A training needs analysis saw team meetings, interviews, focus groups and observations conducted across the ED. Thematic analysis of the data identified health professionals' communication and influencing challenges. The training needs analysis informed the training programme curriculum's development. The pilot programme involved an interdisciplinary group of seven health professionals across 5 × 2 h sessions over 3 months, followed by a post-training survey. Five themes of communication and influencing challenges were identified: participating in effective handovers, involving patients in bedside handovers, effectively communicating with interdepartmental colleagues, asking ED colleagues to do tasks and understanding ED colleagues' roles, expectations and assumptions. Based on these challenges, the formulated RESPECT model (which stands for Relationships, Expectations, Styles, Partnerships, Enquiry, Coaching and Teamwork) informed the training curriculum. The peer coaching model used in the training programme was highly regarded by participants. Communication and Influencing for ED Professionals™ (Babel Fish Group Pty Ltd, Melbourne, Victoria, Australia) addresses a gap for communication programmes developed in the ED for the ED. Future research will evaluate the programme's impact in this ED. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Exploring the Relationship Among Moral Distress, Coping, and the Practice Environment in Emergency Department Nurses.

PubMed

Zavotsky, Kathleen Evanovich; Chan, Garrett K

2016-01-01

Emergency department (ED) nurses practice in environments that are highly charged and unpredictable in nature and can precipitate conflict between the necessary prescribed actions and the individual's sense of what is morally the right thing to do. As a consequence of multiple moral dilemmas, ED staff nurses are at risk for experiencing distress and how they cope with these challenges may impact their practice. To examine moral distress in ED nurses and its relationship to coping in that specialty group. Using survey methods approach. One hundred ninety-eight ED nurses completed a moral distress, coping, and demographic collection instruments. Advanced statistical analysis was completed to look at relationships between the variables. Data analysis did show that moral distress is present in ED nurses (M = 80.19, SD = 53.27), and when separated into age groups, the greater the age, the less the experience of moral distress. A positive relationship between moral distress and some coping mechanisms and the ED environment was also noted. This study's findings suggest that ED nurses experience moral distress and could receive some benefit from utilization of appropriate coping skills. This study also suggests that the environment in which ED nurses practice has a significant impact on the experience of moral distress. Because health care is continuing to evolve, it is critical that issues such as moral distress and coping be studied in ED nurses to help eliminate human suffering.

Trauma airway management in emergency departments: a multicentre, prospective, observational study in Japan.

PubMed

Nakao, Shunichiro; Kimura, Akio; Hagiwara, Yusuke; Hasegawa, Kohei

2015-02-04

Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan. Analysis of data from a prospective, observational, multicentre registry-the Japanese Emergency Airway Network (JEAN) registry. 13 academic and community EDs from different geographic regions across Japan. 723 trauma patients who underwent emergency intubation from March 2010 through August 2012. ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events. A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0-50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs. In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Practice Characteristics of Emergency Department Extracorporeal Cardiopulmonary Resuscitation (eCPR) Programs in the United States: The Current State of the Art of Emergency Department Extracorporeal Membrane Oxygenation (ED ECMO)

PubMed Central

Tonna, Joseph E.; Johnson, Nicholas J; Greenwood, John; Gaieski, David F; Shinar, Zachary; Bellezo, Joseph M.; Becker, Lance; Shah, Atman P.; Youngquist, Scott T.; Mallin, Michael P; Fair, James Franklin; Gunnerson, Kyle J.; Weng, Cindy; McKellar, Stephen

2017-01-01

Purpose To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. Methods We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. Results Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤ 3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow®. Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. Conclusions Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable. PMID:27523953

Analysis of patient flow in the emergency department and the effect of an extensive reorganisation

PubMed Central

Miro, O; Sanchez, M; Espinosa, G; Coll-Vinent, B; Bragulat, E; Milla, J; Wardrope, J

2003-01-01

Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators. Methods: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself ; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria. Results: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both). Conclusions: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation. PMID:12642527

Text mining approach to predict hospital admissions using early medical records from the emergency department.

PubMed

Lucini, Filipe R; S Fogliatto, Flavio; C da Silveira, Giovani J; L Neyeloff, Jeruza; Anzanello, Michel J; de S Kuchenbecker, Ricardo; D Schaan, Beatriz

2017-04-01

Emergency department (ED) overcrowding is a serious issue for hospitals. Early information on short-term inward bed demand from patients receiving care at the ED may reduce the overcrowding problem, and optimize the use of hospital resources. In this study, we use text mining methods to process data from early ED patient records using the SOAP framework, and predict future hospitalizations and discharges. We try different approaches for pre-processing of text records and to predict hospitalization. Sets-of-words are obtained via binary representation, term frequency, and term frequency-inverse document frequency. Unigrams, bigrams and trigrams are tested for feature formation. Feature selection is based on χ 2 and F-score metrics. In the prediction module, eight text mining methods are tested: Decision Tree, Random Forest, Extremely Randomized Tree, AdaBoost, Logistic Regression, Multinomial Naïve Bayes, Support Vector Machine (Kernel linear) and Nu-Support Vector Machine (Kernel linear). Prediction performance is evaluated by F1-scores. Precision and Recall values are also informed for all text mining methods tested. Nu-Support Vector Machine was the text mining method with the best overall performance. Its average F1-score in predicting hospitalization was 77.70%, with a standard deviation (SD) of 0.66%. The method could be used to manage daily routines in EDs such as capacity planning and resource allocation. Text mining could provide valuable information and facilitate decision-making by inward bed management teams. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

Safety and efficiency of emergency department interrogation of cardiac devices

PubMed Central

Neuenschwander, James F.; Peacock, W. Frank; Migeed, Madgy; Hunter, Sara A.; Daughtery, John C.; McCleese, Ian C.; Hiestand, Brian C.

2016-01-01

Objective Patients with implanted cardiac devices may wait extended periods for interrogation in emergency departments (EDs). Our purpose was to determine if device interrogation could be done safely and faster by ED staff. Methods Prospective randomized, standard therapy controlled, trial of ED staff device interrogation vs. standard process (SP), with 30-day follow-up. Eligibility criteria: ED presentation with a self-report of a potential device related complaint, with signed informed consent. SP interrogation was by company representative or hospital employee. Results Of 60 patients, 42 (70%) were male, all were white, with a median (interquartile range) age of 71 (64 to 82) years. No patient was lost to follow up. Of all patients, 32 (53%) were enrolled during business hours. The overall median (interquartile range) ED vs. SP time to interrogation was 98.5 (40 to 260) vs. 166.5 (64 to 412) minutes (P=0.013). While ED and SP interrogation times were similar during business hours, 102 (59 to 138) vs. 105 (64 to 172) minutes (P=0.62), ED interrogation times were shorter vs. SP during non-business hours; 97 (60 to 126) vs. 225 (144 to 412) minutes, P=0.002, respectively. There was no difference in ED length of stay between the ED and SP interrogation, 249 (153 to 390) vs. 246 (143 to 333) minutes (P=0.71), regardless of time of presentation. No patient in any cohort suffered an unplanned medical contact or post-discharge adverse device related event. Conclusion ED staff cardiac device interrogations are faster, and with similar 30-day outcomes, as compared to SP. PMID:28168230

Emergency department utilization among Medicaid beneficiaries with schizophrenia and diabetes: The consequences of increasing medical complexity

PubMed Central

Shim, Ruth S.; Druss, Benjamin G.; Zhang, Shun; Kim, Giyeon; Oderinde, Adesoji; Shoyinka, Sosunmolu; Rust, George

2014-01-01

Objective Individuals with both physical and mental health problems may have elevated levels of emergency department (ED) service utilization either for index conditions or for associated comorbidities. This study examines the use of ED services by Medicaid beneficiaries with comorbid diabetes and schizophrenia, a dyad with particularly high levels of clinical complexity. Methods Retrospective cohort analysis of claims data for Medicaid beneficiaries with both schizophrenia and diabetes from fourteen Southern states was compared with patients with diabetes only, schizophrenia only, and patients with any diagnosis other than schizophrenia and diabetes. Key outcome variables for individuals with comorbid schizophrenia and diabetes were ED visits for diabetes, mental health-related conditions, and other causes. Results Medicaid patients with comorbid diabetes and schizophrenia had an average number of 7.5 ED visits per year, compared to the sample Medicaid population with neither diabetes nor schizophrenia (1.9 ED visits per year), diabetes only (4.7 ED visits per year), and schizophrenia only (5.3 ED visits per year). Greater numbers of comorbidities (over and above diabetes and schizophrenia) were associated with substantial increases in diabetes-related, mental health-related and all-cause ED visits. Most ED visits in all patients, but especially in patients with more comorbidities, were for causes other than diabetes or mental health-related conditions. Conclusion Most ED utilization by individuals with diabetes and schizophrenia is for increasing numbers of comorbidities rather than the index conditions. Improving care in this population will require management of both index conditions as well as comorbid ones. PMID:24380780

Design, development, and evaluation of an online virtual emergency department for training trauma teams.

PubMed

Youngblood, Patricia; Harter, Phillip M; Srivastava, Sakti; Moffett, Shannon; Heinrichs, Wm LeRoy; Dev, Parvati

2008-01-01

Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)-the predominant method for training healthcare teams-are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method. In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects' leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases-a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases. Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects' performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive. This study shows the potential value of using virtual learning environments for developing medical students' and resident physicians' team leadership and crisis management skills.

77 FR 25658 - Negotiated Rulemaking Committee; Public Hearings

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-01

...://www2.ed.gov/policy/highered/reg/hearulemaking/2012/index.html or contact: Wendy Macias, U.S. Department... select, from the nominees, individual negotiators who reflect the diversity among program participants.../reg/retrospective-analysis/index.html ). The Department's plan creates a defined policy, method, and...

Admission time to hospital: a varying standard for a critical definition for admissions to an intensive care unit from the emergency department.

PubMed

Nanayakkara, Shane; Weiss, Heike; Bailey, Michael; van Lint, Allison; Cameron, Peter; Pilcher, David

2014-11-01

Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of 'time of admission' for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU). Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67,787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED. Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83-5.35) to 5.1 h (2.82-8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay. Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. WHAT IS KNOWN ABOUT THE TOPIC?: There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision-making. WHAT DOES THIS PAPER ADD?: This paper quantifies the variability of times measured and analyses why the variability exists. It also discusses the impact of this variability on assessment of outcomes and provides suggestions to improve standardisation. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: This paper provides a clearer view on standards regarding length of stay in the ICU, highlighting the importance of key performance indicators, as well as the quality of data that underlies them. This will lead to significant changes in the way we standardise and interpret data regarding length of stay.

Using Queuing Theory and Simulation Modelling to Reduce Waiting Times in An Iranian Emergency Department

PubMed Central

Haghighinejad, Hourvash Akbari; Kharazmi, Erfan; Hatam, Nahid; Yousefi, Sedigheh; Hesami, Seyed Ali; Danaei, Mina; Askarian, Mehrdad

2016-01-01

Background: Hospital emergencies have an essential role in health care systems. In the last decade, developed countries have paid great attention to overcrowding crisis in emergency departments. Simulation analysis of complex models for which conditions will change over time is much more effective than analytical solutions and emergency department (ED) is one of the most complex models for analysis. This study aimed to determine the number of patients who are waiting and waiting time in emergency department services in an Iranian hospital ED and to propose scenarios to reduce its queue and waiting time. Methods: This is a cross-sectional study in which simulation software (Arena, version 14) was used. The input information was extracted from the hospital database as well as through sampling. The objective was to evaluate the response variables of waiting time, number waiting and utilization of each server and test the three scenarios to improve them. Results: Running the models for 30 days revealed that a total of 4088 patients left the ED after being served and 1238 patients waited in the queue for admission in the ED bed area at end of the run (actually these patients received services out of their defined capacity). The first scenario result in the number of beds had to be increased from 81 to179 in order that the number waiting of the “bed area” server become almost zero. The second scenario which attempted to limit hospitalization time in the ED bed area to the third quartile of the serving time distribution could decrease the number waiting to 586 patients. Conclusion: Doubling the bed capacity in the emergency department and consequently other resources and capacity appropriately can solve the problem. This includes bed capacity requirement for both critically ill and less critically ill patients. Classification of ED internal sections based on severity of illness instead of medical specialty is another solution. PMID:26793727

Level of impact on the public health of universal human immunodeficiency virus screening in an Emergency Department.

PubMed

Reyes-Urueña, Juliana; Fernàndez-López, Laura; Force, Luis; Daza, Manel; Agustí, Cristina; Casabona, Jordi

The aim of this study was to determine the prevalence of HIV and the acceptability of rapid testing in an emergency department (ED), Barcelona (6/07/2011 to 8/03/2013). A convenience sample was used, depending on nurse availability in the ED. Participants signed an informed consent. Results were confirmed by conventional methods. A total of 2,140 individuals were offered testing, and 5% rejected taking part (107/2,140). Three subjects (3/2,033 [0.15%]) had confirmed reactive test. Individuals with a higher education were more likely to perform a rapid HIV test in ED (P<.005). A low prevalence of new HIV diagnoses was found among participants, although there was a high acceptability rate to perform rapid testing in the ED. Copyright © 2015 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Anxiety-related visits to New Jersey emergency departments after September 11, 2001.

PubMed

Adinaro, David J; Allegra, John R; Cochrane, Dennis G; Cable, Gregory

2008-04-01

The purpose of this study was to examine the effect of September 11, 2001 on anxiety-related visits to selected Emergency Departments (EDs). We performed a retrospective analysis of consecutive patients seen by emergency physicians in 15 New Jersey EDs located within a 50-mile radius of the World Trade Center from July 11 through December 11 in each of 6 years, 1996--2001. We chose by consensus all ICD-9 (International Classification of Diseases, 9th revision) codes related to anxiety. We used graphical methods, Box-Jenkins modeling, and time series regression to determine the effect of September 11 to 14 on daily rates of anxiety-related visits. We found that the daily rate of anxiety-related visits just after September 11th was 93% higher (p < 0.0001) than the average for the remaining 150 days for 2001. This represents, on average, one additional daily visit for anxiety at each ED. We concluded that there was an increase in anxiety-related ED visits after September 11, 2001.

Right service, right place: optimising utilisation of a community nursing service to reduce planned re-presentations to the emergency department

PubMed Central

Lawton, Jessica Kirsten; Kinsman, Leigh; Dalton, Lisa; Walsh, Fay; Bryan, Helen; Williams, Sharon

2017-01-01

Background Congruent with international rising emergency department (ED) demand, a focus on strategies and services to reduce burden on EDs and improve patient outcomes is necessary. Planned re-presentations of non-urgent patients at a regional Australian hospital exceeded 1200 visits during the 2013–2014 financial year. Planned re-presentations perpetuate demand and signify a lack of alternative services for non-urgent patients. The Community Nursing Enhanced Connections Service (CoNECS) collaboratively evolved between acute care and community services in 2014 to reduce planned ED re-presentations. Objective This study aimed to investigate the evolution and impact of a community nursing service to reduce planned re-presentations to a regional Australian ED and identify enablers and barriers to interventionist effectiveness. Methods A mixed-methods approach evaluated the impact of CoNECS. Data from hospital databases including measured numbers of planned ED re-presentations by month, time of day, age, gender and reason were used to calculate referral rates to CoNECS. These results informed two semistructured focus groups with ED and community nurses. The researchers used a theoretical lens, ‘diffusion of innovation’, to understand how this service could inform future interventions. Results Analyses showed that annual ED planned re-presentations decreased by 43% (527 presentations) after implementation. Three themes emerged from the focus groups. These were right service at the right time, nursing uncertainty and system disconnect and medical disengagement. Conclusions CoNECS reduced overall ED planned re-presentations and was sustained longer than many complex service-level interventions. Factors supporting the service were endorsement from senior administration and strong leadership to drive responsive quality improvement strategies. This study identified a promising alternative service outside the ED, highlighting possibilities for other hospital emergency services aiming to reduce planned re-presentations. PMID:29450293

Efficiency of International Classification of Diseases, Ninth Revision, Billing Code Searches to Identify Emergency Department Visits for Blood or Body Fluid Exposures through a Statewide Multicenter Database

PubMed Central

Rosen, Lisa M.; Liu, Tao; Merchant, Roland C.

2016-01-01

BACKGROUND Blood and body fluid exposures are frequently evaluated in emergency departments (EDs). However, efficient and effective methods for estimating their incidence are not yet established. OBJECTIVE Evaluate the efficiency and accuracy of estimating statewide ED visits for blood or body fluid exposures using International Classification of Diseases, Ninth Revision (ICD-9), code searches. DESIGN Secondary analysis of a database of ED visits for blood or body fluid exposure. SETTING EDs of 11 civilian hospitals throughout Rhode Island from January 1, 1995, through June 30, 2001. PATIENTS Patients presenting to the ED for possible blood or body fluid exposure were included, as determined by prespecified ICD-9 codes. METHODS Positive predictive values (PPVs) were estimated to determine the ability of 10 ICD-9 codes to distinguish ED visits for blood or body fluid exposure from ED visits that were not for blood or body fluid exposure. Recursive partitioning was used to identify an optimal subset of ICD-9 codes for this purpose. Random-effects logistic regression modeling was used to examine variations in ICD-9 coding practices and styles across hospitals. Cluster analysis was used to assess whether the choice of ICD-9 codes was similar across hospitals. RESULTS The PPV for the original 10 ICD-9 codes was 74.4% (95% confidence interval [CI], 73.2%–75.7%), whereas the recursive partitioning analysis identified a subset of 5 ICD-9 codes with a PPV of 89.9% (95% CI, 88.9%–90.8%) and a misclassification rate of 10.1%. The ability, efficiency, and use of the ICD-9 codes to distinguish types of ED visits varied across hospitals. CONCLUSIONS Although an accurate subset of ICD-9 codes could be identified, variations across hospitals related to hospital coding style, efficiency, and accuracy greatly affected estimates of the number of ED visits for blood or body fluid exposure. PMID:22561713

Understanding patient acceptance and refusal of HIV testing in the emergency department

PubMed Central

2012-01-01

Background Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing. Methods In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California. Results Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records. Conclusions Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup. PMID:22214543

A descriptive study of access to services in a random sample of Canadian rural emergency departments

PubMed Central

Fleet, Richard; Poitras, Julien; Maltais-Giguère, Julie; Villa, Julie; Archambault, Patrick

2013-01-01

Objective To examine 24/7 access to services and consultants in a sample of Canadian rural emergency departments (EDs). Design Cross-sectional study—mixed methods (structured interview, survey and government data bases) with random sampling of hospitals. Setting Canadian rural EDs (rural small town (RST) definition—Statistics Canada). Participants 28% (95/336) of Canadian rural EDs providing 24/7 physician coverage located in hospitals with acute care hospitalisation beds. Main outcome measures General characteristics of the rural EDs, information about 24/7 access to consultants, equipment and services, and the proportion of rural hospitals more than 300 km from levels 1 and 2 trauma centres. Results Of the 336 rural EDs identified, 122 (36%) were randomly selected and contacted. Overall, 95 EDs participated in the study (participation rate, 78%). Hospitals had, on an average, 23 acute care beds, 7 ED stretchers and 13 500 annual ED visits. The proportion of rural hospitals with local access to the following 24/7 services was paediatrician, 5%; obstetrician, 10%; psychiatrist, 11%; internist, 12%; intensive care unit, 17%; CT scanner, 20%; surgeon, 26%; ultrasound, 28%; basic X-ray, 97% and laboratory services, 99%. Forty-four per cent and 54% of the RST EDs were more than 300 km from a level 1 and level 2 trauma centre, respectively. Conclusions This is the first study describing the services available in Canadian rural EDs. Apart from basic laboratory and X-ray services, most rural EDs have limited access to consultants, advanced imaging and critical care services. A detailed study is needed to evaluate the impact of these limited services on patient outcomes, costs and interfacility transport demands. PMID:24285633

Identifying Patients With Problematic Drug Use in the Emergency Department: Results of a Multisite Study

PubMed Central

Konstantopoulos, Wendy L. Macias; Dreifuss, Jessica A.; McDermott, Katherine A.; Parry, Blair Alden; Howell, Melissa L.; Mandler, Raul N.; Fitzmaurice, Garrett M.; Bogenschutz, Michael P.; Weiss, Roger D.

2014-01-01

Study objective Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. Methods Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. Results Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. Conclusion Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs. PMID:24999283

Retrospective observational study of emergency department syndromic surveillance data during air pollution episodes across London and Paris in 2014

PubMed Central

Morbey, Roger; Fouillet, Anne; Caserio-Schönemann, Céline; Dobney, Alec; Hughes, Thomas C; Smith, Gillian E

2018-01-01

Introduction Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014. Methods Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ. Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ. Results Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0–14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0–14 years), whereas during the second period the increase was greater in adults. Discussion This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand. PMID:29674360

Examining emergency department communication through a staff-based participatory research method: identifying barriers and solutions to meaningful change.

PubMed

Cameron, Kenzie A; Engel, Kirsten G; McCarthy, Danielle M; Buckley, Barbara A; Mercer Kollar, Laura Min; Donlan, Sarah M; Pang, Peter S; Makoul, Gregory; Tanabe, Paula; Gisondi, Michael A; Adams, James G

2010-12-01

We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED). ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes. A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice. Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Violence toward health workers in Bahrain Defense Force Royal Medical Services’ emergency department

PubMed Central

Rafeea, Faisal; Al Ansari, Ahmed; Abbas, Ehab M; Elmusharaf, Khalifa; Abu Zeid, Mohamed S

2017-01-01

Background Employees working in emergency departments (EDs) in hospital settings are disproportionately affected by workplace violence as compared to those working in other departments. Such violence results in minor or major injury to these workers. In other cases, it leads to physical disability, reduced job performance, and eventually a nonconducive working environment for these workers. Materials and methods A cross-sectional exploratory questionnaire was used to collect data used for the examination of the incidents of violence in the workplace. This study was carried out at the ED of the Bahrain Defense Force (BDF) Hospital. Participants for the study were drawn from nurses, support staff, and emergency physicians. Both male and female workers were surveyed. Results The study included responses from 100 staff in the ED of the BDF Hospital in Bahrain (doctors, nurses, and support personnel). The most experienced type of violence in the workers in the past 12 months in this study was verbal abuse, which was experienced by 78% of the participants, which was followed by physical abuse (11%) and then sexual abuse (3%). Many cases of violence against ED workers occurred during night shifts (53%), while physical abuse was reported to occur during all the shifts; 40% of the staff in the ED of the hospital were not aware of the policies against workplace violence, and 26% of the staff considered leaving their jobs at the hospital. Conclusion This study reported multiple findings on the number of workplace violence incidents, as well as the characteristics and factors associated with violence exposure in ED staff in Bahrain. The results clearly demonstrate the importance of addressing the issue of workplace violence in EDs in Bahrain and can be used to demonstrate the strong need for interventions. PMID:29184452

Network analysis of team communication in a busy emergency department

PubMed Central

2013-01-01

Background The Emergency Department (ED) is consistently described as a high-risk environment for patients and clinicians that demands colleagues quickly work together as a cohesive group. Communication between nurses, physicians, and other ED clinicians is complex and difficult to track. A clear understanding of communications in the ED is lacking, which has a potentially negative impact on the design and effectiveness of interventions to improve communications. We sought to use Social Network Analysis (SNA) to characterize communication between clinicians in the ED. Methods Over three-months, we surveyed to solicit the communication relationships between clinicians at one urban academic ED across all shifts. We abstracted survey responses into matrices, calculated three standard SNA measures (network density, network centralization, and in-degree centrality), and presented findings stratified by night/day shift and over time. Results We received surveys from 82% of eligible participants and identified wide variation in the magnitude of communication cohesion (density) and concentration of communication between clinicians (centralization) by day/night shift and over time. We also identified variation in in-degree centrality (a measure of power/influence) by day/night shift and over time. Conclusions We show that SNA measurement techniques provide a comprehensive view of ED communication patterns. Our use of SNA revealed that frequency of communication as a measure of interdependencies between ED clinicians varies by day/night shift and over time. PMID:23521890

Data sharing for prevention: a case study in the development of a comprehensive emergency department injury surveillance system and its use in preventing violence and alcohol-related harms

PubMed Central

Quigg, Zara; Hughes, Karen; Bellis, Mark A

2012-01-01

Objective To examine emergency department (ED) data sharing via a local injury surveillance system and assess its contribution to the prevention of violence and alcohol-related harms. Methods 6-year (2004–2010) exploratory study analysing injury attendances to one ED in the North West of England using descriptive and trend analyses. Results Over the 6-year period, there were 242 796 ED injury attendances, including 21 683 for intentional injuries. Compared with unintentional injury patients, intentional injury patients were more likely to be men, aged 18–34 years, live in the most deprived communities, have attended the ED at night/weekends, have been injured in a public place and have consumed alcohol prior to the injury. Detailed data collected on alcohol and violence-related ED attendances were shared with local partners to monitor local trends and inform prevention activity including targeted policing and licensing enforcement. Over the 6-year period, intentional ED injury attendances decreased by 35.6% and alcohol-related assault attendances decreased by 30.3%. Conclusions The collection of additional ED data on assault details and alcohol use prior to injury, and its integration into multi-agency policy and practice, played an important role in driving local violence prevention activity. Further research is needed to assess the direct contribution ED data sharing makes to reductions in violence. PMID:22210640

Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly Emergency Department Patients.

PubMed

Sri-On, Jiraporn; Tirrell, Gregory P; Bean, Jonathan F; Lipsitz, Lewis A; Liu, Shan W

2017-10-01

We seek to describe the risk during 6 months and specific risk factors for recurrent falls, emergency department (ED) revisits, subsequent hospitalizations, and death within 6 months after a fall-related ED presentation. This was a secondary analysis of a retrospective cohort of elderly fall patients who presented to the ED from one urban teaching hospital. We included patients aged 65 years and older who had an ED fall visit in 2012. We examined the frequency and risk factors of adverse events (composite of recurrent falls, ED revisits, subsequent hospitalization, and death, selected a priori) at 6 months. Our study included 350 older adults. Adverse events steadily increased, from 7.7% at 7 days, 21.4% at 30 days, and 50.3% at 6 months. Within 6 months, 22.6% of patients had at least one recurrent fall, 42.6% revisited the ED, 31.1% had subsequent hospitalizations, and 2.6% died. In multivariable logistic regression analysis, psychological or sedative drug use predicted recurrent falls, ED revisits, subsequent hospitalizations, and adverse events. More than half of fall patients had an adverse event within 6 months of presenting to the ED after a fall. The risk during 6 months of these adverse events increased with psychological or sedative drug use. Larger future studies should confirm this association and investigate methods to minimize recurrent falls through management of such medications. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Adolescent and Parent Attitudes Toward Screening for Suicide Risk and Mental Health Problems in the Pediatric Emergency Department

PubMed Central

O’Mara, Roisin M.; Hill, Ryan M.; Cunningham, Rebecca M.; King, Cheryl A.

2016-01-01

Objective The objective of this study was to investigate adolescent and parent attitudes toward screening adolescents for suicide risk and other mental health problems in the emergency department (ED). Methods Two hundred ninety-four adolescents and 300 parents completed questionnaires about the importance of screening for suicide risk and other mental health problems in the ED, what would be helpful if the screen was positive, their concerns about screening in the ED, whether they believe screening should be a routine part of an ED visit, and whether they would complete a screening during the current visit if offered the opportunity. Results Overall, parents and adolescents reported positive attitudes toward screening for suicide risk and other mental health problems in the ED, with the majority responding that it should be a routine part of ED care. Suicide risk and drug and alcohol misuse were rated as more important to screen for than any of the other mental health problems by both parents and adolescents. Adolescent females and mothers were more supportive of screening for suicide risk and mental health problems in the ED than male adolescents and fathers. Descriptive data regarding screening concerns and follow-up preferences are reported. Conclusions Study results suggest overall positive support for screening for suicide risk and other mental health problems in the ED, with some important preferences, concerns, and parent versus adolescent and male versus female differences. PMID:22743751

At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses.

PubMed

Morphet, Julia; Griffiths, Debra; Plummer, Virginia; Innes, Kelli; Fairhall, Robyn; Beattie, Jill

2014-05-01

Violence is widespread in Australian emergency departments (ED) and most prevalent at triage. The aim of the present study was to identify the causes and common acts of violence in the ED perceived by three distinct groups of nurses. The Delphi technique is a method for consensus-building. In the present study a three-phase Delphi technique was used to identify and compare what nurse unit managers, triage and non-triage nurses believe is the prevalence and nature of violence and aggression in the ED. Long waiting times, drugs and alcohol all contributed to ED violence. Triage nurses also indicated that ED staff, including security staff and the triage nurses themselves, can contribute to violence. Improved communication at triage and support from management to follow up episodes of violence were suggested as strategies to reduce violence in the ED CONCLUSION :There is no single solution for the management of ED violence. Needs and strategies vary because people in the waiting room have differing needs to those inside the ED. Participants agreed that the introduction and enforcement of a zero tolerance policy, including support from managers to follow up reports of violence, would reduce violence and improve safety for staff. Education of the public regarding ED processes, and the ED staff in relation to patient needs, may contribute to reducing ED violence. What is known about the topic? Violence is prevalent in Australian healthcare, and particularly in emergency departments (ED). Several organisations and government bodies have made recommendations aimed at reducing the prevalence of violence in healthcare but, to date, these have not been implemented consistently, and violence continues. What does this paper add? This study examined ED violence from the perspective of triage nurses, nurse unit managers and non-triage nurses, and revealed that violence is experienced differently by emergency nurses, depending on their area of work. Triage nurses have identified that they themselves contribute to violence in the ED by their style of communication. Nurse unit managers and non-triage nurses perceive that violence is the result of drugs and alcohol, as well as long waiting times. What are the implications for practitioners? Strategies to reduce violence must address the needs of patients and staff both within the ED and in the waiting room. Such strategies should be multifaceted and include education of ED consumers and staff, as well as support from management to respond to reports of violence.

Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change.

PubMed

Burkett, Ellen; Martin-Khan, Melinda G; Scott, Justin; Samanta, Mayukh; Gray, Leonard C

2017-07-01

Objectives The aim of the present study was to describe trends in and age and gender distributions of presentations of older people to Australian emergency departments (EDs) from July 2006 to June 2011, and to develop ED utilisation projections to 2050. Methods A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess trends in ED presentations. Three standard Australian Bureau of Statistics population growth models, with and without adjustment for current trends in ED presentation growth and effects of climate change, were examined with projections of ED presentations across three age groups (0-64, 65-84 and ≥85 years) to 2050. Results From 2006-07 to 2010-11, ED presentations increased by 12.63%, whereas the Australian population over this time increased by only 7.26%. Rates of presentation per head of population were greatest among those aged ≥85 years. Projections of ED presentations to 2050 revealed that overall ED presentations are forecast to increase markedly, with the rate of increase being most marked for older people. Conclusion Growth in Australian ED presentations from 2006-07 to 2010-11 was greater than that expected from population growth alone. The predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic? Rapid population aging is anticipated over coming decades. International studies and specific local-level Australian studies have demonstrated significant growth in ED presentations. There have been no prior national-level Australian studies of ED presentation trends by age group. What does this paper add? The present study examined national ED presentation trends from July 2006 to June 2011, with specific emphasis on trends in presentation by age group. ED presentation growth was found to exceed population growth in all age groups. The rate of ED presentations per head of population was highest among those aged ≥85 years. ED utilisation projections to 2050, using standard Australian Bureau of Statistics population modelling, with and without adjustment for current ED growth, were developed. The projections demonstrated linear growth in ED presentation for those aged 0-84 years, with growth in ED presentations of the ≥85 year age group demonstrating marked acceleration after 2030. What are the implications for practitioners? Growth in ED presentations exceeding population growth suggests that current models of acute health care delivery require review to ensure that optimal care is delivered in the most fiscally efficient manner. Trends in presentation of older people emphasise the imperative for ED workforce planning and education in care of this complex patient cohort, and the requirement to review funding models to incentivise investment in ED avoidance and substitutive care models targeting older people.

Engaging stakeholders to design a comparative effectiveness trial in children with uncontrolled asthma.

PubMed

Erwin, Kim; Martin, Molly A; Flippin, Tara; Norell, Sarah; Shadlyn, Ariana; Yang, Jie; Falco, Paula; Rivera, Jaime; Ignoffo, Stacy; Kumar, Rajesh; Margellos-Anast, Helen; McDermott, Michael; McMahon, Kate; Mosnaim, Giselle; Nyenhuis, Sharmilee M; Press, Valerie G; Ramsay, Jessica E; Soyemi, Kenneth; Thompson, Trevonne M; Krishnan, Jerry A

2016-01-01

To present the methods and outcomes of stakeholder engagement in the development of interventions for children presenting to the emergency department (ED) for uncontrolled asthma. We engaged stakeholders (caregivers, physicians, nurses, administrators) from six EDs in a three-phase process to: define design requirements; prototype and refine; and evaluate. Interviews among 28 stakeholders yielded themes regarding in-home asthma management practices and ED discharge experiences. Quantitative and qualitative evaluation showed strong preference for the new discharge tool over current tools. Engaging end-users in contextual inquiry resulted in CAPE (CHICAGO Action Plan after ED discharge), a new stakeholder-balanced discharge tool, which is being tested in a multicenter comparative effectiveness trial.

Self perceived work related stress and the relation with salivary IgA and lysozyme among emergency department nurses

PubMed Central

Yang, Y; Koh, D; Ng, V; Lee, C; Chan, G; Dong, F; Goh, S; Anantharaman, V; Chia, S

2002-01-01

Aims: To assess and compare the self perceived work related stress among emergency department (ED) and general ward (GW) nurses, and to investigate its relation with salivary IgA and lysozyme. Methods: One hundred and thirty two of 208 (63.5%) registered female ED and GW nurses participated in the study. A modified mental health professional stress scale (PSS) was used to measure self perceived stress. ELISA methods were used to determine the salivary IgA and lysozyme levels. Results: On PSS, ED nurses had higher scores (mean 1.51) than GW nurses (1.30). The scores of PSS subscales such as organisational structure and processes (OS), lack of resources (RES), and conflict with other professionals (COF) were higher in ED than in GW nurses. ED nurses had lower secretion rates of IgA (geometric mean (GM) 49.1 µg/min) and lysozyme (GM 20.0 µg/min) than GW nurses (68.2 µg/min, 30.5 µg/min). Significant correlations were observed between PSS and log IgA and lysozyme secretion rates. OS, RES, and COF were correlated with log IgA and lysozyme levels. Conclusion: ED nurses, who reported a higher level of professional stress, showed significantly lower secretion rates of salivary IgA and lysozyme compared to GW nurses. Salivary IgA and lysozyme were inversely correlated with self perceived work related stress. As these salivary biomarkers are reflective of the mucosal immunity, results support the inverse relation between stress and mucosal immunity. PMID:12468751

Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations.

PubMed

Egerton-Warburton, Diana; Gosbell, Andrew; Wadsworth, Angela; Moore, Katie; Richardson, Drew B; Fatovich, Daniel M

2016-03-07

To survey emergency department (ED) clinical staff about their perceptions of alcohol-related presentations. A mixed methods online survey of ED clinicians in Australia and New Zealand, conducted from 30 May to 7 July 2014. The frequency of aggression from alcohol-affected patients or their carers experienced by ED staff; the perceived impact of alcohol-related presentations on ED function, waiting times, other patients and staff. In total, 2002 ED clinical staff completed the survey, including 904 ED nurses (45.2%) and 1016 ED doctors (50.7%). Alcohol-related verbal aggression from patients had been experienced in the past 12 months by 97.9% of respondents, and physical aggression by 92.2%. ED nurses were the group most likely to have felt unsafe because of the behaviour of these patients (92% reported such feelings). Alcohol-related presentations were perceived to negatively or very negatively affect waiting times (noted by 85.5% of respondents), other patients in the waiting room (94.4%), and the care of other patients (88.3%). Alcohol-affected patients were perceived to have a negative or very negative impact on staff workload (94.2%), wellbeing (74.1%) and job satisfaction (80.9%). Verbal and physical aggression by alcohol-affected patients is commonly experienced by ED clinical staff. This has a negative impact on the care of other patients, as well as on staff wellbeing. Managers of health services must ensure a safe environment for staff and patients. More importantly, a comprehensive public health approach to changing the prevailing culture that tolerates alcohol-induced unacceptable behaviour is required.

Child, caregiver, and family characteristics associated with emergency department use by children who remain at home after a child protective services investigation

PubMed Central

Hurlburt, Michael S.; Leslie, Laurel K.; Zhang, Jinjin; Horwitz, Sarah McCue

2012-01-01

Objectives To examine emergency department (ED) use among children involved with child protective services (CPS) in the U.S. but who remain at home, and to determine if ED use is related to child, caregiver and family characteristics as well as receipt of CPS services. Method We analyzed data on 4,001 children in the National Survey of Child and Adolescent Well-being. Multivariate models compared rates of ED use for whether the family received CPS services or did not receive CPS services as well as child characteristics, caregiver characteristics and caregiver/family psychological variables. Results ED use among children who remained at home receiving CPS services was similar to that of children who did not receive CPS services (35.6% and 37.4%, respectively). In multivariate modeling, children with families who received CPS services, children six years or older, and children without a chronic health problem were less likely to use the ED. Children who remained at home in families identified with numerous stressors and, therefore, likely at high risk for future abuse and neglect were 1.73 times (95% CI, 1.14–2.63) more likely to have repeat ED use than children in low risk families. Conclusion Children who remain at home after a CPS evaluation are at high risk for ED use. Future research should focus on the health problems that precipitate an ED visit as well as the relationship between primary care and ED use. PMID:22265905

Operational methods of HIV testing in emergency departments: a systematic review.

PubMed

Haukoos, Jason S; White, Douglas A E; Lyons, Michael S; Hopkins, Emily; Calderon, Yvette; Kalish, Brian; Rothman, Richard E

2011-07-01

Casual review of existing literature reveals a multitude of individualized approaches to emergency department (ED) HIV testing. Cataloging the operational options of each approach could assist translation by disseminating existing knowledge, endorsing variability as a means to address testing barriers, and laying a foundation for future work in the area of operational models and outcomes investigation. The objective of this study is to provide a detailed account of the various models and operational constructs that have been described for performing HIV testing in EDs. Systematic review of PUBMED, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Web of Science through February 6, 2009 was performed. Three investigators independently reviewed all potential abstracts and identified all studies that met the following criteria for inclusion: original research, performance of HIV testing in an ED in the United States, description of operational methods, and reporting of specific testing outcomes. Each study was independently assessed and data from each were abstracted with standardized instruments. Summary and pooled descriptive statistics were reported by using recently published nomenclature and definitions for ED HIV testing. The primary search yielded 947 potential studies, of which 25 (3%) were included in the final analysis. Of the 25 included studies, 13 (52%) reported results using nontargeted screening as the only patient selection method. Most programs reported using voluntary, opt-in consent and separate, signed consent forms. A variety of assays and communication methods were used, but relatively limited outcomes data were reported. Currently, limited evidence exists to inform HIV testing practices in EDs. There appears to be recent progression toward the use of rapid assays and nontargeted patient selection methods, with the rate at which reports are published in the peer-reviewed literature increasing. Additional research will be required, including controlled clinical trials, more structured program evaluation, and a focus on an expanded profile of outcome measures, to further improve our understanding of which HIV testing methods are most effective in the ED. Copyright © 2011. Published by Mosby, Inc.

Barriers and facilitators of suicide risk assessment in emergency departments: a qualitative study of provider perspectives.

PubMed

Petrik, Megan L; Gutierrez, Peter M; Berlin, Jon S; Saunders, Stephen M

2015-01-01

To understand emergency department (ED) providers' perspectives regarding the barriers and facilitators of suicide risk assessment and to use these perspectives to inform recommendations for best practices in ED suicide risk assessment. Ninety-two ED providers from two hospital systems in a Midwestern state responded to open-ended questions via an online survey that assessed their perspectives on the barriers and facilitators to assess suicide risk as well as their preferred assessment methods. Responses were analyzed using an inductive thematic analysis approach. Qualitative analysis yielded six themes that impact suicide risk assessment. Time, privacy, collaboration and consultation with other professionals and integration of a standard screening protocol in routine care exemplified environmental and systemic themes. Patient engagement/participation in assessment and providers' approach to communicating with patients and other providers also impacted the effectiveness of suicide risk assessment efforts. The findings inform feasible suicide risk assessment practices in EDs. Appropriately utilizing a collaborative, multidisciplinary approach to assess suicide-related concerns appears to be a promising approach to ameliorate the burden placed on ED providers and facilitate optimal patient care. Recommendations for clinical care, education, quality improvement and research are offered. Published by Elsevier Inc.

Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

PubMed Central

Steinman, Michael A.

2013-01-01

Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults. Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates. Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003). Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population. PMID:23597348

Perceptions of the effect of information and communication technology on the quality of care delivered in emergency departments: a cross-site qualitative study.

PubMed

Callen, Joanne; Paoloni, Richard; Li, Julie; Stewart, Michael; Gibson, Kathryn; Georgiou, Andrew; Braithwaite, Jeffrey; Westbrook, Johanna

2013-02-01

We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED. A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations. Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge. Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed. Copyright © 2012. Published by Mosby, Inc.

"They Shouldn't Be Coming to the ED, Should They?": A Descriptive Service Evaluation of Why Patients With Palliative Care Needs Present to the Emergency Department.

PubMed

Green, Emilie; Ward, Sarah; Brierley, Will; Riley, Ben; Sattar, Henna; Harris, Tim

2017-12-01

Patients with palliative care needs frequently attend the emergency department (ED). There is no international agreement on which patients are best cared for in the ED, compared to the primary care setting or direct admission to the hospital. This article presents the quantitative phase of a mixed-methods service evaluation, exploring the reasons why patients with palliative care needs present to the ED. This is a single-center, observational study including all patients under the care of a specialist palliative care team who presented to the ED over a 10-week period. Demographic and clinical data were collected from electronic health records. A total of 105 patients made 112 presentations to the ED. The 2 most common presenting complaints were shortness of breath (35%) and pain (28%). Eighty-three percent of presentations required care in the ED according to a priori defined criteria. They either underwent urgent investigation or received immediate interventions that could not be delivered in another setting, were referred by a health-care professional, or were admitted. Findings challenge the misconception that patients known to a palliative care team should be cared for outside the ED. The importance and necessity of the ED for patients in their last years of life has been highlighted, specifically in terms of managing acute, unpredictable crises. Future service provision should not be based solely on a patient's presenting complaint. Further qualitative research exploring patient perspective is required in order to explore the decision-making process that leads patients with palliative care needs to the ED.

Delirium in the Emergency Department and Its Extension into Hospitalization (DELINEATE) Study: Effect on 6-month Function and Cognition.

PubMed

Han, Jin H; Vasilevskis, Eduard E; Chandrasekhar, Rameela; Liu, Xulei; Schnelle, John F; Dittus, Robert S; Ely, E Wesley

2017-06-01

The natural course and clinical significance of delirium in the emergency department (ED) is unclear. We sought to (1) describe the extent to which delirium in the ED persists into hospitalization (ED delirium duration) and (2) determine how ED delirium duration is associated with 6-month functional status and cognition. Prospective cohort study. Tertiary care, academic medical center. ED patients ≥65 years old who were admitted to the hospital. The modified Brief Confusion Assessment Method was used to ascertain delirium in the ED and hospital. Premorbid and 6-month function were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire which ranged from 0 (completely dependent) to 28 (completely dependent). Premorbid and 6-month cognition were determined using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranged from 1 to 5 (severe dementia). Multiple linear regression was performed to determine if ED delirium duration was associated with 6-month function and cognition adjusted for baseline OARS ADL and IQCODE, and other confounders. A total of 228 older ED patients were enrolled. Of the 105 patients who were delirious in the ED, 81 (77.1%) patients' delirium persisted into hospitalization. For every ED delirium duration day, the 6-month OARS ADL decreased by 0.63 points (95% CI: -1.01 to -0.24), indicating poorer function. For every ED delirium duration day, the 6-month IQCODE increased 0.06 points (95% CI: 0.01-0.10) indicating poorer cognition. Delirium in the ED is not a transient event and frequently persists into hospitalization. Longer ED delirium duration is associated with an incremental worsening of 6-month functional and cognitive outcomes. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Travel distance and sociodemographic correlates of potentially avoidable emergency department visits in California, 2006-2010: an observational study.

PubMed

Chen, Brian K; Hibbert, James; Cheng, Xi; Bennett, Kevin

2015-03-21

Use of the hospital emergency department (ED) for medical conditions not likely to require immediate treatment is a controversial topic. It has been faulted for ED overcrowding, increased expenditures, and decreased quality of care. On the other hand, such avoidable ED utilization may be a manifestation of barriers to primary care access. A random 10% subsample of all ED visits with unmasked variables, or approximately 7.2% of all ED visits in California between 2006 and 2010 are used in the analysis. Using panel data methods, we employ linear probability and fractional probit models with hospital fixed effects to analyze the associations between avoidable ED utilization in California and observable patient characteristics. We also test whether shorter estimated road distances to the hospital ED are correlated with non-urgent ED utilization, as defined by the New York University ED Algorithm. We then investigate whether proximity of a Federally Qualified Health Center (FQHC) is correlated with reductions in non-urgent ED utilization among Medicaid patients. We find that relative to the reference group of adults aged 35-64, younger patients generally have higher scores for non-urgent conditions and lower scores for urgent conditions. However, elderly patients (≥65) use the ED for conditions more likely to be urgent. Relative to male and white patients, respectively, female patients and all identified racial and ethnic minorities use the ED for conditions more likely to be non-urgent. Patients with non-commercial insurance coverage also use the ED for conditions more likely to be non-urgent. Medicare and Medicaid patients who live closer to the hospital ED have higher probability scores for non-emergent visits. However, among Medicaid enrollees, those who live in zip codes with an FQHC within 0.5 mile of the zip code population centroid visit the ED for medical conditions less likely to be non-emergent. These patterns of ED utilization point to potential barriers to care among historically vulnerable groups, observable even when using rough estimates of travel distances and avoidable ED utilization.

Emergency department characteristics and capabilities in Beijing, China.

PubMed

Wen, Leana S; Xu, Jun; Steptoe, Anne P; Sullivan, Ashley F; Walline, Joseph H; Yu, Xuezhong; Camargo, Carlos A

2013-06-01

Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China. Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008. Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000-118,508). The vast majority (91%; 95% confidence interval [CI] 78-98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32-67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21-54%) of respondents considered their ED over capacity. Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs. Copyright © 2013 Elsevier Inc. All rights reserved.

Low acuity and general practice-type presentations to emergency departments: a rural perspective.

PubMed

Allen, Penny; Cheek, Colleen; Foster, Simon; Ruigrok, Marielle; Wilson, Deborah; Shires, Lizzi

2015-04-01

To estimate the number of general practice (GP)-type patients attending a rural ED and provide a comparative rural estimate to a metropolitan study. Analysis of presentations to the two EDs in Northwest Tasmania from 1 January 2009 to 31 December 2013 using the Diagnosis, Sprivulis, Australian College of Emergency Medicine (ACEM) and the Australian Institute of Health and Welfare (AIHW) methods to estimate the number of GP-type presentations. There were 255,365 ED presentations in Northwest Tasmania during the study period. There were 86,973 GP-type presentations using the ACEM method, 142,006 using the AIHW method, 174,748 using the Diagnosis method and 28,922 low acuity patients identified using the Sprivulis method. The proportion of GP-type presentations identified using the four methods ranged from 15% to 69%. The results suggest that triage status and self-referral are not reliable indicators of low acuity in this rural area. In rural areas with a shortage of GPs, it is likely that many people appropriately self-refer to ED because they cannot access a GP. The results indicate that the ACEM method might be most useful for identifying GP-type patients in rural ED. However, this requires validation in other regions of Australia. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

The emergency department prediction of disposition (EPOD) study.

PubMed

Vaghasiya, Milan R; Murphy, Margaret; O'Flynn, Daniel; Shetty, Amith

2014-11-01

Emergency departments (ED) continue to evolve models of care and streaming as interventions to tackle the effects of access block and overcrowding. Tertiary ED may be able to design patient-flow based on predicted dispositions in the department. Segregating discharge-stream patients may help develop patient-flows within the department, which is less affected by availability of beds in a hospital. We aim to determine if triage nurses and ED doctors can predict disposition outcomes early in the patient journey and thus lead to successful streaming of patients in the ED. During this study, triage nurses and ED doctors anonymously predicted disposition outcomes for patients presenting to triage after their brief assessments. Patient disposition at the 24-h post ED presentation was considered as the actual outcome and compared against predicted outcomes. Triage nurses were able to predict actual discharges of 445 patients out of 490 patients with a positive predictive value (PPV) of 90.8% (95% CI 87.8-93.2%). ED registrars were able to predict actual discharges of 85 patients out of 93 patients with PPV of 91.4% (95% CI 83.3-95.9%). ED consultants were able to predict actual discharges of 111 patients out of 118 patients with PPV 94.1% (95% CI 87.7-97.4%). PPVs for admission among ED consultants, ED registrars and Triage nurses were 59.7%, 54.4% and 48.5% respectively. Triage nurses, ED consultants and ED registrars are able to predict a patient's discharge disposition at triage with high levels of confidence. Triage nurses, ED consultants, and ED registrars can predict patients who are likely to be admitted with equal ability. This data may be used to develop specific admission and discharge streams based on early decision-making in EDs by triage nurses, ED registrars or ED consultants. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Determining Chronic Disease Prevalence in Local Populations Using Emergency Department Surveillance

PubMed Central

Long, Judith A.; Wall, Stephen P.; Carr, Brendan G.; Satchell, Samantha N.; Braithwaite, R. Scott; Elbel, Brian

2015-01-01

Objectives. We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence. Methods. Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses. Results. We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts. Conclusions. Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence. PMID:26180983

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation.

PubMed

Schumacher, Jessica R; Lutz, Barbara J; Hall, Allyson G; Pines, Jesse M; Jones, Andrea L; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L

2017-06-01

Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients' care-seeking decisions. We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients' reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. PAM scores fell in both groups after the ED visit but fell significantly more in "usual care" (average decline -4.64) than "intervention" participants (average decline -2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare.

Design and implementation of a controlled clinical trial to evaluate the effectiveness and efficiency of routine opt-out rapid human immunodeficiency virus screening in the emergency department.

PubMed

Haukoos, Jason S; Hopkins, Emily; Byyny, Richard L; Conroy, Amy A; Silverman, Morgan; Eisert, Sheri; Thrun, Mark; Wilson, Michael; Boyett, Brian; Heffelfinger, James D

2009-08-01

In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.

Work conditions, mental workload and patient care quality: a multisource study in the emergency department.

PubMed

Weigl, Matthias; Müller, Andreas; Holland, Stephan; Wedel, Susanne; Woloshynowych, Maria

2016-07-01

Workflow interruptions, multitasking and workload demands are inherent to emergency departments (ED) work systems. Potential effects of ED providers' work on care quality and patient safety have, however, been rarely addressed. We aimed to investigate the prevalence and associations of ED staff's workflow interruptions, multitasking and workload with patient care quality outcomes. We applied a mixed-methods design in a two-step procedure. First, we conducted a time-motion study to observe the rate of interruptions and multitasking activities. Second, during 20-day shifts we assessed ED staff's reports on workflow interruptions, multitasking activities and mental workload. Additionally, we assessed two care quality indicators with standardised questionnaires: first, ED patients' evaluations of perceived care quality; second, patient intrahospital transfers evaluated by ward staff. The study was conducted in a medium-sized community ED (16 600 annual visits). ED personnel's workflow was disrupted on average 5.63 times per hour. 30% of time was spent on multitasking activities. During 20 observations days, data were gathered from 76 ED professionals, 239 patients and 205 patient transfers. After aggregating daywise data and controlling for staffing levels, prospective associations revealed significant negative associations between ED personnel's mental workload and patients' perceived quality of care. Conversely, workflow interruptions were positively associated with patient-related information on discharge and overall quality of transfer. Our investigation indicated that ED staff's capability to cope with demanding work conditions was associated with patient care quality. Our findings contribute to an improved understanding of the complex effects of interruptions and multitasking in the ED environment for creating safe and efficient ED work and care systems. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

An emergency department-based mental health nurse practitioner outpatient service: part 2, staff evaluation.

PubMed

Wand, Timothy; White, Kathryn; Patching, Joanna; Dixon, Judith; Green, Timothy

2011-12-01

The nurse practitioner role incorporates enhancing access to health-care services, particularly for populations that are underserved. This entails working collaboratively with colleagues across multidisciplinary teams and emphasizing a nursing model of practice within the nurse practitioner role. In Australia, the added value associated with establishing mental health nurse practitioner (MHNP) positions based in the emergency department (ED) is emerging. This paper presents qualitative findings from a study using a mixed-method design to evaluate an ED-based MHNP outpatient service in Sydney, Australia. One component of the evaluation involved semistructured interviews conducted with a random selection of study participants and a stratified sample of ED staff. This is the second of a two-part paper that presents an analysis of the qualitative data derived from the staff interviews (n = 20). Emergency staff were very supportive of the outpatient service, and perceived that it enhanced overall service provision and improved outcomes for patients. Moreover, staff expressed interest in receiving more formal feedback on the outcomes of the service. Staff also felt that service provision would be enhanced through additional mental health liaison nurses working in the department, especially after hours. An ED-based MHNP outpatient service expedites access to follow up to individuals with a broad range of problems, and supports ED staff in the provision of safe, effective, and more holistic care. © 2011 The Authors. International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

'Registrar in charge shifts': learning how to run a busy emergency department.

PubMed

Craig, Simon; Dowling, Jonathan

2013-04-01

In Australasia, emergency registrars usually gain experience 'running' an ED overnight - without supervision. This paper describes the introduction of FACEM-supervised daytime 'registrar in charge' (RIC) shifts into a tertiary adult ED over a 6 month period. Each registrar was allocated at least one RIC shift during their 13 week ED term. Structured questionnaires gathered data regarding the educational impact of the shifts, any adverse effects on departmental function, changes to work practices, and perceptions of teaching and learning. Data were analysed using thematic analysis. During the study period, 16 senior ED registrars were rostered for 26 RIC shifts. Questionnaires were completed by 16/16 registrars and 13/16 emergency physicians. The RIC shifts were viewed positively by the emergency registrars - 93% reported useful feedback, felt that the shifts provided a good insight into their workplace behaviour, and that they should be rolled out across other departments. FACEMs were also positive in their evaluation, and reported little negative impact on departmental function. Major themes identified by both registrars and emergency physicians included communication skills, knowledge and experience, delegation, professionalism and organisational skills. Additional themes that were more prominent in FACEM responses included multitasking, dealing with interruptions, managing patient flow and being aware of the whole department. RIC shifts are a feasible and acceptable method to teach running the floor in the ED. Further study should assess impact on patient outcomes. © 2013 The Authors. EMA © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Use of the Emergency Department for Severe Headache. A population-based study

PubMed Central

Friedman, Benjamin W.; Serrano, Daniel; Reed, Michael; Diamond, Merle; Lipton, Richard B.

2008-01-01

Background Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache. Methods As part of the American Migraine Prevalence and Prevention study, a validated self-administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be socio-demographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, socio-demographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, “frequent” ED use was defined as a particpants report of four or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology. Results Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Socio-demographic characteristics did not differ substantially between responders and non-responders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension-type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95%CI 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95%CI: 17, 22%) of subjects who used the ED in the previous year, though frequent users accounted for 51% (95%CI: 49, 53) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socio-economic status, and a predilection for ED use for conditions other than headache. Conclusions Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use. PMID:19040677

Tick bite and Lyme disease-related emergency department encounters in New Hampshire, 2010-2014.

PubMed

Daly, E R; Fredette, C; Mathewson, A A; Dufault, K; Swenson, D J; Chan, B P

2017-12-01

Lyme disease (LD) is a common tick-borne disease in New Hampshire (NH). While LD is a reportable condition and cases are counted for public health surveillance, many more people receive care for tick bites or diagnoses of LD than are reflected in surveillance data. NH's emergency department (ED) data system was queried for tick bite and LD-related encounters. Chief complaint text was queried for words related to LD or tick bites. International Classification of Diseases 9th Revision (ICD-9) codes were queried for the LD diagnosis code (088.81). Emergency department patient data were matched to reportable disease data to determine the proportion of ED patients reported to the health department as a suspected LD case. Data were analysed to calculate frequencies for key demographic and reporting characteristics. From 2010 to 2014, 13,615 tick bite or LD-related ED encounters were identified in NH, with most due to tick bites (76%). Of 3,256 patients with a LD-related ED encounter, 738 (23%) were reported to the health department as a suspected LD case. The geographic distribution of ED patients was similar to reported LD cases; however, the regions of the state that experienced higher rates of ED encounters were different than the regions that observed higher rates of reported LD cases. Seasonal distribution of ED encounters peaked earlier than reported LD cases with a second peak in the fall. While age and sex distribution was similar among ED patients and reported LD cases, the rates for children 5 years and younger and adults 65 years and older were greater for ED encounters. Patients frequently visit the ED to seek care for tick bites and suspected LD. Results of ED data analyses can be used to target education, in particular for ED providers and the public through timely distribution of evidence-based educational materials and training programmes. © 2017 Blackwell Verlag GmbH.

The Ottawa Knee Rule: Examining Use in an Academic Emergency Department

PubMed Central

Beutel, Bryan G.; Trehan, Samir K.; Shalvoy, Robert M.; Mello, Michael J.

2012-01-01

Introduction: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance. Methods: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors related to the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables. Results: ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were “patient expectations” and system issues, such as “orthopedics referral requirement.” We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation between Ottawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others. Conclusion: Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions. PMID:23251717

Feasibility of Screening Patients With Nonpsychiatric Complaints for Suicide Risk in a Pediatric Emergency Department

PubMed Central

Horowitz, Lisa; Ballard, Elizabeth; Teach, Stephen J.; Bosk, Abigail; Rosenstein, Donald L.; Joshi, Paramjit; Dalton, Marc E.; Pao, Maryland

2012-01-01

Objective Screening children for suicide risk when they present to the emergency department (ED) with nonpsychiatric complaints could lead to better identification and treatment of high-risk youth. Before suicide screening protocols can be implemented for nonpsychiatric patients in pediatric EDs, it is essential to determine whether such efforts are feasible. Methods As part of an instrument validation study, ED patients (10–21 years old) with both psychiatric and nonpsychiatric presenting complaints were recruited to take part in suicide screening. Clinically significant suicidal thoughts, as measured by the Suicidal Ideation Questionnaire, and suicidal behaviors were assessed, as well as patient opinions about suicide screening. Recruitment rates for the study as well as impact on length of stay were assessed. Results Of the 266 patients and parents approached for the study, 159 (60%) agreed to participate. For patients entering the ED for nonpsychiatric reasons (n = 106), 5.7% (n = 6) reported previous suicidal behavior, and 5.7% (n = 6) reported clinically significant suicidal ideation. There were no significant differences for mean length of stay in the ED for nonpsychiatric patients with positive triggers and those who screened negative (means, 382 [SD, 198] and 393 [SD, 166] minutes, respectively; P = 0.80). Ninety-six percent of participants agreed that suicide screening should occur in the ED. Conclusions Suicide screening of nonpsychiatric patients in the ED is feasible in terms of acceptability to parents, prevalence of suicidal thoughts and behaviors, practicality to ED flow, and patient opinion. Future endeavors should address brief screening tools validated on nonpsychiatric populations. PMID:20944511

Interprofessional communication supporting clinical handover in emergency departments: An observation study.

PubMed

Redley, Bernice; Botti, Mari; Wood, Beverley; Bucknall, Tracey

2017-08-01

Poor interprofessional communication poses a risk to patient safety at change-of-shift in emergency departments (EDs). The purpose of this study was to identify and describe patterns and processes of interprofessional communication impacting quality of ED change-of-shift handovers. Observation of 66 change-of-shift handovers at two acute hospital EDs in Victoria, Australia. Focus groups with 34 nurse participants complemented the observations. Qualitative data analysis involved content and thematic methods. Four structural components of ED handover processes emerged represented by (ABCD): (1) Antecedents; (2) Behaviours and interactions; (3) Content; and (4) Delegation of ongoing care. Infrequent and ad hoc interprofessional communication and discipline-specific handover content and processes emerged as specific risks to patient safety at change-of-shift handovers. Three themes related to risky and effective practices to support interprofessional communications across the four stages of ED handovers emerged: 1) standard processes and practices, 2) teamwork and interactions and 3) communication activities and practices. Unreliable interprofessional communication can impact the quality of change-of-shift handovers in EDs and poses risk to patient safety. Structured reflective analysis of existing practices can identify opportunities for standardisation, enhanced team practices and effective communication across four stages of the handover process to support clinicians to enhance local handover practices. Future research should test and refine models to support analysis of practice, and identify and test strategies to enhance ED interprofessional communication to support clinical handovers. Copyright © 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

The Effect of Utilization Review on Emergency Department Operations.

PubMed

Desai, Shoma; Gruber, Phillip F; Eiting, Erick; Seabury, Seth A; Mack, Wendy J; Voyageur, Christian; Vasquez, Veronica; Kim, Hyung T; Terp, Sophie

2017-11-01

Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis-based criteria) or secondary review (medical necessity as determined by an on-site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30-day ED revisits, and 30-day admission rates. Excluding a 6-month implementation period, monthly summary metrics were compared pre- and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30-day ED revisits, 30-day admission rate among return visitors to the ED, and estimated cost. Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty-day revisits increased (20.4% to 24.4%), although the 30-day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled $193.17 per ED visit. The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30-day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Deliberate self-harm in the emergency department: experience from Karachi, Pakistan.

PubMed

Shahid, Muhammad; Khan, Murad M; Saleem Khan, Muhammad; Jamal, Yasir; Badshah, Aaref; Rehmani, Rifat

2009-01-01

Suicidal behavior is an understudied subject in Pakistan, a South-Asian developing country with a predominantly Muslim population. This study examined the characteristics and management of patients presenting with Deliberate Self-Harm (DSH) to the Emergency Department (ED) of a tertiary care teaching hospital in Karachi, Pakistan. A retrospective chart review of all patients (n = 98), over a period of 12 months was carried out. The demographic details of patients; method of DSH and, if drugs were used, their type, route, and quantity; reason for DSH; past psychiatric history; and outcome were recorded. The mean age of subjects was 23.5 years. The majority of patients were female; most had used drugs for DSH. After initial treatment in the ED, 34 patients were admitted to medical wards for further treatment, 12 were discharged from ED, while 52 patients left against medical advice. The main reasons for leaving against medical advice were financial constraints and fear of legal issues. Seven patients had at least one previous episode of DSH. Patients who left the ED without psychosocial assessment are at increased risk for repetition of DSH as well as suicide.

Dedicated Pediatricians in Emergency Department: Shorter Waiting Times and Lower Costs

PubMed Central

Melo, Manuel Rocha; Ferreira-Magalhães, Manuel; Flor-Lima, Filipa; Rodrigues, Mariana; Severo, Milton; Almeida-Santos, Luis; Caldas-Afonso, Alberto; Barros, Pedro Pita; Ferreira, António

2016-01-01

Background Dedicated pediatricians in emergency departments (EDs) may be beneficial, though no previous studies have assessed the related costs and benefits/harms. We aimed to evaluate the net benefits and costs of dedicated emergency pediatricians in a pediatric ED. Methods Cost-consequences analysis of visits to a pediatric ED of a tertiary hospital. Two pediatric ED Medical Teams (MT) were compared: MT-A (May–September 2012), with general pediatrics physicians only; and MT-B (May–September 2013), with emergency dedicated pediatricians. The main outcomes analyzed were relevant clinical outcomes, patient throughput time and costs. Results We included 8,694 children in MT-A and 9,417 in MT-B. Medication use in the ED increased from 42.3% of the children in MT-A to 49.6% in MT-B; diagnostic tests decreased from 24.2% in MT-A to 14.3% in MT-B. Hospitalization increased from 1.3% in MT-A to 3.0% in MT-B; however, there was no significant difference in diagnosis-related group relative weight of hospitalized children in MT-A and MT-B (MT-A, 0.979; MT-B, 1.075). No differences were observed in ED readmissions or in patients leaving without being seen by a physician. The patient throughput time was significantly shorter in MT-B, with faster times to first medical observation. Within the cost domains analyzed, the total expenditures per children observed in the ED were 16% lower in MT-B: 37.87 euros in MT-A; 31.97 euros in MT-B. Conclusion The presence of dedicated emergency pediatricians in a pediatric ED was associated with significantly lower waiting times in the ED, reduced costs, and similar clinical outcomes. PMID:27564093

Right service, right place: optimising utilisation of a community nursing service to reduce planned re-presentations to the emergency department.

PubMed

Lawton, Jessica Kirsten; Kinsman, Leigh; Dalton, Lisa; Walsh, Fay; Bryan, Helen; Williams, Sharon

2017-01-01

Congruent with international rising emergency department (ED) demand, a focus on strategies and services to reduce burden on EDs and improve patient outcomes is necessary. Planned re-presentations of non-urgent patients at a regional Australian hospital exceeded 1200 visits during the 2013-2014 financial year. Planned re-presentations perpetuate demand and signify a lack of alternative services for non-urgent patients. The Community Nursing Enhanced Connections Service (CoNECS) collaboratively evolved between acute care and community services in 2014 to reduce planned ED re-presentations. This study aimed to investigate the evolution and impact of a community nursing service to reduce planned re-presentations to a regional Australian ED and identify enablers and barriers to interventionist effectiveness. A mixed-methods approach evaluated the impact of CoNECS. Data from hospital databases including measured numbers of planned ED re-presentations by month, time of day, age, gender and reason were used to calculate referral rates to CoNECS. These results informed two semistructured focus groups with ED and community nurses. The researchers used a theoretical lens, 'diffusion of innovation', to understand how this service could inform future interventions. Analyses showed that annual ED planned re-presentations decreased by 43% (527 presentations) after implementation. Three themes emerged from the focus groups. These were right service at the right time, nursing uncertainty and system disconnect and medical disengagement. CoNECS reduced overall ED planned re-presentations and was sustained longer than many complex service-level interventions. Factors supporting the service were endorsement from senior administration and strong leadership to drive responsive quality improvement strategies. This study identified a promising alternative service outside the ED, highlighting possibilities for other hospital emergency services aiming to reduce planned re-presentations.

Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department

PubMed Central

Gabrielian, Sonya; Chen, Jennifer C.; Minhaj, Beena P.; Manchanda, Rishi; Altman, Lisa; Koosis, Ella; Gelberg, Lillian

2017-01-01

Objectives: Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population’s acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians’ attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. Methods: To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. Results: Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. Conclusion: Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic’s acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs. PMID:28367682

Temporal and Spatial Patterns in Utilization of Mental Health Services During and After Hurricane Sandy: Emergency Department and Inpatient Hospitalizations in New York City.

PubMed

He, Fangtao Tony; Lundy De La Cruz, Nneka; Olson, Donald; Lim, Sungwoo; Levanon Seligson, Amber; Hall, Gerod; Jessup, Jillian; Gwynn, Charon

2016-06-01

Hurricane Sandy made landfall on October 29, 2012, causing a coastal storm surge and extensive flooding, which led to the closure of several health care facilities in New York City (NYC) and prolonged interruptions in service delivery. The impact on mental health-related emergency department (ED) and inpatient hospital service utilization was studied. Data came from the New York Statewide Planning and Research Cooperative System. We obtained mental health-related data among NYC residents from 2010 to 2013. Patients were grouped into 5 geographic areas, including service areas of closed hospitals, the Hurricane Sandy evaluation zone, and all of NYC. The Farrington method was used to detect increases in ED visits and hospitalizations for the post-Sandy period. Open hospitals experienced a substantial increase in psychiatric ED visits from patients living in the service areas of closed hospitals. This surge in psychiatric ED visits persisted for 4 to 6 months after Hurricane Sandy. However, the increase in psychiatric hospitalizations was observed for 1 to 3 months. Several NYC hospitals received a substantially larger number of ED patients from service areas of closed hospitals after Hurricane Sandy, unlike other hospitals that experienced a decrease. Because of potential surges in the number of psychiatric ED visits, resource allocation to hospitals should be considered. (Disaster Med Public Health Preparedness. 2016;10:512-517).

Redesigning emergency department patient flows: application of Lean Thinking to health care.

PubMed

King, Diane L; Ben-Tovim, David I; Bassham, Jane

2006-08-01

To describe in some detail the methods used and outcome of an application of concepts from Lean Thinking in establishing streams for patient flows in a teaching general hospital ED. Detailed understanding was gained through process mapping with staff followed by the identification of value streams (those patients likely to be discharged from the ED, those who were likely to be admitted) and the implementation of a process of seeing those patients that minimized complex queuing in the ED. Streaming had a significant impact on waiting times and total durations of stay in the ED. There was a general flattening of the waiting time across all groups. A slight increase in wait for Triage categories 2 and 3 patients was offset by reductions in wait for Triage category 4 patients. All groups of patients spent significantly less overall time in the department and the average number of patients in the ED at any time decreased. There was a significant reduction in number of patients who do not wait and a slight decrease in access block. The streaming of patients into groups of patients cared for by a specific team of doctors and nurses, and the minimizing of complex queues in this ED by altering the practices in relation to the function of the Australasian Triage Scale improved patient flow, thereby decreasing potential for overcrowding.

Soap Suds Enema are Efficacious and Safe for Treating Fecal Impaction in Children with Abdominal Pain

PubMed Central

Chumpitazi, Corrie E.; Henkel, Erin B.; Valdez, Karina L.; Chumpitazi, Bruno P.

2016-01-01

Importance Constipation is a common cause of pediatric abdominal pain and emergency department (ED) presentation. Despite the high prevalence, there is a dearth of clinical information and wide practice variation in childhood constipation management in the ED. Objective To assess the efficacy and safety of soap suds enema (SSE) in the treatment of fecal impaction in children with abdominal pain within the pediatric emergency department (ED) setting. The primary outcome was stool output following SSE. Secondary outcomes were adverse events, admissions, and return visits within 72 hours. Methods This is a retrospective cross-sectional study performed in the ED at a quaternary care children’s hospital of patients seen over a 12-month period who received a SSE for fecal impaction. Results Five hundred twelve patients (53% female, median age 7.8 years, range: 8 months-23 years) received SSE therapy over a 1-year period. Successful therapy (bowel movement) following SSE occurred in 419 (82%). Adverse events included abdominal pain in 24 (5%) and nausea/vomiting in 18 (4%). No SSE-related serious adverse events were identified. Following SSE, 405 (79%) were subsequently discharged, of which 15 (3.7%) returned to the ED for re-evaluation within 72 hours. Conclusions and Relevance SSE is an efficacious and safe therapeutic option for the acute treatment of childhood fecal impaction in the ED setting. PMID:26655947

Patterns of low acuity patient presentations to emergency departments in New South Wales, Australia.

PubMed

Stephens, Alexandre S; Broome, Richard A

2017-06-01

To explore the patterns of low acuity patient (LAP) presentations to EDs in New South Wales (NSW), Australia. Retrospective study of NSW public hospital ED presentations between January 2013 and December 2014 that were registered in the NSW Emergency Department Data Collection (n = 409 035). LAPs were defined according to the Australian Institute of Health and Welfare (AIHW), Sprivulis and multiple ACEM methods. Multivariable logistic regression was used to assess the adjusted odds of LAP ED presentation by a suite of sociodemographic factors. The percentage of LAPs varied considerably by definition, being as high as 54.7% (inner regional areas) and as low as 3.2% (major cities) using revised ACEM methods modified to contain unlimited consultation times or consultation times of 15 min or less, respectively. For each method, higher proportions of LAPs were observed in inner regional and remote/very remote areas relative to major cities. LAP ED presentations, based on ACEM definition with 1 h or 15 min consultation times, were greater in younger patients, increased during out of business hours and weekends, and decreased with increasing general practitioner (GP) density. The percentage of LAPs varied substantially by definition, and further work is required to validate the methods, particularly around the appropriateness of length of consultation time with ACEM, between different hospitals and remoteness areas. Age was strongly associated with low acuity, with substantial effects also observed for GP density, and attendances during out of hours and weekends. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Telephone-based low intensity therapy after crisis presentations to the emergency department is associated with improved outcomes.

PubMed

Bidargaddi, Niranjan; Bastiampillai, Tarun; Allison, Stephen; Jones, Gabrielle M; Furber, Gareth; Battersby, Malcolm; Richards, David

2015-10-01

In Australia there is an overwhelming need to provide effective treatment to patients presenting to the Emergency Department (ED) in mental health crisis. We adapted Improving Access to Psychological Therapies service model (IAPT) from the National Health Service (NHS) method for the large scale delivery of psychological therapies throughout the United Kingdom to an Australian ED setting. This telephone-based low intensity therapy was provided to people presenting in crisis to the EDs with combinations of anxiety, depression, substance use, and suicidal thinking. This uncontrolled study utilised session-by-session, before-and-after measures of anxiety and depression via Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder-7 (GAD-7). Of 347 eligible post-crisis ED referred patients, 291 (83.9%) engaged with the IAPT team. Most patients (65%) had attended the ED previously on an average of 3.9 (SD = 6.0) occasions. Two hundred and forty one patients received an average of 4.1 (SD = 2.3) contacts of low-intensity psychological therapies including 1.2 (SD = 1.7) community outreach visits between 20th Oct 2011 and 31st Dec 2012. Treated patients reported clinically significant improvements in anxiety, depression and suicidal ideation. Uncontrolled effect sizes were moderate for anxiety (0.6) and depression (0.6). The Australian ED IAPT program demonstrated that the UK IAPT program could be adapted for emergency mental health patients and be associated with similar clinical benefits as the original program. The Flinders Medical Centre IAPT program received Emergency Department project funding from the Australian Commonwealth Government through the Council of Australian Governments (COAG) and the South Australian Government initiative, Every Patient Every Service (EPES). © The Author(s) 2015.

Audit of demand for after-hours CT scanning services in RANZCR-accredited training departments.

PubMed

Goergen, Stacy K; Grimm, Jane; Paul, Eldho; Fabiny, Robert; Lee, Wai Kit; Blome, Steven; Zhou, Kim; Munro, Philip L

2016-02-01

The aims of this study were to measure: (i) the growth in after-hours emergency department--referred CT (ED-CT) performed in accredited training departments between 2011 and 2013; (ii) the growth in ED CT relative to growth in ED presentations at the same hospitals; and (iii) trainee workload resulting from after-hours ED CT. Ethics approval was obtained for all participating sites. Accredited training facilities in Australia and New Zealand with three or more trainees and serving one or more EDs were invited to participate (N = 32). Four nights were surveyed between August and December 2013. For data collection, the number of ED patients having one or more CT scans; ED CT scan total images; non-contrast head CTs; and ED patients (total and categories 1 and 2) attending the ED in the preceding 24 h and first half of calendar year were collected for 2013 and corresponding days in 2012 and 2011. Trainee staffing levels were measured. Eleven of 32 sites provided data for all four nights and 14 of 32 for one or more nights. A 15.7% increase in number of ED CTs between 1700 and 2200 h and 16.8% increase between 2201 and 0730 h occurred in the 2 years between 2011 and 2013 compared with a 6.9% increase in overall ED and 26% increase in categories 1 and 2 presentations over the same period. The number of CT images, however, increased 23%. Growth in demand by EDs for after-hours CT services has implications for service provision and trainee workloads in Royal Australian and New Zealand College of Radiologists-accredited training departments. © 2015 The Royal Australian and New Zealand College of Radiologists.

Western Australian emergency department presentations related to child maltreatment and intentional injury: population level study utilising linked health and child protection data.

PubMed

O'Donnell, Melissa; Nassar, Natasha; Jacoby, Peter; Stanley, Fiona

2012-01-01

The aim of this study is to determine the proportion of child maltreatment-related emergency department (ED) presentations in Western Australia (WA) and describe the type of injuries associated with them. It is also to investigate the proportion of maltreatment-related ED presentations resulting in hospitalisation, the proportion referred to the Department for Child Protection and their outcomes. This is a retrospective cohort study of all children aged 0-17 years residing in WA from 2001 to 2005 who had an ED presentation recorded in the ED Data Collection. This study used de-identified administrative data linked across the Departments of Health and Child Protection. Only 0.03% of ED presentations were identified as maltreatment related and 0.2% for all intentional injury presentations. One in five children with maltreatment-related ED presentations was admitted to hospital and a similar proportion had a notification to Department for Child Protection and 87% of these subsequently substantiated. This study showed that there are limitations with ED data for child maltreatment surveillance in WA and raises concerns that there may be missed opportunities for identifying maltreatment and for referring families for further assessment and support. Recommendations are provided to improve maltreatment surveillance and ED data, particularly for the identification of external causes of injury. © 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when?

PubMed

Tenbensel, Tim; Chalmers, Linda; Jones, Peter; Appleton-Dyer, Sarah; Walton, Lisa; Ameratunga, Shanthi

2017-09-26

In 2009, the New Zealand government introduced a hospital emergency department (ED) target - 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when. We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing. Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing. While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in 'standing for' improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain.

Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments.

PubMed

Schnitker, Linda M; Martin-Khan, Melinda; Burkett, Ellen; Brand, Caroline A; Beattie, Elizabeth R A; Jones, Richard N; Gray, Len C

2015-03-01

The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs. © 2015 by the Society for Academic Emergency Medicine.

Differences in Access to Services in Rural Emergency Departments of Quebec and Ontario

PubMed Central

Archambault, Patrick; Audette, Louis David; Plant, Jeff; Bégin, François; Poitras, Julien

2015-01-01

Introduction Rural emergency departments (EDs) are important safety nets for the 20% of Canadians who live there. A serious problem in access to health care services in these regions has emerged. However, there are considerable geographic disparities in access to trauma center in Canada. The main objective of this project was to compare access to local 24/7 support services in rural EDs in Quebec and Ontario as well as distances to Levels 1 and 2 trauma centers. Materials and Methods Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities. There were 26 rural EDs in Quebec and 62 in Ontario meeting these criteria. Data were collected from ministries of health, local health authorities, and ED statistics. Fisher’s exact test, the t-test or Wilcoxon-Mann-Whitney test, were performed to compare rural EDs of Quebec and Ontario. Results All selected EDs of Quebec and Ontario agreed to participate in the study. The number of EDs visits was higher in Quebec than in Ontario (19 322 ± 6 275 vs 13 446 ± 8 056, p = 0.0013). There were no significant differences between Quebec and Ontario’s local population and small town population density. Quebec’s EDs have better access to advance imaging services such as CT scanner (77% vs 15%, p < .0001) and most the consultant support and ICU (92% vs 31%, p < .0001). Finally, more than 40% of rural EDs in Quebec and Ontario are more than 300 km away from Levels 1 and 2 trauma centers. Conclusions Considering that Canada has a Universal health care system, the discrepancies between Quebec and Ontario in access to support services are intriguing. A nationwide study is justified to address this issue. PMID:25874948

State Regulation Of Freestanding Emergency Departments Varies Widely, Affecting Location, Growth, And Services Provided.

PubMed

Gutierrez, Catherine; Lindor, Rachel A; Baker, Olesya; Cutler, David; Schuur, Jeremiah D

2016-10-01

Freestanding emergency departments (EDs), which offer emergency medical care at sites separate from hospitals, are a rapidly growing alternative to traditional hospital-based EDs. We evaluated state regulations of freestanding EDs and describe their effect on the EDs' location, staffing, and services. As of December 2015, thirty-two states collectively had 400 freestanding EDs. Twenty-one states had regulations that allowed freestanding EDs, and twenty-nine states did not have regulations that applied specifically to such EDs (one state had hospital regulations that precluded them). State policies regarding freestanding EDs varied widely, with no standard requirements for location, staffing patterns, or clinical capabilities. States requiring freestanding EDs to have a certificate of need had fewer of such EDs per capita than states without such a requirement. For patients to better understand the capabilities and costs of freestanding EDs and to be able to choose the most appropriate site of emergency care, consistent state regulation of freestanding EDs is needed. Project HOPE—The People-to-People Health Foundation, Inc.

Managing Injuries of the Neck Trial (MINT): design of a randomised controlled trial of treatments for whiplash associated disorders

PubMed Central

Lamb, Sarah E; Gates, Simon; Underwood, Martin R; Cooke, Matthew W; Ashby, Deborah; Szczepura, Ala; Williams, Mark A; Williamson, Esther M; Withers, Emma J; Mt Isa, Shahrul; Gumber, Anil

2007-01-01

Background A substantial proportion of patients with whiplash injuries develop chronic symptoms. However, the best treatment of acute injuries to prevent long-term problems is uncertain. A stepped care treatment pathway has been proposed, in which patients are given advice and education at their initial visit to the emergency department (ED), followed by review at three weeks and physiotherapy for those with persisting symptoms. MINT is a two-stage randomised controlled trial to evaluate two components of such a pathway: 1. use of The Whiplash Book versus usual advice when patients first attend the emergency department; 2. referral to physiotherapy versus reinforcement of advice for patients with continuing symptoms at three weeks. Methods Evaluation of the Whiplash Book versus usual advice uses a cluster randomised design in emergency departments of eight NHS Trusts. Eligible patients are identified by clinicians in participating emergency departments and are sent a study questionnaire within a week of their ED attendance. Three thousand participants will be included. Patients with persisting symptoms three weeks after their ED attendance are eligible to join an individually randomised study of physiotherapy versus reinforcement of the advice given in ED. Six hundred participants will be randomised. Follow-up is at 4, 8 and 12 months after their ED attendance. Primary outcome is the Neck Disability Index (NDI), and secondary outcomes include quality of life and time to return to work and normal activities. An economic evaluation is being carried out. Conclusion This paper describes the protocol and operational aspects of a complex intervention trial based in NHS emergency and physiotherapy departments, evaluating two components of a stepped-care approach to the treatment of whiplash injuries. The trial uses two randomisations, with the first stage being cluster randomised and the second individually randomised. PMID:17257408

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

PubMed

Neven, Darin; Paulozzi, Leonard; Howell, Donelle; McPherson, Sterling; Murphy, Sean M; Grohs, Becky; Marsh, Linda; Lederhos, Crystal; Roll, John

2016-11-01

Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing. Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.

When the visit to the emergency department is medically nonurgent: provider ideologies and patient advice.

PubMed

Guttman, N; Nelson, M S; Zimmerman, D R

2001-03-01

It is estimated that more than half of pediatric hospital emergency department (ED) visits are medically nonurgent. Anecdotal impressions suggest that ED providers castigate medically nonurgent visits, yet studies on such visits are scarce. This study explored the perspectives of 26 providers working in the EDs of two urban hospitals regarding medically nonurgent pediatric ED visits and advising parents or guardians on appropriate ED use. Three provider ideologies regarding the appropriateness of medically nonurgent ED use were identified and found to be linked to particular communication strategies that providers employed with ED users: restrictive, pragmatic, and all-inclusive. The analysis resulted in the development of a typology of provider ideological orientations toward ED use, distinguished according to different orientations toward professional dominance.

Time series modeling for syndromic surveillance.

PubMed

Reis, Ben Y; Mandl, Kenneth D

2003-01-23

Emergency department (ED) based syndromic surveillance systems identify abnormally high visit rates that may be an early signal of a bioterrorist attack. For example, an anthrax outbreak might first be detectable as an unusual increase in the number of patients reporting to the ED with respiratory symptoms. Reliably identifying these abnormal visit patterns requires a good understanding of the normal patterns of healthcare usage. Unfortunately, systematic methods for determining the expected number of (ED) visits on a particular day have not yet been well established. We present here a generalized methodology for developing models of expected ED visit rates. Using time-series methods, we developed robust models of ED utilization for the purpose of defining expected visit rates. The models were based on nearly a decade of historical data at a major metropolitan academic, tertiary care pediatric emergency department. The historical data were fit using trimmed-mean seasonal models, and additional models were fit with autoregressive integrated moving average (ARIMA) residuals to account for recent trends in the data. The detection capabilities of the model were tested with simulated outbreaks. Models were built both for overall visits and for respiratory-related visits, classified according to the chief complaint recorded at the beginning of each visit. The mean absolute percentage error of the ARIMA models was 9.37% for overall visits and 27.54% for respiratory visits. A simple detection system based on the ARIMA model of overall visits was able to detect 7-day-long simulated outbreaks of 30 visits per day with 100% sensitivity and 97% specificity. Sensitivity decreased with outbreak size, dropping to 94% for outbreaks of 20 visits per day, and 57% for 10 visits per day, all while maintaining a 97% benchmark specificity. Time series methods applied to historical ED utilization data are an important tool for syndromic surveillance. Accurate forecasting of emergency department total utilization as well as the rates of particular syndromes is possible. The multiple models in the system account for both long-term and recent trends, and an integrated alarms strategy combining these two perspectives may provide a more complete picture to public health authorities. The systematic methodology described here can be generalized to other healthcare settings to develop automated surveillance systems capable of detecting anomalies in disease patterns and healthcare utilization.

Non-Traumatic Dental Condition-Related Emergency Department Visits and Associated Costs for Children and Adults with Autism Spectrum Disorders

PubMed Central

Nakao, Sy; Scott, JoAnna M.; Masterson, Erin E.; Chi, Donald L.

2014-01-01

We analyzed 2010 U.S. National Emergency Department Sample data and ran regression models to test the hypotheses that individuals with ASD are more likely to have non-traumatic dental condition (NTDC)-related emergency department (ED) visits and to incur greater costs for these visits than those without ASD. There were nearly 2.3 million NTDC-related ED visits in 2010. Less than 1.0% (children) and 2.1% (adults) of all ED visits were for NTDC. There was no significant difference in NTDC-related ED visits or costs for children by ASD status. Adults with ASD had significantly lower odds of NTDC-related ED visits (OR=0.39; 95% CI: 0.29, 0.52; P<0.001) but incurred significantly greater mean costs for NTDC-related ED visits (P<0.006) than did adults without ASD. PMID:25374135

An emergency department-based mental health nurse practitioner outpatient service: part 1, participant evaluation.

PubMed

Wand, Timothy; White, Kathryn; Patching, Joanna; Dixon, Judith; Green, Timothy

2011-12-01

The mental health liaison nurse role in the emergency department (ED) has demonstrated a range of positive outcomes for both consumers and staff. In Australia, the added value associated with establishing mental health nurse practitioner (MHNP) positions based on this model is emerging. This paper presents qualitative findings from a study using a mixed-method design to evaluate an ED-based MHNP outpatient service in Sydney, Australia. In evaluating this new service, semistructured interviews were conducted with a random selection of study participants and a stratified sample of ED staff. This is the first of a two-part paper that presents an analysis of qualitative data from interviews conducted with study participants (n = 23). Participants reported numerous therapeutic benefits from the service, such as support, understanding, and a focus on solutions rather than problems, and high levels of satisfaction with the accessibility of the service and follow up. Suggestions for improving the service were also offered. Participants emphasized that overall ED service provision would be enhanced through additional resources, especially an extension of operating hours. Findings from these participant interviews provide strong support for an ED-based MHNP outpatient service. © 2011 The Authors. International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

Ambient versus traditional environment in pediatric emergency department.

PubMed

Robinson, Patricia S; Green, Jeanette

2015-01-01

We sought to examine the effect of exposure to an ambient environment in a pediatric emergency department. We hypothesized that passive distraction from ambient lighting in an emergency department would lead to reduction in patient pain and anxiety and increased caregiver satisfaction with services. Passive distraction has been associated with lower anxiety and pain in patients and affects perception of wait time. A pediatric ED was designed that optimized passive distraction techniques using colorful ambient lighting. Participants were nonrandomly assigned to either an ambient ED environment or a traditional ED environment. Entry and exit questionnaires assessed caregiver expectations and experiences. Pain ratings were obtained with age-appropriate scales, and wait times were recorded. A total of 70 participants were assessed across conditions, that is, 40 in the ambient ED group and 30 in the traditional ED group. Caregivers in the traditional ED group expected a longer wait, had higher anxiety pretreatment, and felt more scared than those in the ambient ED group. Caregivers in the ambient ED group felt more included in the care of their child and rated quality of care higher than caregivers in the traditional ED group. Pain ratings and administrations of pain medication were lower in the ambient ED group. Mean scores for the ambient ED group were in the expected direction on several items measuring satisfaction with ED experiences. Results were suggestive of less stress in caregivers, less pain in patients, and higher satisfaction levels in the ambient ED group. © The Author(s) 2015.

Factors Associated with Emergency Department Use among the Rural Elderly

ERIC Educational Resources Information Center

Fan, Lin; Shah, Manish N.; Veazie, Peter J.; Friedman, Bruce

2011-01-01

Context: Emergency Department (ED) use among the rural elderly may present a different pattern from the urban elderly, thus requiring different policy initiatives. However, ED use among the rural elderly has seldom been studied and is little understood. Purpose: To characterize factors associated with having any versus no ED use among the rural…

The cost of fall related presentations to the ED: a prospective, in-person, patient-tracking analysis of health resource utilization.

PubMed

Woolcott, J C; Khan, K M; Mitrovic, S; Anis, A H; Marra, C A

2012-05-01

We prospectively collected data on elderly fallers to estimate the total cost of a fall requiring an Emergency Department presentation. Using data collected on 102 falls, we found the average cost per fall causing an Emergency Department presentation of $11,408. When hospitalization was required, the average cost per fall was $29,363. For elderly persons, falls are a major source of mortality, morbidity, and disability. Previous Canadian cost estimates of seniors' falls were based upon administrative data that has been shown to underestimate the incidence of falls. Our objective was to use a labor-intensive, direct observation patient-tracking method to accurately estimate the total cost of falls among seniors who presented to a major urban Emergency Department (ED) in Canada. We prospectively collected data from seniors (>70 years) presenting to the Vancouver General Hospital ED after a fall. We excluded individuals who where cognitively impaired or unable to read/write English. Data were collected on the care provided including physician assessments/consultations, radiology and laboratory tests, ED/hospital time, rehabilitation facility time, and in-hospital procedures. Unit costs of health resources were taken from a fully allocated hospital cost model. Data were collected on 101 fall-related ED presentations. The most common diagnoses were fractures (n = 33) and lacerations (n = 11). The mean cost of a fall causing ED presentation was $11,408 (SD: $19,655). Thirty-eight fallers had injuries requiring hospital admission with an average total cost of $29,363 (SD: $22,661). Hip fractures cost $39,507 (SD: $17,932). Among the 62 individuals not admitted to the hospital, the average cost of their ED visit was $674 (SD: $429). Among the growing population of Canadian seniors, falls have substantial costs. With the cost of a fall-related hospitalization approaching $30,000, there is an increased need for fall prevention programs.

Care initiation area yields dramatic results.

PubMed

2009-03-01

The ED at Gaston Memorial Hospital in Gastonia, NC, has achieved dramatic results in key department metrics with a Care Initiation Area (CIA) and a physician in triage. Here's how the ED arrived at this winning solution: Leadership was trained in and implemented the Kaizen method, which eliminates redundant or inefficient process steps. Simulation software helped determine additional space needed by analyzing arrival patterns and other key data. After only two days of meetings, new ideas were implemented and tested.

Does an integrated Emergency Department Information System change the sequence of clinical work? A mixed-method cross-site study.

PubMed

Callen, Joanne; Li, Ling; Georgiou, Andrew; Paoloni, Richard; Gibson, Kathryn; Li, Julie; Stewart, Michael; Braithwaite, Jeffrey; Westbrook, Johanna I

2014-12-01

(1) to describe Emergency Department (ED) physicians' and nurses' perceptions about the sequence of work related to patient management with use of an integrated Emergency Department Information System (EDIS), and (2) to measure changes in the sequence of clinician access to patient information. A mixed method study was conducted in four metropolitan EDs. Each used the same EDIS which is a module of the hospitals' enterprise-wide clinical information system composed of many components of an electronic medical record. This enabled access to clinical and management information relating to patients attending all hospitals in the region. Phase one - data were collected from ED physicians and nurses (n=97) by 69 in-depth interviews, five focus groups (28 participants), and 26 h of observations. Phase two - physicians (n=34) in one ED were observed over 2 weeks. Data included whether and what type of information was accessed from the EDIS prior to first examination of the patient. Clinicians reported, and phase 2 observations confirmed, that the integrated EDIS led to changes to the order of information access, which held implications for when tests were ordered and results accessed. Most physicians accessed patient information using EDIS prior to taking the patients' first medical history (77/116; 66.4%, 95% CI: 57.8-75.0%). Previous discharge summaries (74%) and past test results (61%) were most frequently accessed and junior doctors were more likely to access electronic past history information than their senior colleagues (χ(2)=20.717, d.f.=1, p<0.001). The integrated EDIS created new ways of working for ED clinicians. Such changes could hold positive implications for: time taken to reach a diagnosis and deliver treatments; length of stay; patient outcomes and experiences. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Frequent Users of Hospital Emergency Departments in Korea Characterized by Claims Data from the National Health Insurance: A Cross Sectional Study

PubMed Central

Woo, Jung Hoon; Grinspan, Zachary; Shapiro, Jason; Rhee, Sang Youl

2016-01-01

The Korean National Health Insurance, which provides universal coverage for the entire Korean population, is now facing financial instability. Frequent emergency department (ED) users may represent a medically vulnerable population who could benefit from interventions that both improve care and lower costs. To understand the nature of frequent ED users in Korea, we analyzed claims data from a population-based national representative sample. We performed both bivariate and multivariable analyses to investigate the association between patient characteristics and frequent ED use (4+ ED visits in a year) using claims data of a 1% random sample of the Korean population, collected in 2009. Among 156,246 total ED users, 4,835 (3.1%) were frequent ED users. These patients accounted for 14% of 209,326 total ED visits and 17.2% of $76,253,784 total medical expenses generated from all ED visits in the 1% data sample. Frequent ED users tended to be older, male, and of lower socio-economic status compared with occasional ED users (p < 0.001 for each). Moreover, frequent ED users had longer stays in the hospital when admitted, higher probability of undergoing an operative procedure, and increased mortality. Among 8,425 primary diagnoses, alcohol-related complaints and schizophrenia showed the strongest positive correlation with the number of ED visits. Among the frequent ED users, mortality and annual outpatient department visits were significantly lower in the alcohol-related patient subgroup compared with other frequent ED users; furthermore, the rate was even lower than that for non-frequent ED users. Our findings suggest that expanding mental health and alcohol treatment programs may be a reasonable strategy to decrease the dependence of these patients on the ED. PMID:26809051

Emergency nurses' perception of department design as an obstacle to providing end-of-life care.

PubMed

Beckstrand, Renea L; Rasmussen, Ryan J; Luthy, Karlen E; Heaston, Sondra

2012-09-01

Of the 119.2 million visits to the emergency department in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In 2 national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses and to determine how much input emergency nurses have on the design of their emergency department. A 25-item questionnaire regarding ED design as it affects EOL care was sent to a national, geographically dispersed, random sample of 500 members of ENA. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis. Two mailings yielded 198 usable responses. Nurses did not report that ED design was as large an obstacle to EOL care as previous studies had suggested. Nurses reported that the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested ED designs. Overall, nurses reported some dissatisfaction with ED design and believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department. Copyright © 2012 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.

Development and testing of emergency department patient transfer communication measures.

PubMed

Klingner, Jill; Moscovice, Ira

2012-01-01

Communication problems are a major contributing factor to adverse events in hospitals.(1) The contextual environment in small rural hospitals increases the importance of emergency department (ED) patient transfer communication quality. This study addresses the communication problems through the development and testing of ED quality measurement of interfacility patient transfer communication. Input from existing measures, measurement and health care delivery experts, as well as hospital frontline staff was used to design and modify ED quality measures. Three field tests were conducted to determine the feasibility of data collection and the effectiveness of different training methods and types of partnerships. Measures were evaluated based on their prevalence, ease of data collection, and usefulness for internal and external improvement. It is feasible to collect ED quality measure data. Different data sources, data collection, and data entry methods, training and partners can be used to examine hospital ED quality. There is significant room for improvement in the communication of patient information between health care facilities. Current health care reform efforts highlight the importance of clear communication between organizations held accountable for patient safety and outcomes. The patient transfer communication measures have been tested in a wide range of rural settings and have been vetted nationally. They have been endorsed by the National Quality Forum, are included in the National Quality Measurement Clearinghouse supported by the Agency for Health Care Research and Quality (AHRQ), and are under consideration by the Centers for Medicare and Medicaid Services for future payment determinations beginning in calendar year 2013. © 2011 National Rural Health Association.

Effectiveness of Emergency Department Based Palliative Care for Adults with Advanced Disease: A Systematic Review

PubMed Central

Nunes, Cristina Moura; Gomes, Barbara

2016-01-01

Abstract Background: Emergency departments (EDs) are seeing more patients with palliative care (PC) needs, but evidence on best practice is scarce. Objectives: To examine the effectiveness of ED-based PC interventions on hospital admissions (primary outcome), length of stay (LOS), symptoms, quality of life, use of other health care services, and PC referrals for adults with advanced disease. Methods: We searched five databases until August 2014, checked reference lists/conference abstracts, and contacted experts. Eligible studies were controlled trials, pre-post studies, cohort studies, and case series reporting outcomes of ED-based PC. Results: Five studies with 4374 participants were included: three case series and two cohort studies. Interventions included a screening tool, traditional ED-PC, and integrated ED-PC. Two studies reported on hospital admissions: in one study there was no statistically significant difference in 90-day readmission rates between patients who initiated integrated PC at the ED (11/50 patients, 22%) compared to those who initiated PC after hospital admission (179/1385, 13%); another study showed a high admission rate (90%) in 14 months following ED-PC, but without comparison. One study showed an LOS reduction (mean 4.32 days in ED-initiated PC group versus 8.29 days in postadmission-initiated group; p < 0.01). There was scarce evidence on other outcomes except for conflicting findings on survival: in one study, ED-PC patients were more likely to experience an interval between ED presentation and death >9 hours (OR 2.75, 95% CI 2.21–3.41); another study showed increased mortality risk in the intervention group; and a case series described a higher in-hospital death rate when PC was ED-initiated (62%), compared to ward (16%) or ICU (50%) (unknown p-value). Conclusions: There is yet no evidence that ED-based PC affects patient outcomes except for indication from one study of no association with 90-day hospital readmission but a possible reduction in LOS if integrated PC is introduced early at ED rather than after hospital admission. There is an urgent need for trials to confirm these findings alongside other potential benefits and survival effects. PMID:27115914

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

PubMed Central

Rust, George; Baltrus, Peter; Ye, Jiali; Daniels, Elvan; Quarshie, Alexander; Boumbulian, Paul; Strothers, Harry

2009-01-01

CONTEXT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE We compared uninsured ED visit rates between rural counties in Georgia which have a community health center clinic site vs. counties without a CHC presence. METHODS We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003-2005. Counties were classified as having a CHC presence if a federally funded (Section 330) community health center had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and presence of a CHC. To assure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS Counties without a community health center primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio=1.33, 95% CI=1.11-1.59). Higher ED visit rates remained significant (RR=1.21, 95% CI=1.02-1.42) after adjustment for percent of population below poverty level, percent black, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR=1.22, 95% CI=1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR=1.06, 95% CI=0.92-1.22). CONCLUSIONS Absence of a community health center is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured. PMID:19166556

Why Do Patients With Cancer Visit Emergency Departments? Results of a 2008 Population Study in North Carolina

PubMed Central

Mayer, Deborah K.; Travers, Debbie; Wyss, Annah; Leak, Ashley; Waller, Anna

2011-01-01

Purpose Emergency departments (EDs) in the United States are used by patients with cancer for disease or treatment-related problems and unrelated issues. The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) collects information about ED visits through a statewide database. Patients and Methods After approval by the institutional review board, 2008 NC DETECT ED visit data were acquired and cancer-related visits were identified. Descriptive statistics and logistic regressions were performed. Of 4,190,911 ED visits in 2008, there were 37,760 ED visits by 27,644 patients with cancer. Results Among patients, 77.2% had only one ED visit in 2008, the mean age was 64 years, and there were slightly more men than women. Among visits, the payor was Medicare for 52.4% and Medicaid for 12.1%. More than half the visits by patients with cancer occurred on weekends or evenings, and 44.9% occurred during normal hours. The top three chief complaints were related to pain, respiratory distress, and GI issues. Lung, breast, prostate, and colorectal cancers were identified in 26.9%, 6.3%, 6%, and 7.7% of visits, respectively, with diagnosis. A total of 63.2% of visits resulted in hospital admittance. When controlling for sex, age, time of day, day of week, insurance, and diagnosis position, patients with lung cancer were more likely to be admitted than patients with other types of cancer. Conclusion To the best of our knowledge, this is the first study to provide a population-based snapshot of ED visits by patients with cancer in North Carolina. Efforts that target clinical problems and specific populations may improve delivery of quality cancer care and avoid ED visits. PMID:21606431

Why are alcohol-related emergency department presentations under-detected? An exploratory study using nursing triage text.

PubMed

Indig, Devon; Copeland, Jan; Conigrave, K M; Rotenko, Irene

2008-11-01

This study examined two methods of detecting alcohol-related emergency department (ED) presentations, provisional medical diagnosis and nursing triage text, and compared patient and service delivery characteristics to determine which patients are being missed from formal diagnosis in order to explore why alcohol-related ED presentations are under-detected. Data were reviewed for all ED presentations from 2004 to 2006 (n = 118,881) for a major teaching hospital in Sydney, Australia. Each record included two nursing triage free-text fields, which were searched for over 60 alcohol-related terms and coded for a range of issues. Adjusted odds ratios were used to compare diagnostically coded alcohol-related presentations to those detected using triage text. Approximately 4.5% of ED presentations were identified as alcohol-related, with 24% of these identified through diagnostic codes and the remainder identified by triage text. Diagnostic coding was more likely if the patient arrived by ambulance [odds ratio (OR) = 2.35] or showed signs of aggression (OR = 1.86). Failure to code alcohol-related issues was more than three times (OR = 3.23) more likely for patients with injuries. Alcohol-related presentations place a high demand on ED staff and less than one-quarter have an alcohol-related diagnosis recorded by their treating doctor. In order for routine ED data to be more effective for detecting alcohol-related ED presentations, it is recommended that additional resources such as an alcohol health worker be employed in Australian hospitals. These workers can educate and support ED staff to identify more clearly and record the clinical signs of alcohol and directly provide brief interventions.

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study

PubMed Central

2013-01-01

Background To evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting. Methods A pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression. Results Structured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of “personal information overheard by others”, being “seen by irrelevant persons”, having “unintentionally heard inappropriate conversations from healthcare providers”, and experiencing “providers’ respect for my privacy”. There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis. Conclusions Significant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction. PMID:23421603

Lean techniques for the improvement of patients’ flow in emergency department

PubMed Central

Chan, HY; Lo, SM; Lee, LLY; Lo, WYL; Yu, WC; Wu, YF; Ho, ST; Yeung, RSD; Chan, JTS

2014-01-01

BACKGROUND: Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called “lean” management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process. METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared. RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05). CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction. PMID:25215143

Consensus Statement on Advancing Research in Emergency Department Operations and Its Impact on Patient Care

PubMed Central

Ward, Michael J.; Chang, Anna Marie; Pines, Jesse M.; Jouriles, Nick; Yealy, Donald M.

2016-01-01

The Consensus Conference on “Advancing Research in Emergency Department (ED) Operations and Its Impact on Patient Care,” hosted by The ED Operations Study Group (EDOSG), convened to craft a framework for future investigations in this important but underserved area. The EDOSG is a research consortium dedicated to promoting evidence based clinical practice in Emergency Medicine. The consensus process format was a modified version of the NIH Model for Consensus Conference Development. Recommendations provide an action plan for how to improve ED operations study design, create a facilitating research environment, identify data measures of value for process and outcomes research, and disseminate new knowledge in this area. Specifically, we called for eight key initiatives: 1) the development of universal measures for ED patient care processes; 2) attention to patient outcomes, in addition to process efficiency and best practice compliance; 3) the promotion of multi-site clinical operations studies to create more generalizable knowledge; 4) encouraging the use of mixed methods to understand the social community and human behavior factors that influence ED operations; 5) the creation of robust ED operations research registries to drive stronger evidence based research, 6) prioritizing key clinical questions with the input of patients, clinicians, medical leadership, emergency medicine organizations, payers, and other government stakeholders; 7) more consistently defining the functional components of the ED care system including observation units, fast tracks, waiting rooms, laboratories and radiology sub-units; and 8) maximizing multidisciplinary knowledge dissemination via emergency medicine, public health, general medicine, operations research and nontraditional publications. PMID:26014365

Consensus statement on advancing research in emergency department operations and its impact on patient care.

PubMed

Yiadom, Maame Yaa A B; Ward, Michael J; Chang, Anna Marie; Pines, Jesse M; Jouriles, Nick; Yealy, Donald M

2015-06-01

The consensus conference on "Advancing Research in Emergency Department (ED) Operations and Its Impact on Patient Care," hosted by The ED Operations Study Group (EDOSG), convened to craft a framework for future investigations in this important but understudied area. The EDOSG is a research consortium dedicated to promoting evidence-based clinical practice in emergency medicine. The consensus process format was a modified version of the NIH Model for Consensus Conference Development. Recommendations provide an action plan for how to improve ED operations study design, create a facilitating research environment, identify data measures of value for process and outcomes research, and disseminate new knowledge in this area. Specifically, we call for eight key initiatives: 1) the development of universal measures for ED patient care processes; 2) attention to patient outcomes, in addition to process efficiency and best practice compliance; 3) the promotion of multisite clinical operations studies to create more generalizable knowledge; 4) encouraging the use of mixed methods to understand the social community and human behavior factors that influence ED operations; 5) the creation of robust ED operations research registries to drive stronger evidence-based research; 6) prioritizing key clinical questions with the input of patients, clinicians, medical leadership, emergency medicine organizations, payers, and other government stakeholders; 7) more consistently defining the functional components of the ED care system, including observation units, fast tracks, waiting rooms, laboratories, and radiology subunits; and 8) maximizing multidisciplinary knowledge dissemination via emergency medicine, public health, general medicine, operations research, and nontraditional publications. © 2015 by the Society for Academic Emergency Medicine.

Comparing the validity of different sources of information on emergency department visits: a latent class analysis.

PubMed

Dendukuri, Nandini; McCusker, Jane; Bellavance, François; Cardin, Sylvie; Verdon, Josée; Karp, Igor; Belzile, Eric

2005-03-01

Emergency department (ED) use in Quebec may be measured from varied sources, eg, patient's self-reports, hospital medical charts, and provincial health insurance claims databases. Determining the relative validity of each source is complicated because none is a gold standard. We sought to compare the validity of different measures of ED use without arbitrarily assuming one is perfect. Data were obtained from a nursing liaison intervention study for frail seniors visiting EDs at 4 university-affiliated hospitals in Montreal. The number of ED visits during 2 consecutive follow-up periods of 1 and 4 months after baseline was obtained from patient interviews, from medical charts of participating hospitals, and from the provincial health insurance claims database. Latent class analysis was used to estimate the validity of each source. The impact of the following covariates on validity was evaluated: hospital visited, patient's demographic/clinical characteristics, risk of functional decline, nursing liaison intervention, duration of recall, previous ED use, and previous hospitalization. The patient's self-report was found to be the least accurate (sensitivity: 70%, specificity: 88%). Claims databases had the greatest validity, especially after defining claims made on consecutive days as part of the same ED visit (sensitivity: 98%, specificity: 98%). The validity of the medical chart was intermediate. Lower sensitivity (or under-reporting) on the self-report appeared to be associated with higher age, low comorbidity and shorter length of recall. The claims database is the most valid method of measuring ED use among seniors in Quebec compared with hospital medical charts and patient-reported use.

An outcomes evaluation of an emergency department early pregnancy assessment service and early pregnancy assessment protocol

PubMed Central

Wendt, Kim; Crilly, Julia; May, Chris; Bates, Kym; Saxena, Rakhee

2014-01-01

Background Complications in early pregnancy, such as threatened or actual miscarriage is a common occurrence resulting in many women presenting to the emergency department (ED). Early pregnancy service delivery models described in the literature vary in terms of approach, setting and outcomes. Our objective was to determine outcomes of women who presented to an Australian regional ED with diagnoses consistent with early pregnancy complications following the implementation of an early pregnancy assessment service (EPAS) and early pregnancy assessment protocol (EPAP) in July 2011. Methods A descriptive, comparative (6 months before and after) study was undertaken. Data were extracted from the hospital ED information system and medical healthcare records. Outcome measures included: time to see a clinician, ED length of stay, admission rate, re-presentation rate, hospital admission and types of pathology tests ordered. Results Over the 12 -month period, 584 ED presentations were made to the ED with complications of early pregnancy (268 PRE and 316 POST EPAS–EPAP). Outcomes that improved statistically and clinically following implementation included: time to see a clinician (decreased by 6 min from 35 to 29 min), admission rate (decreased 6% from 14.5% to 8.5%), increase in β-human chorionic gonadotrophin ordering by 10% (up to 80% POST), increase in ultrasound (USS) performed by 10% (up to 73% POST) and increase in pain score documentation by 23% (up to 36% POST). Conclusions The results indicate that patient and service delivery improvements can be achieved following the implementation of targeted service delivery models such as EPAS and EPAP in the ED. PMID:24136123

Multimedia education increases elder knowledge of emergency department care.

PubMed

Terndrup, Thomas E; Ali, Sameer; Hulse, Steve; Shaffer, Michele; Lloyd, Tom

2013-03-01

Elders who utilize the emergency department (ED) may have little prospective knowledge of appropriate expectations during an ED encounter. Improving elder orientation to ED expectations is important for satisfaction and health education. The purpose of this study was to evaluate a multi-media education intervention as a method for informing independently living elders about ED care. The program delivered messages categorically as, the number of tests, providers, decisions and disposition decision making. Interventional trial of representative elders over 59 years of age comparing pre and post multimedia program exposure. A brief (0.3 hour) video that chronicled the key events after a hypothetical 911 call for chest pain was shown. The video used a clinical narrator, 15 ED health care providers, and 2 professional actors for the patient and spouse. Pre- and post-video tests results were obtained with audience response technology (ART) assessed learning using a 4 point Likert scale. Valid data from 142 participants were analyzed pre to post rankings (Wilcoxon signed-rank tests). The following four learning objectives showed significant improvements: number of tests expected [median differences on a 4-point Likert scale with 95% confidence intervals: 0.50 (0.00, 1.00)]; number of providers expected 1.0 (1.00, 1.50); communications 1.0 (1.00, 1.50); and pre-hospital medical treatment 0.50 (0.00, 1.00). Elders (96%) judged the intervention as improving their ability to cope with an ED encounter. A short video with graphic side-bar information is an effective educational strategy to improve elder understanding of expectations during a hypothetical ED encounter following calling 911.

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program

PubMed Central

2009-01-01

Background This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). Methods All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Results Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Conclusion Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care. PMID:19968871

Integrating Point-of-Care Testing into a Community Emergency Department: A Mixed-Methods Evaluation.

PubMed

Pines, Jesse M; Zocchi, Mark S; Carter, Caitlin; Marriott, Charles Z; Bernard, Matthew; Warner, Leah H

2018-05-13

Point-of-care testing (POCT) is a commonly used technology that hastens the time to laboratory results in emergency departments (ED). We evaluated an ED-based POCT program on ED length of stay and time to care, coupled with qualitative interviews of local ED stakeholders. We conducted a mixed-methods study (2012-16) to examine the impact of point-of-care testing in a single, community ED. The quantiative analysis involved an observational before-after study comparing time to laboratory test result (POC troponin or POC chemistry) and ED length of stay after implementation of POCT, using a propensity-weighted interrupted time series analysis (ITSA). A complementary qualitative analysis involved five semi-structured interviews with staff using grounded theory on the benefits and challenges to ED POCT. A total of 47,399 ED visits were included in the study (24,705 in pre-intervention period and 22,694 in post-intervention). After POCT implementation, overall laboratory testing increased marginally from 61 to 62%. Central laboratory troponin and chemistry declined by >50% and was replaced by POCT. Prior to POCT implementation, time to troponin and chemistry had declined steadily due to other improvements in laboratory efficiency. After POCT implementation, there was an immediate 20 minute further decline (p<0.001) in both time to troponin and time to chemistry results using the propensity-weighted comparisons. However, the declining trend observed prior to POCT implementation did not continue at the same rate post implementation. Similarly, prior to POCT implementation, ED length of stay (LOS) declined due to other quality improvements. After POCT implementation, LOS continued declined at a similar rate. Because of this prior trend, the ITSA did not show a significant decline in LOS attributable to POCT. Common benefits of POCT perceived by staff in qualitative interviews included improved quality of care (64%), and reductions in time to test results (44%). Common challenges included concerns over POCT accuracy (32%), and technical barriers (29%). In the study ED, implementation of POCT was associated with a reduction in time to test result for both troponin and chemistry. Local staff felt that faster time to test result improved quality of care; however, concerns were raised with POCT accuracy. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Why Do Cancer Patients Die in the Emergency Department? An Analysis of 283 Deaths in NC EDs

PubMed Central

Leak, Ashley; Mayer, Deborah K.; Wyss, Annah; Travers, Debbie; Waller, Anna

2013-01-01

Emergency department (ED) visits are made by cancer patients for symptom management, treatment effects, oncologic emergencies, or end of life care. While most patients prefer to die at home, many die in health care institutions. The purpose of this study is to describe visit characteristics of cancer patients who died in the ED and their most common chief complaints using 2008 ED visit data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). Of the 37,760 cancer-related ED visits, 283 resulted in death. For lung cancer patients, 104 died in the ED with 70.9% dying on their first ED visit. Research on factors precipitating ED visits by cancer patients is needed to address end of life care needs. PMID:22556288

National survey of emergency departments in Denmark.

PubMed

Wen, Leana S; Anderson, Philip D; Stagelund, Søren; Sullivan, Ashley F; Camargo, Carlos A

2013-06-01

Emergency departments (EDs) are the basic unit of emergency medicine, but often differ in fundamental features. We sought to describe and characterize EDs in Denmark. All EDs open 24/7 to the general public were surveyed using the National ED Inventories survey instrument (http://www.emnet-nedi.org). ED staff were asked about ED characteristics with reference to the calendar year 2008. Twenty-eight EDs participated (82% response). All were located in hospitals. Less than half [43%, 95% confidence interval (CI) 24-63%] were independent departments. Thirty-nine percent (95% CI 22-59%) had a contiguous layout, with medical and surgical care provided in one area. The vast majority of EDs saw both adults and children; only 10% saw adults only and none saw children only. The median number of annual visits was 32 000 (interquartile range, 14 700-47 000). The majority (68%, 95% CI 47-89%) believed that their ED was at good balance or capacity, with 22% responding that they were under capacity and 9% reporting overcapacity. Technological resources were generally available, with the exception of dedicated computed tomography scanners and negative-pressure rooms. Almost all common emergencies were identified as being treatable 24/7 in the EDs. Although there is some variation in their layout and characteristics, most Danish EDs have a high degree of resource availability and are able to treat common emergencies. As Denmark seeks to reform emergency care through ED consolidation, this national survey helps to establish a benchmark for future comparisons.

Characteristics of Asthmatic Patients with and without Repeat Emergency Department Visits at an Inner City Hospital

PubMed Central

Pai, Sucheta; Mancuso, Carol A.; Loganathan, Raghu; Boutin-Foster, Carla; Basir, Riyad; Kanna, Balavenkatesh

2014-01-01

Objective The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma. Methods During an ED visit for asthma in an inner city hospital (‘index visit’), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit. Results 192 patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multivariate model, more past ED visits (OR 1.7, 95% CI 1.4, 2.1; p<.0001) and male gender (OR 2.5, 95% CI 1.2, 5.4; p=.02) remained associated with having a repeat ED visit. Most patients had the first repeat ED visit within 30 days and 18 returned within only 7 days. Among all patients with a repeat visit, those who were not hospitalized for the index visit were more likely to have a repeat visit within 7 days (37%) compared to those who were hospitalized (17%) (p=.05 in multivariate analysis). Conclusions Repeat ED visits were prevalent among inner city asthma patients and most occurred shortly after the index visit. The strongest predictors of repeat visits were male gender and more ED visits in the 12 months before the index visit. PMID:24588683

Marketing and public relations in the emergency department.

PubMed

Mayer, T A; Tilson, W; Hemingway, J

1987-02-01

This article outlines the elements of successful ED marketing, as well as providing definitions for terms used within the marketing process. In today's competition and rapidly changing environment, marketing and public relations are tools that every ED Medical Director may want to consider. Because the marketing process requires a great deal of time and effort, as well as a high degree of intellectual honesty, it should never be entered into without a strong commitment. However, marketing the ED can be among the most productive, stimulating, and gratifying experiences for the ED Medical Director, the emergency department physicians, and all ED service personnel.

Don't panic--prepare: towards crisis-aware models of emergency department operations.

PubMed

Ceglowski, Red; Churilov, Leonid; Wasserheil, Jeff

2005-12-01

The existing models of Emergency Department (ED) operations that are based on the "flow-shop" management logic do not provide adequate decision support in dealing with the ED overcrowding crises. A conceptually different crisis-aware approach to ED modelling and operational decision support is introduced in this paper. It is based on Perrow's theory of "normal accidents" and calls for recognizing the inevitable nature of ED overcrowding crises within current health system setup. Managing the crisis before it happens--a standard approach in crisis management area--should become an integral part of ED operations management. The potential implications of adopting such a crisis-aware perspective for health services research and ED management are outlined.

Curriculum and Methods (EDS 300).

ERIC Educational Resources Information Center

McNaughton, Robert H.; And Others

This course is a team taught, 12 quarter-hour block course, which combines a general teaching, competency segment and a specialized subject area methods segment. It is required of all students seeking secondary certification and is supported out of the regular secondary department budget. The teaching competency segment has the following three…

Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: a Bayesian change-point analysis.

PubMed

Schluter, Philip J; Hamilton, Greg J; Deely, Joanne M; Ardagh, Michael W

2016-05-11

To chart emergency department (ED) attendance and acute admission following a devastating earthquake in 2011 which lead to Canterbury's rapidly accelerated integrated health system transformations. Interrupted time series analysis, modelling using Bayesian change-point methods, of ED attendance and acute admission rates over the 2008-2014 period. ED department within the Canterbury District Health Board; with comparison to two other district health boards unaffected by the earthquake within New Zealand. Canterbury's health system services ∼500 000 people, with around 85 000 ED attendances and 37 000 acute admissions per annum. De-seasoned standardised population ED attendance and acute admission rates overall, and stratified by age and sex, compared before and after the earthquake. Analyses revealed five global patterns: (1) postearthquake, there was a sudden and persisting decrease in the proportion of the population attending the ED; (2) the growth rate of ED attendances per head of population did not change between the pre-earthquake and postearthquake periods; (3) postearthquake, there was a sudden and persisting decrease in the proportion of the population admitted to hospital; (4) the growth rate of hospital admissions per head of the population declined between pre-earthquake and postearthquake periods and (5) the most dramatic reduction in hospital admissions growth after the earthquake occurred among those aged 65+ years. Extrapolating from the projected and fitted deseasoned rates for December 2014, ∼676 (16.8%) of 4035 projected hospital admissions were avoided. While both necessarily and opportunistically accelerated, Canterbury's integrated health systems transformations have resulted in a dramatic and sustained reduction in ED attendances and acute hospital admissions. This natural intervention experiment, triggered by an earthquake, demonstrated that integrated health systems with high quality out-of-hospital care models are likely to successfully curb growth in acute hospital demand, nationally and internationally. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Advancing Patient-centered Outcomes in Emergency Diagnostic Imaging: A Research Agenda.

PubMed

Kanzaria, Hemal K; McCabe, Aileen M; Meisel, Zachary M; LeBlanc, Annie; Schaffer, Jason T; Bellolio, M Fernanda; Vaughan, William; Merck, Lisa H; Applegate, Kimberly E; Hollander, Judd E; Grudzen, Corita R; Mills, Angela M; Carpenter, Christopher R; Hess, Erik P

2015-12-01

Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging. © 2015 by the Society for Academic Emergency Medicine.

Determining Chronic Disease Prevalence in Local Populations Using Emergency Department Surveillance.

PubMed

Lee, David C; Long, Judith A; Wall, Stephen P; Carr, Brendan G; Satchell, Samantha N; Braithwaite, R Scott; Elbel, Brian

2015-09-01

We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence. Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses. We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts. Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence.

Using Video Conferencing to Deliver a Brief Motivational Intervention for Alcohol and Sex Risk to Emergency Department Patients: A Proof-of-Concept Pilot Study

PubMed Central

Celio, Mark A.; Mastroleo, Nadine R.; DiGuiseppi, Graham; Barnett, Nancy P.; Colby, Suzanne M.; Kahler, Christopher W.; Operario, Don; Suffoletto, Brian; Monti, Peter M.

2016-01-01

Brief motivational intervention (MI) is an efficacious approach to reduce heavy drinking and associated sexual risk behavior among Emergency Department (ED) patients, but the intensity of demands placed on ED staff makes the implementation of in-person MIs logistically challenging. This proof-of-concept pilot study examined the acceptability and logistic feasibility of using video-conferencing technology to deliver an MI targeting heavy drinking and risky sexual behavior to patients in an ED setting. Rigorous screening procedures were employed to ensure that the pilot sample represents the target portion of ED patients who would benefit from this multi-target MI. Mixed qualitative and quantitative data from a sample of seven ED patients (57% Female; Mage = 35 years) who received MI by video conference consistently demonstrated high levels of satisfaction, engagement, and acceptability. The observed completion rate supports logistic feasibility, and patient feedback identified methods to improve the experience by using high-definition hardware, ensuring stronger network connectivity, and effectively communicating information regarding protection of privacy. Post-intervention patient ratings and independent ratings of the audio-recorded sessions (using the Motivational Interviewing Skills Coding system) were very high, suggesting that intervention fidelity and MI adherence was not compromised by delivery modality. Collectively, these data suggest video conferencing is a viable technology that can be employed to implement brief evidence-based MIs in ED settings. PMID:28649188

Characteristics of Children and Youth Who Visit the Emergency Department for a Behavioural Disorder

PubMed Central

Liu, Stacy; Ali, Samina; Rosychuk, Rhonda J.; Newton, Amanda S.

2014-01-01

Objective: Relatively little is known about children who present to emergency departments (EDs) to stabilize acute emergencies related to behavioural disorders. This study describes patient and treatment characteristics of such children/youth. Methods: We conducted a retrospective medical record review of consecutive ED presentations made by children/youth (10 to 17 years) between January 2009 and December 2011 for visits with a main discharge diagnosis of hyperkinetic disorder, mixed disorder of conduct and emotions, or conduct disorder. Socio-demographic and ED visit data were analyzed descriptively. Results: During the study period, 365 consecutive presentations made by 325 children/youth. The most common presenting complaints were related to depression/self-harm (45.8%) and violent behaviours (28.8%). Many children/youth had a previously diagnosed psychiatric disorder (59.4%) and identified being under the care of a child psychiatrist (42.2%). The majority of ED visits were triaged as urgent or emergent (51.5% and 41.1%, respectively) and included mood and suicidality assessments (84.7% and 80.8%, respectively). Follow-up with various services was made for all visits. Conclusion: Children and youth presented to the ED for a behavioural disorder had urgent needs related to self-harm, depression and violent behaviours. These findings draw attention to the important role of the ED in managing physical safety and well-being concerns for families and recommending follow-up in the post-crisis period. PMID:24872826

The association between the availability of ambulatory care and non-emergency treatment in emergency medicine departments: a comprehensive and nationwide validation.

PubMed

Chan, Chien-Lung; Lin, Wender; Yang, Nan-Ping; Huang, Hsin-Tsung

2013-05-01

To quantify dynamic availability of ambulatory care, and to examine possible associations with non-emergency treatments in emergency departments (EDs). Longitudinal data from the Taiwan National health Insurance Research Database were used to evaluate 749,584 emergency-medicine cases occurring between 2005 and 2010 according to a modified New York University algorithm. Multivariable-cumulative-logistic-regression analysis with generalized estimating-equation methods was used to determine associations between availability of ambulatory care and the urgency of patients' medical needs during ED visits. More than half (53.04%) of the ED visits that were evaluated in our study were classified as non-emergencies, and over half of these occurred despite a high availability of ambulatory care facilities (median > 96%). Compared with patients in areas with a low availability of ambulatory care, patients in areas of medium to high availability showed approximately 0.8 times lower odds ratios for associations with non-emergency ED visits. Non-emergency ED visits may be reduced by increasing the availability of ambulatory care facilities in areas with deficits in the availability of such facilities. However, increasing the availability of ambulatory care by raising the number of available ambulatory care physicians or the number of ambulatory care facilities may not reduce non-emergency ED visits in areas with medium to high availability of ambulatory care facilities. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

The Abbreviated Mental Test 4 for cognitive screening of older adults presenting to the Emergency Department.

PubMed

Dyer, Adam H; Briggs, Robert; Nabeel, Shamis; O'Neill, Desmond; Kennelly, Sean P

2017-12-01

A commonly cited reason for the infrequent detection of cognitive impairment in the Emergency Department (ED) is the lack of an appropriate screening tool. The Abbreviated Mental Test 4 (AMT4) is a brief instrument recommended for cognitive screening of older adults in the ED. However, its exact utility in the detection of altered mental status in the ED is yet to be fully determined. The present study evaluated the ability of the AMT4 to identify impaired mental status in the ED, defined as positive scores on either the Confusion Assessment Method-ICU for delirium, the standardized Mini Mental State Examination as a general cognitive screener or the Eight-item Interview to Differentiate Aging and Dementia for dementia. Of 196 adults at least 70 years of age (mean: 78.5±5.9), the AMT4 had a sensitivity of 0.53 (0.42-0.63) and a specificity of 0.96 (0.89-0.99) for impaired mental status in the ED. The AMT4 was positive in almost all patients (92%; 24/26) screening positive for delirium, but less than half (47.8%; 22/46) of those screening positive for probable dementia, and less than a quarter (22.2%; 6/27) of those screening positive for probable cognitive impairment. The present study found that the limited sensitivity of the AMT4 in identifying the majority of cognitively impaired persons restricts its use in isolation as a general cognitive screener in the ED.

Using Video Conferencing to Deliver a Brief Motivational Intervention for Alcohol and Sex Risk to Emergency Department Patients: A Proof-of-Concept Pilot Study.

PubMed

Celio, Mark A; Mastroleo, Nadine R; DiGuiseppi, Graham; Barnett, Nancy P; Colby, Suzanne M; Kahler, Christopher W; Operario, Don; Suffoletto, Brian; Monti, Peter M

2017-01-01

Brief motivational intervention (MI) is an efficacious approach to reduce heavy drinking and associated sexual risk behavior among Emergency Department (ED) patients, but the intensity of demands placed on ED staff makes the implementation of in-person MIs logistically challenging. This proof-of-concept pilot study examined the acceptability and logistic feasibility of using video-conferencing technology to deliver an MI targeting heavy drinking and risky sexual behavior to patients in an ED setting. Rigorous screening procedures were employed to ensure that the pilot sample represents the target portion of ED patients who would benefit from this multi-target MI. Mixed qualitative and quantitative data from a sample of seven ED patients (57% Female; M age = 35 years) who received MI by video conference consistently demonstrated high levels of satisfaction, engagement, and acceptability. The observed completion rate supports logistic feasibility, and patient feedback identified methods to improve the experience by using high-definition hardware, ensuring stronger network connectivity, and effectively communicating information regarding protection of privacy. Post-intervention patient ratings and independent ratings of the audio-recorded sessions (using the Motivational Interviewing Skills Coding system) were very high, suggesting that intervention fidelity and MI adherence was not compromised by delivery modality. Collectively, these data suggest video conferencing is a viable technology that can be employed to implement brief evidence-based MIs in ED settings.

Workplace violence against physicians in Turkey’s emergency departments: a cross-sectional survey

PubMed Central

Bayram, Başak; Çetin, Murat; Çolak Oray, Neşe; Can, İsmail Özgür

2017-01-01

Objective We aimed to determine the prevalence of violence directed at emergency department (ED) physicians in Turkey and confirm the factors influencing such violence. Design Cross-sectional survey study. Setting Country of Turkey. Participants Physicians currently practising in EDs in Turkey. Main outcome measures The prevalence of violence directed at physicians and factors that may influence it, such as physicians’ personal characteristics, ED characteristics and physicians’ opinions regarding the causes of and suggested methods of preventing violence. Results A total of 713 physicians participated. Of these, 78.1% reported being subjected to violence in the past year and 65.9% reported more than one such incident. Being subjected to violence was related to age (p=0.008), working in an ED with a high patient admission rate (p=0.018), current position (p<0.001), working outside regular work hours (p<0.001), working in a state hospital (p<0.001) and level of experience (p<0.001). Gender, type of patient typically seen, region and patient waiting period did not influence subjection to violence. The present safety precautions against violence do not appear to influence the prevalence of violence. Conclusions Our results indicated that ED physicians’ experience of violence is related to personal characteristics such as age and level of expertise, and hospital and ED characteristics such as high patient admission rates. Presently, no measures taken to reduce this violence have been proven effective. PMID:28663323

oneED: Embedding a mindfulness-based wellness programme into an emergency department.

PubMed

Braganza, Shahina; Young, Jessica; Sweeny, Amy; Brazil, Victoria

2018-03-30

ED staff are subject to many stressors, but there are few descriptions of collective approaches to enhancing wellness in this setting. We aim to describe a programme developed to address these issues at department level, to report the feasibility and sustainability of the programme, and its impact on staff. The oneED programme was developed and delivered in a tertiary ED. The programme included a 1 day mindfulness workshop, followed by ongoing mindfulness activities embedded in clinical areas over the subsequent 12 months. A mixed-methods evaluation of the programme was conducted, which included quantitative validated psychological tools to measure anxiety, depression and emotional exhaustion, and pragmatic evaluation using surveys of participants and iterative appreciative inquiry. Eighty staff members attended the mindfulness workshop; 66 from ED. Following the workshop, understanding and frequency of mindfulness practice increased significantly in 47% of participants. Free-text survey results demonstrated that staff found the programme to be acceptable (80% survey participants) and of perceived value to themselves (50%) and the ED (60%). Appreciative inquiry led to modification of the programme: the 4 min pause is now conducted weekly rather than daily, the pause consists of a variety of activities, and group activities are made more overtly optional. A departmental wellness programme embedding mindfulness practice is feasible and sustainable. Potential for success is enhanced by an approach that is open to modification according to each institution's culture. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department

PubMed Central

Dahlquist, Robert T.; Reyner, Karina; Robinson, Richard D.; Farzad, Ali; Laureano-Phillips, Jessica; Garrett, John S.; Young, Joseph M.; Zenarosa, Nestor R.; Wang, Hao

2018-01-01

Background Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change. Methods We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS. Results The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05). Conclusions Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS. PMID:29581808

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department.

PubMed

Dahlquist, Robert T; Reyner, Karina; Robinson, Richard D; Farzad, Ali; Laureano-Phillips, Jessica; Garrett, John S; Young, Joseph M; Zenarosa, Nestor R; Wang, Hao

2018-05-01

Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change. We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS. The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05). Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS.

Mental Health and Drivers of Need in Emergent and Non-Emergent Emergency Department (ED) Use: Do Living Location and Non-Emergent Care Sources Matter?

PubMed

McManus, Moira C; Cramer, Robert J; Boshier, Maureen; Akpinar-Elci, Muge; Van Lunen, Bonnie

2018-01-13

Emergency department (ED) utilization has increased due to factors such as admissions for mental health conditions, including suicide and self-harm. We investigate direct and moderating influences on non-emergent ED utilization through the Behavioral Model of Health Services Use. Through logistic regression, we examined correlates of ED use via 2014 New York State Department of Health Statewide Planning and Research Cooperative System outpatient data. Consistent with the primary hypothesis, mental health admissions were associated with emergent use across models, with only a slight decrease in effect size in rural living locations. Concerning moderating effects, Spanish/Hispanic origin was associated with increased likelihood for emergent ED use in the rural living location model, and non-emergent ED use for the no non-emergent source model. 'Other' ethnic origin increased the likelihood of emergent ED use for rural living location and no non-emergent source models. The findings reveal 'need', including mental health admissions, as the largest driver for ED use. This may be due to mental healthcare access, or patients with mental health emergencies being transported via first responders to the ED, as in the case of suicide, self-harm, manic episodes or psychotic episodes. Further educating ED staff on this patient population through gatekeeper training may ensure patients receive the best treatment and aid in driving access to mental healthcare delivery changes.

Trends in the Incidence of Hypertensive Emergencies in US Emergency Departments From 2006 to 2013.

PubMed

Janke, Alexander T; McNaughton, Candace D; Brody, Aaron M; Welch, Robert D; Levy, Phillip D

2016-12-05

The incidence of hypertensive emergency in US emergency departments (ED) is not well established. This study is a descriptive epidemiological analysis of nationally representative ED visit-level data from the Nationwide Emergency Department Sample for 2006-2013. Nationwide Emergency Department Sample is a publicly available database maintained by the Healthcare Cost and Utilization Project. An ED visit was considered to be a hypertensive emergency if it met all the following criteria: diagnosis of acute hypertension, at least 1 diagnosis indicating acute target organ damage, and qualifying disposition (admission to the hospital, death, or transfer to another facility). The incidence of adult ED visits for acute hypertension increased monotonically in the period from 2006 through 2013, from 170 340 (1820 per million adult ED visits overall) to 496 894 (4610 per million). Hypertensive emergency was rare overall, accounting for 63 406 visits (677 per million adult ED visits overall) in 2006 to 176 769 visits (1670 per million) in 2013. Among adult ED visits that had any diagnosis of hypertension, hypertensive emergency accounted for 3309 per million in 2006 and 6178 per million in 2013. The estimated number of visits for hypertensive emergency and the rate per million adult ED visits has more than doubled from 2006 to 2013. However, hypertensive emergencies are rare overall, occurring in about 2 in 1000 adult ED visits overall, and 6 in 1000 adult ED visits carrying any diagnosis of hypertension in 2013. This figure is far lower than what has been sometimes cited in previous literature. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

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Opinion paper on utility of point-of-care biomarkers in the emergency department pathways decision making.

PubMed

Di Somma, Salvatore; Zampini, Giorgio; Vetrone, Francesco; Soto-Ruiz, Karina M; Magrini, Laura; Cardelli, Patrizia; Ronco, Claudio; Maisel, Alan; Peacock, Frank W

2014-10-01

Overcrowding of the emergency department (ED) is rapidly becoming a global challenge and a major source of concern for emergency physicians. The evaluation of cardiac biomarkers is critical for confirming diagnoses and expediting treatment decisions to reduce overcrowding, however, physicians currently face the dilemma of choosing between slow and accurate central-based laboratory tests, or faster but imprecise assays. With improvements in technology, point-of-care testing (POCT) systems facilitate the efficient and high-throughput evaluation of biomarkers, such as troponin (cTn), brain natriuretic peptide (BNP) and neutrophil gelatinase-associated lipocalin (NGAL). In this context, POCT may help ED physicians to confirm a diagnosis of conditions, such as acute coronary syndrome, heart failure or kidney damage. Compared with classic laboratory methods, the use of cTn, BNP, and NGAL POCT has shown comparable sensitivity, specificity and failure rate, but with the potential to provide prompt and accurate diagnosis, shorten hospital stay, and alleviate the burden on the ED. Despite this potential, the full advantages of rapid delivery results will only be reached if POCT is implemented within hospital standardized procedures and ED staff receive appropriate training.

Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive, Comparative Analysis Over Time.

PubMed

Fruth, Stacie J; Wiley, Steve

2016-09-01

Emergency department (ED) use in the United States is expected to rapidly increase. Nearly half of all ED visits are classified as semiurgent or nonurgent, and many fall into the musculoskeletal category. Despite growing international evidence that patients are appropriately and safely managed by ED physical therapists in a time-efficient manner, physical therapist practice in EDs is not widely understood or utilized in the United States. To date, no studies have reported the impressions of ED physicians about this practice. The purposes of this study were: (1) to assess ED physicians' impressions of ED physical therapist practice 2 years after practice was initiated and (2) to determine whether physicians' impressions changed 7 years later. All ED staff physicians and medical residents at a level I trauma hospital were invited to complete a survey in 2004 and 2011. In both years, a majority of physicians reported favorable impressions of ED physical therapist practice. Physical therapists were valued for educating patients about safety and injury prevention, providing appropriate gait training, assisting with disposition planning, and providing interventions as alternatives to pain medication. Many physicians supported standing physical therapist orders for certain musculoskeletal conditions. The most common concern was the additional time that patients spend in the ED for a physical therapist consult. The results of this study may not reflect the impressions of physicians in all EDs that employ physical therapists. Emergency department physicians reported favorable impressions of ED physical therapist practice 2 years and 9 years following its implementation in this hospital. This study showed that ED physicians support standing physical therapist orders for certain musculoskeletal conditions, which suggests that direct triage to ED physical therapists for these conditions could be considered. © 2016 American Physical Therapy Association.

Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010.

PubMed

Hasegawa, Kohei; Tsugawa, Yusuke; Brown, David F M; Mansbach, Jonathan M; Camargo, Carlos A

2014-01-01

To examine temporal trends in emergency departments (EDs) visits for bronchiolitis among US children between 2006 and 2010. Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We used International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate and ED charges. Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend = 0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase;Ptrend < 0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend < 0.001). Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted odds ratio for comparison of 2010 with 2006, 0.84; 95% confidence interval: 0.76-0.93; P < 0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend < 0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend < 0.001). Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.

U.S. Department of Education, Office of Inspector General Semiannual Report to Congress, October 1, 1998-March 31, 1999.

ERIC Educational Resources Information Center

Office of Inspector General (ED), Washington, DC.

This report from the Department of Education's (ED) Office of Inspector General (OIG) focuses on ED's information technology and Year 2000 readiness. It also reviews elementary and secondary education and student financial-assistance programs to ensure that ED programs are administered with efficiency, effectiveness, and integrity. A review of…

Emergency Department Use for Dental Problems among Homeless Individuals: A Population-Based Cohort Study.

PubMed

Figueiredo, Rafael; Dempster, Laura; Quiñonez, Carlos; Hwang, Stephen W

2016-01-01

To evaluate emergency department (ED) visits for dental problems among Toronto's homeless population (Ontario, Canada). A random sample of 1,189 homeless was recruited from shelters and meal programs. Emergency department visits for non-traumatic dental problems (ICD-10-CA codes K00-K14) were identified using participants' health insurance number, during 2005-2009. Age- and sex-matched controls were selected from low-income neighborhoods. Homeless and matched controls had 182 and 10 ED visits for dental problems, respectively. Homeless people were more significantly more likely (OR=2.27, p=.007) to make ED visit for dental problems compared with controls. Over 80% of the ED visits by homeless people were for odontogenic infections, and 46% of homeless people had more than one such visit. The high rate of ED visits for dental problems by people who are homeless suggests that access to dental care is inadequate. The large number of repeat visits indicates that ED settings are ineffective for treatment of dental problems.

Emergency department and 'Google flu trends' data as syndromic surveillance indicators for seasonal influenza.

PubMed

Thompson, L H; Malik, M T; Gumel, A; Strome, T; Mahmud, S M

2014-11-01

We evaluated syndromic indicators of influenza disease activity developed using emergency department (ED) data - total ED visits attributed to influenza-like illness (ILI) ('ED ILI volume') and percentage of visits attributed to ILI ('ED ILI percent') - and Google flu trends (GFT) data (ILI cases/100 000 physician visits). Congruity and correlation among these indicators and between these indicators and weekly count of laboratory-confirmed influenza in Manitoba was assessed graphically using linear regression models. Both ED and GFT data performed well as syndromic indicators of influenza activity, and were highly correlated with each other in real time. The strongest correlations between virological data and ED ILI volume and ED ILI percent, respectively, were 0·77 and 0·71. The strongest correlation of GFT was 0·74. Seasonal influenza activity may be effectively monitored using ED and GFT data.

The use of hospital emergency departments for nonurgent health problems: a national perspective.

PubMed

Cunningham, P J; Clancy, C M; Cohen, J W; Wilets, M

1995-11-01

The use of the hospital emergency department (ED) for nonurgent health problems has been a subject of considerable controversy, in part because there is no widely accepted definition of "nonurgent." Elimination or substantial reduction in nonurgent ED use is frequently offered as a strategy for reducing health expenditures. Previous studies, often limited to individual hospitals or communities, have limited generalizability and do not permit examination of multiple factors likely to influence nonurgent ED utilization or examination of ED use for nonurgent problems in the context of overall outpatient utilization. This analysis of the 1987 National Medical Expenditure Survey (NMES) provides a nationally representative examination of nonurgent ED utilization that describes the frequency of ED use for nonurgent problems, characteristics of individuals that are associated with an increased likelihood of nonurgent ED use, the use of other outpatient physician services, and expenditures associated with nonurgent ED visits.

Bomb blast injuries: an exploration of patient characteristics and outcome using Pakistan National Emergency Departments Surveillance (Pak-NEDS) data

PubMed Central

2015-01-01

Background Bomb blast injuries result in premature deaths and burdening of healthcare systems. The objective of this study was to explore the characteristics and outcome of patients presenting to the emergency departments in Pakistan with bomb blast injuries. Methods Active surveillance was conducted in seven major emergency departments of Pakistan from November 2010-March 2011. All the sites are tertiary care urban centers. All the patients who presented to the hospital's emergency department (ED) following a bomb blast injury as per self-report or the ambulance personnel were included in the study. Frequency of demographics, injury pattern, and outcomes were calculated. Results A total of 103 patients with bomb blast injuries presented to the selected emergency departments. The median age of patients was 30 years. Around three-fourth of the patients were males (n = 74, 74.7%). Most of the bomb blast patients were seen in Peshawar (n = 41, 39.8%) and Karachi city (n = 31, 30.1%) and the most common mode of arrival was non-ambulance transport (n = 71, 76.3%). Upper limb injuries (n = 12, 40%) were common in the under 18 age group and lower limb injuries (n = 31, 39.2%) in the 18 years and above group. There were a total of 8 (7.7%) deaths reported out of these 103 patients. Conclusion Bomb blast injuries in Pakistan generally affect young males. Non-ambulance transport is the most common way to access emergency departments (ED). Overall ED mortality is high and capturing data during a disaster in an emergency department is challenging. PMID:26692453

Dedication increases productivity: an analysis of the implementation of a dedicated medical team in the emergency department.

PubMed

Ramos, Pedro; Paiva, José Artur

2017-12-01

In several European countries, emergency departments (EDs) now employ a dedicated team of full-time emergency medicine (EM) physicians, with a distinct leadership and bed-side emergency training, in all similar to other hospital departments. In Portugal, however, there are still two very different models for staffing EDs: a classic model, where EDs are mostly staffed with young inexperienced physicians from different medical departments who take turns in the ED in 12-h shifts and a dedicated model, recently implemented in some hospitals, where the ED is staffed by a team of doctors with specific medical competencies in emergency medicine that work full-time in the ED. Our study assesses the effect of an intervention in a large academic hospital ED in Portugal in 2002, and it is the first to test the hypothesis that implementing a dedicated team of doctors with EM expertise increases the productivity and reduces costs in the ED, maintaining the quality of care provided to patients. A pre-post design was used for comparing the change on the organisational model of delivering care in our medical ED. All emergency medical admissions were tracked in 2002 (classic model with 12-h shift in the ED) and 2005/2006 (dedicated team with full-time EM physicians), and productivity, costs with medical human resources and quality of care measures were compared. We found that medical productivity (number of patients treated per hour of medical work) increased dramatically after the creation of the dedicated team (X 2 KW = 31.135; N = 36; p < 0.001) and costs with ED medical work reduced both in regular hours and overtime. Moreover, hospitalisation rates decreased and the length of stay in the ED increased significantly after the creation of the dedicated team. Implementing a dedicated team of doctors increased the medical productivity and reduced costs in our ED. Our findings have straightforward implication for Portuguese policymakers aiming at reducing hospital costs while coping with increased ED demand.

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A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related ED Visits

PubMed Central

Paulozzi, Leonard J.; Howell, Donelle; McPherson, Sterling; Murphy, Sean M.; Grohs, Becky; Marsh, Linda; Lederhos, Crystal; Roll, Jon

2017-01-01

Background Increasing prescription overdose deaths have demonstrated the need for safer ED prescribing practices for patients who are frequent ED users. Objectives We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. Methods We conducted a multi-site randomized controlled trial (RCT) across all EDs in a metropolitan area. 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. Results The intervention arm experienced a 34% decrease (IRR = 0.66, p < 0.001; 95% CI: 0.57 – 0.78) in ED visits and an 80% decrease (OR = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers. Conclusion This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing. PMID:27624507

Trends in Adult Cancer-Related Emergency Department Utilization: An Analysis of Data From the Nationwide Emergency Department Sample.

PubMed

Rivera, Donna R; Gallicchio, Lisa; Brown, Jeremy; Liu, Benmei; Kyriacou, Demetrios N; Shelburne, Nonniekaye

2017-10-12

The emergency department (ED) is used to manage cancer-related complications among the 15.5 million people living with cancer in the United States. However, ED utilization patterns by the population of US adults with cancer have not been previously evaluated or described in published literature. To estimate the proportion of US ED visits made by adults with a cancer diagnosis, understand the clinical presentation of adult patients with cancer in the ED, and examine factors related to inpatient admission within this population. Nationally representative data comprised of 7 survey cycles (January 2006-December 2012) from the Nationwide Emergency Department Sample were analyzed. Identification of adult (age ≥18 years) cancer-related visits was based on Clinical Classifications Software diagnoses documented during the ED visit. Weighted frequencies and proportions of ED visits among adult patients with cancer by demographic, geographic, and clinical characteristics were calculated. Weighted multivariable logistic regression was used to examine the associations between inpatient admission and key demographic and clinical variables for adult cancer-related ED visits. Adult cancer-related ED utilization patterns; identification of primary reason for ED visit; patient-related factors associated with inpatient admission from the ED. Among an estimated 696 million weighted adult ED visits from January 2006 to December 2012, 29.5 million (4.2%) were made by a patient with a cancer diagnosis. The most common cancers associated with an ED visit were breast, prostate, and lung cancer, and most common primary reasons for visit were pneumonia (4.5%), nonspecific chest pain (3.7%), and urinary tract infection (3.2%). Adult cancer-related ED visits resulted in inpatient admissions more frequently (59.7%) than non-cancer-related visits (16.3%) (P < .001). Septicemia (odds ratio [OR], 91.2; 95% CI, 81.2-102.3) and intestinal obstruction (OR, 10.94; 95% CI, 10.6-11.4) were associated with the highest odds of inpatient admission. Consistent with national prevalence statistics among adults, breast, prostate, and lung cancer were the most common cancer diagnoses presenting to the ED. Pneumonia was the most common reason for adult cancer-related ED visits with an associated high inpatient admission rate. This analysis highlights cancer-specific ED clinical presentations and the opportunity to inform patient and system-directed prevention and management strategies.

Benefit-cost analysis of SBIRT interventions for substance using patients in emergency departments.

PubMed

Horn, Brady P; Crandall, Cameron; Forcehimes, Alyssa; French, Michael T; Bogenschutz, Michael

2017-08-01

Screening, brief intervention, and referral to treatment (SBIRT) has been widely implemented as a method to address substance use disorders in general medical settings, and some evidence suggests that its use is associated with decreased societal costs. In this paper, we investigated the economic impact of SBIRT using data from Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), a multisite, randomized controlled trial. Utilizing self-reported information on medical status, health services utilization, employment, and crime, we conduct a benefit-cost analysis. Findings indicate that neither of the SMART-ED interventions resulted in any significant changes to the main economic outcomes, nor had any significant impact on total economic benefit. Thus, while SBIRT interventions for substance abuse in Emergency Departments may be appealing from a clinical perspective, evidence from this economic study suggests resources could be better utilized supporting other health interventions. Copyright © 2017 Elsevier Inc. All rights reserved.

Patient satisfaction in the emergency department and the use of business cards by physicians.

PubMed

Olsen, Jon C; Olsen, Eric C

2012-03-01

Emergency departments (EDs) across the country become increasingly crowded. Methods to improve patient satisfaction are becoming increasingly important. To determine if the use of business cards by emergency physicians improves patient satisfaction. A prospective, convenience sample of ED patients were surveyed in a tertiary care, suburban teaching hospital. Inclusion criteria were limited to an understanding of written and spoken English. Excluded patients included those with altered mental status or too ill to complete a survey. Patients were assigned to receive a business card on alternate days in the ED from the treating physician(s) during their patient introductions. The business cards listed the physician's name and position (resident or attending physician) and the institution name and phone number. Before hospital admission or discharge, a research assistant asked patients to complete a questionnaire regarding their ED visit to determine patient satisfaction. Three hundred-twenty patients were approached to complete the questionnaire and 259 patients (81%) completed it. Patient demographics were similar in both the business card and non-business-card groups. There were no statistically significant differences for patient responses to any of the study questions whether or not they received a business card during the physician introduction. The use of business cards during physician introduction in the ED does not improve patient satisfaction. Copyright © 2012 Elsevier Inc. All rights reserved.

California Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals

PubMed Central

Liu, Charles; Srebotnjak, Tanja; Hsia, Renee Y.

2014-01-01

Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51 percent while the number of EDs nationwide decreased by 6 percent, which placed unprecedented strain on the nation’s EDs. To investigate the effects of an ED closing on surrounding communities, we identified all ED closures in California during the period 1999–2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that 24.9 percent of hospital admissions in this period occurred near an ED closure, and that these admissions had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policy makers decide how to regulate ED closures. PMID:25092832

The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial

PubMed Central

Drummond, Colin; Deluca, Paolo; Coulton, Simon; Bland, Martin; Cassidy, Paul; Crawford, Mike; Dale, Veronica; Gilvarry, Eilish; Godfrey, Christine; Heather, Nick; McGovern, Ruth; Myles, Judy; Newbury-Birch, Dorothy; Oyefeso, Adenekan; Parrott, Steve; Patton, Robert; Perryman, Katherine; Phillips, Tom; Shepherd, Jonathan; Touquet, Robin; Kaner, Eileen

2014-01-01

Background Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. Methods and Findings Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. Conclusions SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. Trial Registration Current Controlled Trials ISRCTN 93681536 PMID:24963731

Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey.

PubMed

Bauer, Greta R; Scheim, Ayden I; Deutsch, Madeline B; Massarella, Carys

2014-06-01

Transgender, transsexual, or transitioned (trans) people have reported avoiding medical care because of negative experiences or fear of such experiences. The extent of trans-specific negative emergency department (ED) experiences, and of ED avoidance, has not been documented. The Trans PULSE Project conducted a survey of trans people in Ontario, Canada (n=433) in 2009 to 2010, using respondent-driven sampling, a tracked network-based method for studying hidden populations. Weighted frequencies and bootstrapped 95% confidence intervals (CIs) were estimated for the trans population in Ontario and for the subgroup (n=167) reporting ED use in their felt gender. Four hundred eight participants completed the ED experience items. Trans people were young (34% aged 16 to 24 years and only 10% >55 years); approximately half were female-to-male and half male-to-female. Medically supervised hormones were used by 37% (95% CI 30% to 46%), and 27% (95% CI 20% to 35%) had at least 1 transition-related surgery. Past-year ED need was reported by 33% (95% CI 26% to 40%) of trans Ontarians, though only 71% (95% CI 40% to 91%) of those with self-reported need indicated that they were able to obtain care. An estimated 21% (95% CI 14% to 25%) reported ever avoiding ED care because of a perception that their trans status would negatively affect such an encounter. Trans-specific negative ED experiences were reported by 52% (95% CI 34% to 72%) of users presenting in their felt gender. This first exploratory analysis of ED avoidance, utilization, and experiences by trans persons documented ED avoidance and possible unmet need for emergency care among trans Ontarians. Additional research, including validation of measures, is needed. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Emergency department utilization among recently released prisoners: a retrospective cohort study

PubMed Central

2013-01-01

Background The population of ex-prisoners returning to their communities is large. Morbidity and mortality is increased during the period following release. Understanding utilization of emergency services by this population may inform interventions to reduce adverse outcomes. We examined Emergency Department utilization among a cohort of recently released prisoners. Methods We linked Rhode Island Department of Corrections records with electronic health record data from a large hospital system from 2007 to 2009 to analyze emergency department utilization for mental health disorders, substance use disorders and ambulatory care sensitive conditions by ex-prisoners in the year after release from prison in comparison to the general population, controlling for patient- and community-level factors. Results There were 333,369 total ED visits with 5,145 visits by a cohort of 1,434 ex-prisoners. In this group, 455 ex-prisoners had 3 or more visits within 1 year of release and 354 had a first ED visit within 1 month of release. ED visits by ex-prisoners were more likely to be made by men (85% vs. 48%, p < 0.001) and by blacks (26% vs. 16%, p < 0.001) compared to the Rhode Island general population. Ex-prisoners were more likely to have an ED visit for a mental health disorder (6% vs. 4%, p < 0.001) or substance use disorder (16%vs. 4%, p < 0.001). After controlling for patient- and community-level factors, ex-prisoner visits were significantly more likely to be for mental health disorders (OR 1.43; 95% CI 1.27-1.61), substance use disorders (OR 1.93; 95% CI 1.77-2.11) and ambulatory care sensitive conditions (OR 1.09; 95% CI 1.00-1.18). Conclusions ED visits by ex-prisoners were significantly more likely due to three conditions optimally managed in outpatient settings. Future work should determine whether greater access to outpatient services after release from prison reduces ex-prisoners’ utilization of emergency services. PMID:24188513

Contraception Initiation in the Emergency Department: A Pilot Study on Providers' Knowledge, Attitudes, and Practices.

PubMed

Liles, Iyanna; Haddad, Lisa B; Lathrop, Eva; Hankin, Abigail

2016-05-01

Almost half of all pregnancies in the United States are unintended; these pregnancies are associated with adverse outcomes. Many reproductive-age females seek care in the emergency department (ED), are at risk of pregnancy, and are amenable to contraceptive services in this setting. Through a pilot study, we sought to assess ED providers' current practices; attitudes; and knowledge of emergency contraception (EC) and nonemergency contraception (non-EC), as well as barriers with respect to contraception initiation. ED physicians and associate providers in Georgia were e-mailed a link to an anonymous Internet questionnaire using state professional databases and contacts. The questionnaire included Likert scales with multiple-choice questions to assess study objectives. Descriptive statistics were generated as well as univariate analyses using χ(2) and Fisher exact tests. A total of 1232 providers were e-mailed, with 119 questionnaires completed. Participants were predominantly physicians (80%), men (59%), and individuals younger than 45 years (59%). Common practices were referrals (96%), EC prescriptions (77%), and non-EC prescriptions (40%). Common barriers were perceived as low likelihood for follow-up (63%), risk of complications (58%), and adverse effects (51%). More than 70% of participants correctly identified the highly effective contraceptive methods, 3% identified the correct maximum EC initiation time, and 42% correctly recognized pregnancy as a higher risk than hormonal contraception use for pulmonary embolism. Most ED providers in this pilot study referred patients for contraception; however, there was no universal contraceptive counseling and management. Many ED providers in this study had an incorrect understanding of the efficacy, risks, and eligibility associated with contraceptive methods. This lack of understanding may affect patient access and be a barrier to patient care.

A qualitative study of emergency physicians’ perspectives on PROMS in the emergency department

PubMed Central

Dainty, Katie N; Seaton, Bianca; Laupacis, Andreas; Schull, Michael; Vaillancourt, Samuel

2017-01-01

Introduction There is a growing emphasis on including patients' perspectives on outcomes as a measure of quality care. To date, this has been challenging in the emergency department (ED) setting. To better understand the root of this challenge, we looked to ED physicians' perspectives on their role, relationships and responsibilities to inform future development and implementation of patient-reported outcome measures (PROMs). Methods ED physicians from hospitals across Canada were invited to participate in interviews using a snowballing sampling technique. Semistructured interviews were conducted by phone with questions focused on the role and practice of ED physicians, their relationship with their patients and their thoughts on patient-reported feedback as a mechanism for quality improvement. Transcripts were analysed using a modified constant comparative method and interpretive descriptive framework. Results Interviews were completed with 30 individual physicians. Respondents were diverse in location, training and years in practice. Physicians reported being interested in ‘objective’ postdischarge information including adverse events, readmissions, other physicians’ notes, etc in a select group of complex patients, but saw ‘patient-reported’ feedback as less valuable due to perceived biases. They were unsure about the impact of such feedback mainly because of the episodic nature of their work. Concerns about timing, as well as about their legal and ethical responsibilities to follow-up if poor patient outcomes are reported, were raised. Conclusions Data collection and feedback are key elements of a learning health system. While patient-reported outcomes may have a role in feedback, ED physicians are conflicted about the actionability of such data and ethical implications, given the inherently episodic nature of their work. These findings have important implications for PROM design and implementation in this unique clinical setting. PMID:28183828

An Evidence-Based Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Emergency Department (ED) Providers Improves Skills and Utilization

ERIC Educational Resources Information Center

Substance Abuse, 2007

2007-01-01

Objective: Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience…

Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications

PubMed Central

Venkatesh, Arjun K.; Mei, Hao; Kocher, Keith E.; Granovsky, Michael; Obermeyer, Ziad; Spatz, Erica S.; Rothenberg, Craig; Krumholz, Harlan M.; Lin, Zhenqui

2018-01-01

Objectives Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. Methods We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims–based definition, 2) facility claims–based definition, and 3) CMS Research Data Assistance Center (ResDAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. Results Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other definitions including 17% more ED visits than the provider definition and 2% fewer visits than the ResDAC definition. Differences in ED visitation counts between each definition occurred for several reasons including the inclusion of critical care or observation services in the ED, discrepancies between facility and provider billing regulations, and operational decisions of each definition. Conclusion Current operational definitions of ED visitation using administrative claims produce different estimates of ED visitation based on the underlying assumptions applied to billing data and data set availability. Future analyses using administrative claims data should seek to validate specific definitions and inform the development of a consistent, consensus ED visitation definitions to standardize research reporting and the interpretation of policy interventions. PMID:27864915

Time series modelling and forecasting of emergency department overcrowding.

PubMed

Kadri, Farid; Harrou, Fouzi; Chaabane, Sondès; Tahon, Christian

2014-09-01

Efficient management of patient flow (demand) in emergency departments (EDs) has become an urgent issue for many hospital administrations. Today, more and more attention is being paid to hospital management systems to optimally manage patient flow and to improve management strategies, efficiency and safety in such establishments. To this end, EDs require significant human and material resources, but unfortunately these are limited. Within such a framework, the ability to accurately forecast demand in emergency departments has considerable implications for hospitals to improve resource allocation and strategic planning. The aim of this study was to develop models for forecasting daily attendances at the hospital emergency department in Lille, France. The study demonstrates how time-series analysis can be used to forecast, at least in the short term, demand for emergency services in a hospital emergency department. The forecasts were based on daily patient attendances at the paediatric emergency department in Lille regional hospital centre, France, from January 2012 to December 2012. An autoregressive integrated moving average (ARIMA) method was applied separately to each of the two GEMSA categories and total patient attendances. Time-series analysis was shown to provide a useful, readily available tool for forecasting emergency department demand.

Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: results from a national survey.

PubMed

Trautmann, Jennifer; Epstein, Elizabeth; Rovnyak, Virginia; Snyder, Audrey

2015-01-01

The aims of this research study were to investigate moral distress among emergency department (ED) nurse practitioners (NPs) and examine relationships between moral distress and level of practice independence as well as intent to leave a position. Moral distress has been studied regarding registered nurses and physicians (MDs) but less so in NPs. It is important to explore moral distress in NPs because they tread a unique path between nursing and physician roles. Moral distress may play a significant role in staff nurses' intention to leave practice, and level of practice independence is found to have a relationship with NPs' intention to leave. A convenience sample of ED NPs was obtained from a mailing list of a national nursing specialty organization, the Emergency Nurses Association. Using a correlational design, survey methods assessed moral distress with the Moral Distress Scale-Revised (MDS-R), level of practice independence with the Dempster Practice Behavior Scale, and intent to leave with self-report. Correlational and regression analyses of data were conducted to characterize moral distress among ED NPs and associations between moral distress, level of practice independence, and intent to leave. Results found ED NPs do experience moral distress with poor patient care results from inadequate staff communication and working with incompetent coworkers in their practice. The MDS-R was a significant predictor of intention to leave among respondents. This study is the first of its kind to explore moral distress in ED NPs. Results suggest moral distress influences ED NPs' intent to leave their position. Further studies are needed to explore the findings from this research and to formulate interventions to alleviate moral distress in ED NPs and improve retention in the clinical setting.

Past Year Intentional and Unintentional injury Among Teens Treated In An Inner City Emergency Department

PubMed Central

Cunningham, Rebecca M.; Walton, Maureen A.; Harrison, Stephanie Roahen; Resko, Stella M.; Stanley, Rachel; Zimmerman, Marc; Bingham, C. Raymond; Shope, Jean T.

2010-01-01

An inner-city Emergency Department (ED) visit provides an opportunity for contact with high-risk adolescents for promoting injury prevention. Objectives To identify the prevalence of injuries sustained over the past year by teens presenting to an inner city ED, and to identify factors associated with recent injury to inform future ED-based injury prevention initiatives. Methods Over one year, seven days a week, from 1:00–11:00 PM, patients ages 14–18 years presenting to the ED participated in a survey regarding past-year risk behaviors and injuries. Results Of the entire group of teens presenting to the ED (n=1128) who completed the survey (83.8% response rate), 46% were male, and 58% were African-American. Past-year injuries were reported by 768 (68.1%) of the teens; 475 (61.8%) reported an unintentional injury and 293 (38.1%) reported an intentional injury. One-third of all youth seeking care reported a past-year sports-related injury (34.5%) or an injury related to driving or riding in a car (12.3%), and 8.2% reported a gun-related injury. Logistic regression found binge drinking (adjusted odds ratio [AOR]=1.95) and illicit weapon carrying (AOR=2.31) predicted a past-year intentional injury. African American youth (AOR=0.56) and those receiving public assistance (AOR=0.73) were less likely to report past-year unintentional injuries. Conclusions Adolescents seeking care in an inner city ED, regardless of reason for seeking care, report an elevated prevalence of recent injury including violence. Future injury screening and prevention efforts should consider universal screening of all youth seeking ED care. PMID:20149570

Risk factors for repeat adverse asthma events in children after visiting an emergency department.

PubMed

To, Teresa; Wang, Chengning; Dell, Sharon; Fleming-Carroll, Bonnie; Parkin, Patricia; Scolnik, Dennis; Ungar, Wendy

2008-01-01

The aim of this study was to identify risk factors for long-term adverse outcomes in children with asthma after visiting the emergency department (ED). A prospective observational study was conducted at the ED of a pediatric tertiary hospital in Ontario, Canada. Patient outcomes (ie, acute asthma episodes and ED visits) were measured at baseline and at 1- and 6-months post-ED discharge. Time trends in outcomes were assessed using the generalized estimating equations method. Multiple conditional logistic regressions were used to model outcomes at 6 months and examine the impact of drug insurance coverage while adjusting for confounders. Of the 269 children recruited, 81.8% completed both follow-ups. ED use significantly reduced from 39.4% at baseline to 26.8% at 6 months (P < .001), whereas the level of acute asthma episodes remained unchanged. Children with drug insurance coverage were less likely to have acute asthma episodes (adjusted odds ratio [AOR] = 0.36; 95% CI, 0.15-0.85; P < .02) or repeat ED visits (AOR = 0.45; 95% CI, 0.20-0.99; P < .05) at 6 months. Other risk factors for adverse outcomes included previous adverse asthma events and certain asthma triggers (eg, cold/sinus infection). Washing bed linens in hot water weekly was protective against subsequent acute asthma episodes. Our study demonstrated significant improvements in long-term outcomes in children seeking acute care for asthma in the ED. Future efforts remain in targeting the sustainability of improved outcomes beyond 6 months. Risk factors identified can help target vulnerable populations for proper interventions, which may include efforts to maximize insurance coverage for asthma medications and strategies to improve asthma self-management through patient and provider education.

Defining Emergency Department Asthma Visits for Public Health Surveillance, North Carolina, 2008–2009

PubMed Central

Lich, Kristen Hassmiller; Lippmann, Steven J.; Weinberger, Morris; Yeatts, Karin B.; Liao, Winston; Waller, Anna

2014-01-01

Introduction When using emergency department (ED) data sets for public health surveillance, a standard approach is needed to define visits attributable to asthma. Asthma can be the first (primary) or a subsequent (2nd through 11th) diagnosis. Our study objective was to develop a definition of ED visits attributable to asthma for public health surveillance. We evaluated the effect of including visits with an asthma diagnosis in primary-only versus subsequent positions. Methods The study was a cross-sectional analysis of population-level ED surveillance data. Of the 114 North Carolina EDs eligible to participate in a statewide surveillance system in 2008–2009, we used data from the 111 (97%) that participated during those years. Included were all ED visits with an ICD-9-CM diagnosis code for asthma in any diagnosis position (1 through 11). We formed 11 strata based on the diagnosis position of asthma and described common chief complaint and primary diagnosis categories for each. Prevalence ratios compared each category’s proportion of visits that received either asthma- or cardiac-related procedure codes. Results Respiratory diagnoses were most common in records of ED visits in which asthma was the first or second diagnosis, while primary diagnoses of injury and heart disease were more common when asthma appeared in positions 3–11. Asthma-related chief complaints and procedures were most common when asthma was the first or second diagnosis, whereas cardiac procedures were more common in records with asthma in positions 3–11. Conclusion ED visits should be defined as asthma-related when asthma is in the first or second diagnosis position. PMID:24921898

Time-series Analysis of Heat Waves and Emergency Department Visits in Atlanta, 1993 to 2012

PubMed Central

Chen, Tianqi; Sarnat, Stefanie E.; Grundstein, Andrew J.; Winquist, Andrea

2017-01-01

Background: Heat waves are extreme weather events that have been associated with adverse health outcomes. However, there is limited knowledge of heat waves’ impact on population morbidity, such as emergency department (ED) visits. Objectives: We investigated associations between heat waves and ED visits for 17 outcomes in Atlanta over a 20-year period, 1993–2012. Methods: Associations were estimated using Poisson log-linear models controlling for continuous air temperature, dew-point temperature, day of week, holidays, and time trends. We defined heat waves as periods of ≥2 consecutive days with temperatures beyond the 98th percentile of the temperature distribution over the period from 1945–2012. We considered six heat wave definitions using maximum, minimum, and average air temperatures and apparent temperatures. Associations by heat wave characteristics were examined. Results: Among all outcome-heat wave combinations, associations were strongest between ED visits for acute renal failure and heat waves defined by maximum apparent temperature at lag 0 [relative risk (RR) = 1.15; 95% confidence interval (CI): 1.03–1.29], ED visits for ischemic stroke and heat waves defined by minimum temperature at lag 0 (RR = 1.09; 95% CI: 1.02–1.17), and ED visits for intestinal infection and heat waves defined by average temperature at lag 1 (RR = 1.10; 95% CI: 1.00–1.21). ED visits for all internal causes were associated with heat waves defined by maximum temperature at lag 1 (RR = 1.02; 95% CI: 1.00, 1.04). Conclusions: Heat waves can confer additional risks of ED visits beyond those of daily air temperature, even in a region with high air-conditioning prevalence. https://doi.org/10.1289/EHP44 PMID:28599264

Application of time series analysis in modelling and forecasting emergency department visits in a medical centre in Southern Taiwan

PubMed Central

Juang, Wang-Chuan; Huang, Sin-Jhih; Huang, Fong-Dee; Cheng, Pei-Wen; Wann, Shue-Ren

2017-01-01

Objective Emergency department (ED) overcrowding is acknowledged as an increasingly important issue worldwide. Hospital managers are increasingly paying attention to ED crowding in order to provide higher quality medical services to patients. One of the crucial elements for a good management strategy is demand forecasting. Our study sought to construct an adequate model and to forecast monthly ED visits. Methods We retrospectively gathered monthly ED visits from January 2009 to December 2016 to carry out a time series autoregressive integrated moving average (ARIMA) analysis. Initial development of the model was based on past ED visits from 2009 to 2016. A best-fit model was further employed to forecast the monthly data of ED visits for the next year (2016). Finally, we evaluated the predicted accuracy of the identified model with the mean absolute percentage error (MAPE). The software packages SAS/ETS V.9.4 and Office Excel 2016 were used for all statistical analyses. Results A series of statistical tests showed that six models, including ARIMA (0, 0, 1), ARIMA (1, 0, 0), ARIMA (1, 0, 1), ARIMA (2, 0, 1), ARIMA (3, 0, 1) and ARIMA (5, 0, 1), were candidate models. The model that gave the minimum Akaike information criterion and Schwartz Bayesian criterion and followed the assumptions of residual independence was selected as the adequate model. Finally, a suitable ARIMA (0, 0, 1) structure, yielding a MAPE of 8.91%, was identified and obtained as Visitt=7111.161+(at+0.37462 at−1). Conclusion The ARIMA (0, 0, 1) model can be considered adequate for predicting future ED visits, and its forecast results can be used to aid decision-making processes. PMID:29196487

The attitudes of emergency department nurses towards patient safety.

PubMed

Durgun, Hanife; Kaya, Hülya

2017-11-23

This research was planned to identify the attitudes of emergency department nurses towards patient safety. The study was performed as descriptive. The universe of the research the universe comprised hospitals defined as 3rd level according to Turkish health care classification, which provides service to all health disciplines in Istanbul. The sample consisted of emergency department (ED) nurses who work in those hospitals. The data was collected by using tools such as the "Information Questionnaire" and the "Patient Safety Attitudes Scale". In this study, the attitudes of ED nurses towards patient safety were found to be average and was not related to age, gender, education level, nursing experience, ED experience, ED certification, patient safety training, nurse's self sufficiency perception of patient safety, hospital's quality certification or ED quality certification. The attitudes of nurses towards patient safety were compared by age, gender, marital status, education level, ED experience and there was no meaningful difference. However, a meaningful difference was found between the age groups and the "defining stress" sub-dimension of the Patient Safety Attitudes Scale. ED nurses' status of certification for emergency care, patient safety training, training of quality, hospitals' or ED's quality certification status had no significant statistical difference. Copyright © 2017 Elsevier Ltd. All rights reserved.

The role of leader behaviors in hospital-based emergency departments' unit performance and employee work satisfaction.

PubMed

Lin, Blossom Yen-Ju; Hsu, Chung-Ping C; Juan, Chi-Wen; Lin, Cheng-Chieh; Lin, Hung-Jung; Chen, Jih-Chang

2011-01-01

The role of the leader of a medical unit has evolved over time to expand from simply a medical role to a more managerial one. This study aimed to explore how the behavior of a hospital-based emergency department's (ED's) leader might be related to ED unit performance and ED employees' work satisfaction. One hundred and twelve hospital-based EDs in Taiwan were studied: 10 in medical centers, 32 in regional hospitals, and 70 in district hospitals. Three instruments were designed to assess leader behaviors, unit performance and employee satisfaction in these hospital-based EDs. A mail survey revealed that task-oriented leader behavior was positively related to ED unit performance. Both task- and employee-oriented leader behaviors were found to be positively related to ED nurses' work satisfaction. However, leader behaviors were not shown to be related to ED physicians' work satisfaction at a statistically significant level. Some ED organizational characteristics, however, namely departmentalization and hospital accreditation level, were found to be related to ED physicians' work satisfaction. Copyright © 2010 Elsevier Ltd. All rights reserved.

77 FR 73626 - Agency Information Collection Activities; Submission to the Office of Management and Budget for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-11

... DEPARTMENT OF EDUCATION [Docket No. ED-2012-ICCD-0030] Agency Information Collection Activities... Assistance General Provisions--Non-Title IV Revenue Requirements (90/10) AGENCY: Department of Education (ED... Collection Clearance Division, U.S. Department of Education, 400 Maryland Avenue SW, LBJ, Room 2E105...

What's New in Facilities at the U.S. Department of Education?

ERIC Educational Resources Information Center

Falken, Andrea Suarez

2011-01-01

The U.S. Department of Education (ED) has been hard at work developing criteria and award infrastructure for U.S. Department of Education Green Ribbon Schools (ED-GRS), the first comprehensive and coordinated federal policy in the three institutional roles of schools related to environment, health and education. The ground-breaking award…

78 FR 68427 - Agency Information Collection Activities; Submission to the Office of Management and Budget for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-14

... DEPARTMENT OF EDUCATION [Docket No.: ED-2013-ICCD-0118] Agency Information Collection Activities...), Department of Education (ED). ACTION: Notice. SUMMARY: In accordance with the Paperwork Reduction Act of 1995... Information Collection Clearance Division, U.S. Department of Education, 400 Maryland Avenue SW., LBJ, Room...

Using routine clinical and administrative data to produce a dataset of attendances at Emergency Departments following self-harm.

PubMed

Polling, C; Tulloch, A; Banerjee, S; Cross, S; Dutta, R; Wood, D M; Dargan, P I; Hotopf, M

2015-07-16

Self-harm is a significant public health concern in the UK. This is reflected in the recent addition to the English Public Health Outcomes Framework of rates of attendance at Emergency Departments (EDs) following self-harm. However there is currently no source of data to measure this outcome. Routinely available data for inpatient admissions following self-harm miss the majority of cases presenting to services. We aimed to investigate (i) if a dataset of ED presentations could be produced using a combination of routinely collected clinical and administrative data and (ii) to validate this dataset against another one produced using methods similar to those used in previous studies. Using the Clinical Record Interactive Search system, the electronic health records (EHRs) used in four EDs were linked to Hospital Episode Statistics to create a dataset of attendances following self-harm. This dataset was compared with an audit dataset of ED attendances created by manual searching of ED records. The proportion of total cases detected by each dataset was compared. There were 1932 attendances detected by the EHR dataset and 1906 by the audit. The EHR and audit datasets detected 77% and 76 of all attendances respectively and both detected 82% of individual patients. There were no differences in terms of age, sex, ethnicity or marital status between those detected and those missed using the EHR method. Both datasets revealed more than double the number of self-harm incidents than could be identified from inpatient admission records. It was possible to use routinely collected EHR data to create a dataset of attendances at EDs following self-harm. The dataset detected the same proportion of attendances and individuals as the audit dataset, proved more comprehensive than the use of inpatient admission records, and did not show a systematic bias in those cases it missed.

NEDOCS vs subjective evaluation, ¿Is the health personnel of the emergency department aware of its overcrowding?

PubMed Central

Garcia-Romero, Mauricio; Rita-Gáfaro, Claudia Geraldine; Quintero-Manzano, Jairo

2017-01-01

Abstract Introduction: An emergency department (ED) is considered to be "overcrowded" when the number of patients exceeds its treatment capacity and it does not have the conditions to meet the needs of the next patient to be treated. This study evaluates overcrowding in the emergency department of a hospital in Colombia. Objective: To compare the objective NEDOCS scale with a subjective evaluation by ED health staff in order to evaluate the differences between the two. Methods: The NEDOCS scale was applied and a subjective overcrowding survey was administered to the medical staff and the charge nurse on duty 6 times per day (6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m. and 9:00 p.m.) for three consecutive weeks. The results were evaluated with a correlation analysis and measurement of agreement. Results: A median NEDOCS score of 137 was obtained for the total data. There was a moderately positive correlation between the NEDOCS and the subjective scales, with a rho of 0.58 (p (0.001). During times when the ED was the most crowded, 87% of the total subjective health staff evaluations underestimated the level of overcrowding. Conclusions: Health staff do not perceive a risk due to ED overcrowding when the NEDOCS scores correspond to overcrowding categories equal to or over 5 (severely crowded and dangerously crowded), which poses a risk to patient safety and care. PMID:28924304

Post-appendectomy visits to the emergency department within the global period: a target for cost containment.

PubMed

Aiello, Francesco A; Gross, Erica R; Krajewski, Aleksandra; Fuller, Robert; Morgan, Anthony; Duffy, Andrew; Longo, Walter; Kozol, Robert; Chandawarkar, Rajiv

2010-09-01

Postoperative visits to the emergency department (ED) instead of the surgeon's office consume enormous cost. Postoperative ED visits can be avoided. Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine. Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period. Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson chi(2) test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospital's billing department. Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was $55,000 plus physician services. ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access. 2010 Elsevier Inc. All rights reserved.

Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy.

PubMed

Panebianco, Nova; Shofer, Frances; O'Conor, Katie; Wihbey, Tristan; Mulugeta, Lakeisha; Baston, Cameron M; Suzuki, Evan; Alghamdi, Adel; Dean, Anthony

2018-01-30

Emergency department (ED) transvaginal ultrasound (US) is underused in clinical practice. This study assessed pregnant women's perceptions of ED transvaginal US in terms of pain, embarrassment, anxiety, and willingness to receive the procedure. Secondary variables include physicians' perceptions of patients' experiences. Women undergoing US examinations for complications of first-trimester pregnancy were prospectively surveyed before any US and after ED and/or radiology transvaginal US. Patients' and physicians' assessments of pain, embarrassment, and anxiety were measured with visual analog scales (0-100). A total of 398 women were enrolled. In the pre-US survey, the median anxiety score was 14 (interquartile range, 3-51), and 96% of patients were willing to have an ED transvaginal US if necessary. Of those who had ED transvaginal US, 96% would agree to have another examination. Patients reported minimal pain/embarrassment, and there was no difference if performed in the ED versus radiology (median pain, 11.5 versus 13; P = .433; median embarrassment, 7 versus 4; P = .345). Of the 48 who had both ED and radiology transvaginal US, 85% thought the ED transvaginal US was worthwhile. Physicians accurately assessed patient's embarrassment and pain (mean differences, 3.5 and -1.9, respectively; P > .25 for both); however, they overestimated them relative to the pelvic examination (mean difference for embarrassment, 12.8; P < .0001; pain, 8.0; P = .01). Pregnant ED patients report low levels of anxiety, pain, and embarrassment, and after ED transvaginal US, 96% would agree to have the examination again. There is no difference in pain/embarrassment between ED and radiology transvaginal US. Emergency department physicians accurately assessed patients' pain and embarrassment with ED transvaginal US but overestimated them compared to the pelvic examination. © 2018 by the American Institute of Ultrasound in Medicine.

Emergency Department Use among Adults with Autism Spectrum Disorders (ASD)

ERIC Educational Resources Information Center

Vohra, Rini; Madhavan, Suresh; Sambamoorthi, Usha

2016-01-01

A cross-sectional analyses using Nationwide Emergency Department Sample (2006-2011) was conducted to examine the trends, type of ED visits, and mean total ED charges for adults aged 22-64 years with and without ASD (matched 1:3). Around 0.4% ED visits (n = 25,527) were associated with any ASD and rates of such visits more than doubled from 2006 to…

Patient Reasons for Non-Urgent Utilization of the Dwight David Eisenhower Army Medical Center Emergency Department

DTIC Science & Technology

2004-01-01

patient education opportunities, which may ultimately change both patient perception and ED utilization behavior. Statement of the... Patient education about the Emergency Department policies, triage process, and associated wait times should serve to narrow the gap between the patient’s...perceptions and the provider’s perceptions. The DDEAMC ED has made advancements in the patient education arena, as well as streamlining ED process

Web-Based Predictive Analytics to Improve Patient Flow in the Emergency Department

NASA Technical Reports Server (NTRS)

Buckler, David L.

2012-01-01

The Emergency Department (ED) simulation project was established to demonstrate how requirements-driven analysis and process simulation can help improve the quality of patient care for the Veterans Health Administration's (VHA) Veterans Affairs Medical Centers (VAMC). This project developed a web-based simulation prototype of patient flow in EDs, validated the performance of the simulation against operational data, and documented IT requirements for the ED simulation.

Workplace violence against physicians in Turkey's emergency departments: a cross-sectional survey.

PubMed

Bayram, Başak; Çetin, Murat; Çolak Oray, Neşe; Can, İsmail Özgür

2017-06-29

We aimed to determine the prevalence of violence directed at emergency department (ED) physicians in Turkey and confirm the factors influencing such violence. Cross-sectional survey study. Country of Turkey. Physicians currently practising in EDs in Turkey. The prevalence of violence directed at physicians and factors that may influence it, such as physicians' personal characteristics, ED characteristics and physicians' opinions regarding the causes of and suggested methods of preventing violence. A total of 713 physicians participated. Of these, 78.1% reported being subjected to violence in the past year and 65.9% reported more than one such incident. Being subjected to violence was related to age (p=0.008), working in an ED with a high patient admission rate (p=0.018), current position (p<0.001), working outside regular work hours (p<0.001), working in a state hospital (p<0.001) and level of experience (p<0.001). Gender, type of patient typically seen, region and patient waiting period did not influence subjection to violence. The present safety precautions against violence do not appear to influence the prevalence of violence. Our results indicated that ED physicians' experience of violence is related to personal characteristics such as age and level of expertise, and hospital and ED characteristics such as high patient admission rates. Presently, no measures taken to reduce this violence have been proven effective. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse

PubMed Central

Rosen, Tony; Bloemen, Elizabeth M.; LoFaso, Veronica M.; Clark, Sunday; Flomenbaum, Neal; Lachs, Mark S.

2015-01-01

Background Elder abuse is under-recognized by Emergency Department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma. Objective To describe patterns and circumstances surrounding elder abuse-related and potentially abuse-related injuries in ED patients independently known to be physical elder abuse victims. Methods ED utilization of community-dwelling victims of physical elder abuse in New Haven, CT from 1981-1994 was analyzed previously. Cases were identified using Elderly Protective Services data matched to ED records. 66 ED visits were judged to have high probability of being related to elder abuse and 244 of indeterminate probability. We re-examined these visits to assess whether they occurred due to injury. We identified and analyzed in detail 31 injury-associated ED visits from 26 patients with high probability of being related to elder abuse and 108 visits from 57 patients with intermediate probability and accidental injury. Results Abuse-related injuries were most common on upper extremities (45% of visits) and lower extremities (32%), with injuries on head or neck noted in 13 visits (42%). Bruising was observed in 39% of visits, most commonly on upper extremities. 42% of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring >1 day prior to presentation and the most common suspicious injury pattern being maxillofacial injuries. Conclusion Victims of physical elder abuse commonly have injuries on upper extremities, head, and neck. Suspicious circumstances and injury patterns may be identified and are commonly present when victims of physical elder abuse present with purportedly accidental injuries. PMID:26810019

Is emergency department crowding associated with increased “bounceback” admissions?

PubMed Central

Hsia, Renee Y.; Asch, Steven M.; Weiss, Robert E.; Zingmond, David; Gabayan, Gelareh; Liang, Li-Jung; Han, Weijuan; McCreath, Heather; Sun, Benjamin C.

2013-01-01

Objective Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient’s likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these “bounceback” admissions. Methods We used comprehensive, non-public, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within seven days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intra-hospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission. Results We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR 1.01, 95% CI 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR 1.00, 95% CI 1.00, 1.00). Conclusions Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding. PMID:24036997

Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge☆

PubMed Central

Chavez, Laura J.; Liu, Chuan-Fen; Tefft, Nathan; Hebert, Paul L; Clark, Brendan J.; Rubinsky, Anna D.; Lapham, Gwen T.; Bradley, Katharine A.

2016-01-01

Background Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits. Methods Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009–10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization. Results Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n = 7167) and nondrinking (n =357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0–14.6%; and 14.2%, 95% CI 14.1–14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7–13.0%). Only nondrinkers had increased risk for ED visits. Conclusions Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits. PMID:26644137

Frequency of alcohol use among injured adult patients presenting to a Ghanaian emergency department

PubMed Central

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Ezster; Maio, Ronald F.

2016-01-01

Objective Injuries are the cause of almost six million deaths annually worldwide, with 15–20% alcohol-associated. The frequency of alcohol-associated injury varies among countries, and is unknown in Ghana. We determined the frequency of positive alcohol tests among injured adults in a Ghanaian Emergency Department (ED). Methods This is a cross-sectional chart review of consecutive injured patients 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within eight hours of injury. Patients were tested for alcohol using a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death prior to admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals (95%CIs) were calculated. Results 2,488 injured adult patients presented to the ED from November 2014 to April 2015 with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95%CI 32–38) tested alcohol positive. Forty-two percent of males (320/756), 40% of subjects 25–44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assaults (82/166), 40% of the seriously injured (124/311), and 53% of subjects who died in the ED (8/15) were positive for alcohol. Conclusions The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary hospital ED. These findings have implications for health policy, ED and legislative-based interventions, and acute care. PMID:27241887

Attitudes and beliefs of emergency department staff regarding alcohol-related presentations.

PubMed

Indig, Devon; Copeland, Jan; Conigrave, Katherine M; Rotenko, Irene

2009-01-01

This study examined emergency department (ED) staff attitudes and beliefs about alcohol-related ED presentations in order to recommend improved detection and brief intervention strategies. The survey was conducted at two inner-Sydney hospital EDs in 2006 to explore ED clinical staff's attitudes, current practice and barriers for managing alcohol-related ED presentations. The sample included N=78 ED staff (54% nurses, 46% doctors), representing a 30% response rate. Management of alcohol-related problems was not routine among ED staff, with only 5% usually formally screening for alcohol problems, only 16% usually conducting brief interventions, and only 27% usually providing a referral to specialist treatment services. Over 85% of ED staff indicated that lack of patient motivation made providing alcohol interventions very difficult. Significant predictors of good self-reported practice among ED staff for patients with alcohol problems included: being a doctor, being confident and having a sense of responsibility towards managing patients with alcohol-related problems. This study reported that many staff lack the confidence or sense of clinical responsibility to fully and appropriately manage ED patients with alcohol-related problems. ED staff appear to require additional training, resources and support to enhance their management of patients with alcohol-related problems.

Pain management policies and practices in pediatric emergency care: a nationwide survey of Italian hospitals

PubMed Central

2013-01-01

Background Pain experienced by children in emergency departments (EDs) is often poorly assessed and treated. Although local protocols and strategies are important to ensure appropriate staff behaviours, few studies have focussed on pain management policies at hospital or department level. This study aimed at describing the policies and reported practices of pain assessment and treatment in a national sample of Italian pediatric EDs, and identifying the assocoated structural and organisational factors. Methods A structured questionnaire was mailed to all the 14 Italian pediatric and maternal and child hospitals and to 5 general hospitals with separate pediatric emergency room. There were no refusals. Information collected included the frequency and mode of pain assessment, presence of written pain management protocols, use of local anaesthetic (EMLA cream) before venipuncture, and role of parents. General data on the hospital and ED were also recorded. Multiple Correspondence Analysis was used to explore the multivariable associations between the characteristics of hospitals and EDs and their pain management policies and practices. Results Routine pain assessment both at triage and in the emergency room was carried out only by 26% of surveyed EDs. About one third did not use algometric scales, and almost half (47.4%) did not have local protocols for pain treatment. Only 3 routinely reassessed pain after treatment, and only 2 used EMLA. All EDs allowed parents’ presence and most (17, 89.9%) allowed them to stay when painful procedures were carried out. Eleven hospitals (57.9%) allowed parents to hold their child during blood sampling. Pediatric and maternal and child hospitals, those located in the North of Italy, equipped with medico-surgical-traumatological ED and short stay observation, and providing full assessment triage over 24 hours were more likely to report appropriate policies for pain management both at triage and in ER. A nurses to admissions ratio ≥ median was associated with better pain management at triage. Conclusions Despite availability of national and international guidelines, pediatric pain management is still sub-optimal in Italian emergency departments. Multifaceted strategies including development of local policies, staff educational programs, and parental involvement in pain assessment should be carried out and periodically reinforced. PMID:24020369

Back so soon: rapid re-presentations to the emergency department following intentional self-harm.

PubMed

Kuehl, Silke; Nelson, Katherine; Collings, Sunny

2012-12-14

To describe the number, characteristics and management of patients who presented to an emergency department (ED) with intentional self-harm and then re-presented for any reason within 1 week, over a 1-year period. A retrospective records review from one New Zealand ED over 12 months. Of the 120 patients who attended the ED more than once with intentional self-harm, 48 re-presented on 73 occasions within 7 days of the index presentation. Of the re-presentations, 55% occurred within 1 day. Mental health assessments by emergency department staff were minimal; challenging incidents occurred in 40% of presentations; and there was an increase in the inpatient admission rate for second presentations. We identified a small group of patients who rapidly re-present to the ED following intentional self-harm. The reasons behind those re-presentations could include limited mental health assessments in ED and inadequate follow-up on discharge. System improvements in the ED including better collaboration with mental health services could improve how services address the needs of patients who present with intentional self-harm and reduce costs.

78 FR 71591 - Privacy Act of 1974; Computer Matching Program between the U.S. Department of Education (ED) and...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-29

... DEPARTMENT OF EDUCATION Privacy Act of 1974; Computer Matching Program between the U.S. Department.... ACTION: Notice. SUMMARY: Notice is hereby given of the renewal of the computer matching program between... (VA) (source agency). After the ED and VA Data Integrity Boards approve a new computer matching...

Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: data from the nationwide emergency department sample, 2006 to 2011.

PubMed

Sood, Akshay; Penna, Frank J; Eleswarapu, Sriram; Pucheril, Dan; Weaver, John; Abd-El-Barr, Abd-El-Rahman; Wagner, Jordan C; Lakshmanan, Yegappan; Menon, Mani; Trinh, Quoc-Dien; Sammon, Jesse D; Elder, Jack S

2015-10-01

The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as the urinary tract infections (UTIs). We sought to assess the contemporary trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure, using a large nationally representative pediatric cohort. Further, we describe the predictors of admission following a UTI associated ED visit. The Nationwide Emergency Department Sample (NEDS; 2006-2011) was queried to assess temporal-trends in pediatric (age ≤17 years) ED visits for a primary diagnosis of UTI (ICD9 CM code 590.X, 595.0, and 599.0), subsequent hospital admission, and total charges. These trends were examined using the estimated annual percent change (EAPC) method. Multivariable regression models fitted with generalized estimating equations (GEE) identified the predictors of hospital admission. Of the 1,904,379 children presenting to the ED for management of UTI, 86 042 (4.7%) underwent hospital admission. Female ED visits accounted for almost 90% of visits and increased significantly (EAPC 3.28%; p = 0.003) from 709 visits per 100 000 in 2006 to 844 visits per 100 000 in 2011. Male UTI incidence remained unchanged over the study-period (p = 0.292). The overall UTI associated ED visits also increased significantly during the study-period (EAPC 3.14%; p = 0.006) because of the increase in female UTI associated ED visits. Overall hospital admissions declined significantly over the study-period (EAPC -5.59%; p = 0.021). Total associated charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p < 0.001; Figure). This increase in expenditure was likely driven by increased utilization of diagnostic CT scanning in these patients (EAPC 22.86%; p < 0.001). Ultrasonography (p = 0.805), X-ray (p = 0.196), and urine analysis/culture use (p = 0.121) did not change over the study-period. In multivariable analysis, the independent predictors of admission included younger age (p < 0.001), male gender (OR = 2.05, p < 0.001), higher comorbidity status (OR = 14.81, p < 0.001), pyelonephritis (OR = 4.45, p < 0.001) and concurrent hydronephrosis (OR = 49.42, p < 0.001), stone disease (OR = 6.44, p < 0.001), or sepsis (OR = 18.83, p < 0.001). We show that the incidence of ED visits for pediatric UTI is on the rise. This rise in incidence could be due to several factors, including increasing prevalence of metabolic conditions such as obesity, diabetes and metabolic syndrome in children predisposing them to infections, or could be secondary to increasing sexual activity amongst adolescents and changing patterns of contraceptive use (increased use of OCP in place of condoms), or more simply might just be a reflection of changing practice patterns. Second, we demonstrate that total charges for management of UTI in the ED setting are increasing rapidly; the increase is primarily driven by increasing utilization of diagnostic imaging in the ED setting, as has been demonstrated in other ED based studies as well. In children presenting to the ED with a primary diagnosis of UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% of patients were admitted to the hospital for further management. The strongest predictors of inpatient admission were pyelonephritis, younger age, male gender, higher comorbidity status, and concurrent hydronephrosis, stone disease, or sepsis. Managing these at-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and subsequent hospitalizations, and reduce associated healthcare costs. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

The Impact of a Health IT Changeover on Medical Imaging Department Work Processes and Turnaround Times

PubMed Central

Georgiou, A.; Lymer, S.; Hordern, A.; Ridley, L.; Westbrook, J.

2015-01-01

Summary Objectives To assess the impact of introducing a new Picture Archiving and Communication System (PACS) and Radiology Information System (RIS) on: (i) Medical Imaging work processes; and (ii) turnaround times (TATs) for x-ray and CT scan orders initiated in the Emergency Department (ED). Methods We employed a mixed method study design comprising: (i) semi-structured interviews with Medical Imaging Department staff; and (ii) retrospectively extracted ED data before (March/April 2010) and after (March/April 2011 and 2012) the introduction of a new PACS/RIS. TATs were calculated as: processing TAT (median time from image ordering to examination) and reporting TAT (median time from examination to final report). Results Reporting TAT for x-rays decreased significantly after introduction of the new PACS/RIS; from a median of 76 hours to 38 hours per order (p<.0001) for patients discharged from the ED, and from 84 hours to 35 hours (p<.0001) for patients admitted to hospital. Medical Imaging staff reported that the changeover to the new PACS/RIS led to gains in efficiency, particularly regarding the accessibility of images and patient-related information. Nevertheless, assimilation of the new PACS/RIS with existing Departmental work processes was considered inadequate and in some instances unsafe. Issues highlighted related to the synchronization of work tasks (e.g., porter arrangements) and the material set up of the work place (e.g., the number and location of computers). Conclusions The introduction of new health IT can be a “double-edged sword” providing improved efficiency but at the same time introducing potential hazards affecting the effectiveness of the Medical Imaging Department. PMID:26448790

Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers.

PubMed

Ho, Vivian; Metcalfe, Leanne; Dark, Cedric; Vu, Lan; Weber, Ellerie; Shelton, George; Underwood, Howard R

2017-12-01

We compare utilization, price per visit, and the types of care delivered across freestanding emergency departments (EDs), hospital-based EDs, and urgent care centers in Texas. We analyzed insurance claims processed by Blue Cross Blue Shield of Texas from 2012 to 2015 for patient visits to freestanding EDs, hospital-based EDs, or urgent care centers in 16 Texas metropolitan statistical areas containing 84.1% of the state's population. We calculated the aggregate number of visits, average price per visit, proportion of price attributable to facility and physician services, and proportion of price billed to Blue Cross Blue Shield of Texas versus out of pocket, by facility type. Prices for the top 20 diagnoses and procedures by facility type are compared. Texans use hospital-based EDs and urgent care centers much more than freestanding EDs, but freestanding ED utilization increased 236% between 2012 and 2015. The average price per visit was lower for freestanding EDs versus hospital-based EDs in 2012 ($1,431 versus $1,842), but prices in 2015 were comparable ($2,199 versus $2,259). Prices for urgent care centers were only $164 and $168 in 2012 and 2015. Out-of-pocket liability for consumers for all these facilities increased slightly from 2012 to 2015. There was 75% overlap in the 20 most common diagnoses at freestanding EDs versus urgent care centers and 60% overlap for hospital-based EDs and urgent care centers. However, prices for patients with the same diagnosis were on average almost 10 times higher at freestanding and hospital-based EDs relative to urgent care centers. Utilization of freestanding EDs is rapidly expanding in Texas. Higher prices at freestanding and hospital-based EDs relative to urgent care centers, despite substantial overlap in services delivered, imply potential inefficient use of emergency facilities. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Characterizing New England Emergency Departments by Telemedicine Use.

PubMed

Zachrison, Kori S; Hayden, Emily M; Schwamm, Lee H; Espinola, Janice A; Sullivan, Ashley F; Boggs, Krislyn M; Raja, Ali S; Camargo, Carlos A

2017-10-01

Telemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use. We analyzed data from the National Emergency Department Inventory-New England survey, which assessed basic ED characteristics in 2014. The survey queried directors of every ED (n=195) in the six New England states (excluding federal hospitals and college infirmaries). Descriptive statistics characterized ED telemedicine use; multivariable logistic regression identified independent predictors of use. Of the 169 responding EDs (87% response rate), 82 (49%) reported using telemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of non-users, p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); and less likely to have 24/7 access to neurology (p<0.001), neurosurgery (p<0.001), orthopedics (p=0.01), plastic surgery (p=0.01), psychiatry (p<0.001), and hand surgery (p<0.001) consultants. Neuro/stroke (68%), pediatrics (11%), psychiatry (11%), and trauma (10%) were the most commonly reported applications. On multivariable analysis, telemedicine was more likely in rural EDs (odds ratio [OR] 4.39, 95% confidence interval [CI] 1.30-14.86), and less likely in EDs with 24/7 neurologist availability (OR 0.21, 95% CI [0.09-0.49]), and annual volume <20,000 (OR 0.24, 95% CI [0.08-0.68]). Telemedicine is commonly used in New England EDs. In 2014, use was more common among rural EDs and EDs with limited neurology consultant availability. In contrast, telemedicine use was less common among very low-volume EDs.

Occupational stress and coping strategies among emergency department nurses of China.

PubMed

Lu, Dong-Mei; Sun, Ning; Hong, Su; Fan, Yu-ying; Kong, Fan-ying; Li, Qiu-jie

2015-08-01

Emergency department(ED) nurses work in a rapidly changing environment with patients that have wide variety of conditions. Occupational stress in emergency department nurses is a common problem. The purpose of this study was to describe the relationship between coping strategies and occupational stress among ED nurses in China. A correlational, cross-sectional design was adopted. Two questionnaires were given to a random sample of 127 ED nurses registered at the Heilongjiang Nurses' Association. Data were collected from the nurses that worked in the ED of five general hospitals in Harbin China. Occupational stress and coping strategies were measured by two questionnaires. A multiple regression model was applied to analyze the relationship between stress and coping strategies. The stressors of ED nurses mainly come from the ED specialty of nursing (2.97±0.55), workload and time distribution (2.97±0.58). The mean score of positive coping strategies was 2.19±0.35, higher than the norm (1.78±0.52). The mean score of negative coping strategies was 1.20±0.61, lower than the norm (1.59±0.66), both had significant statistical difference (P<0.001). Too much documents work, criticism, instrument equipment shortage, night shift, rank of professional were the influence factors about occupational stress to positive coping styles. Too much documents work, and medical insurance for ED nurses were the influential factors on occupational stress to negative coping styles. This study identified several factors associated with occupational stress in ED nurses. These results could be used to guide nurse managers of ED nurses to reduce work stress. The managers could pay more attention to the ED nurse's coping strategies which can further influence their health state and quality of nursing care. Reducing occupational stress and enhancing coping strategies are vital not only for encouraging nurses but also for the future of nursing development. Copyright © 2015. Published by Elsevier Inc.

Should diagnosis codes from emergency department data be used for case selection for emergency department key performance indicators?

PubMed

Howell, Stuart C; Wills, Rachael A; Johnston, Trisha C

2014-02-01

The aim of the present study was to assess the suitability of emergency department (ED) discharge diagnosis for identifying patient cohorts included in the definitions of key performance indicators (KPIs) that are used to evaluate ED performance. Hospital inpatient episodes of care with a principal diagnosis that corresponded to an ED-defined KPI were extracted from the Queensland Hospital Admitted Patient Data Collection (QHAPDC) for the year 2010-2011. The data were then linked to the corresponding ED patient record and the diagnoses applied in the two settings were compared. The asthma and injury cohorts produced favourable results with respect to matching the QHAPDC principal diagnosis with the ED discharge diagnosis. The results were generally modest when the QHAPDC principal diagnosis was upper respiratory tract infection, poisoning and toxic effects or a mental health diagnosis, and were quite poor for influenza. There is substantial variation in the capture of patient cohorts using discharge diagnosis as recorded on Queensland Hospital Emergency Department data. WHAT IS KNOWN ABOUT THE TOPIC? There are several existing KPIs that are defined according to the diagnosis recorded on ED data collections. However, there have been concerns over the quality of ED diagnosis in Queensland and other jurisdictions, and the value of these data in identifying patient cohorts for the purpose of assessing ED performance remains uncertain. WHAT DOES THIS PAPER ADD? This paper identifies diagnosis codes that are suitable for use in capturing the patient cohorts that are used to evaluate ED performance, as well as those codes that may be of limited value. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? The limitations of diagnosis codes within ED data should be understood by those seeking to use these data items for healthcare planning and management or for research into healthcare quality and outcomes.

Early diagnosis of iliofemoral DVT in pregnancy in the emergency department.

PubMed

van Zyl Smit, Nellis; Govind, Abha; Sharma, Devesh

2012-06-12

The case of a 26-year-old woman who was 23 weeks pregnant is described; the patient presented, on a weekend, to the emergency department (ED) with left groin pain. There were few clinical signs of deep venous thrombosis (DVT) but ED ultrasound (US) showed a left external iliac vein thrombus. This is a new technique in the ED. Not only does this case show the importance of using this technique in the ED, but it also shows the importance of correct training in how to examine for thrombus in the external iliac vein in the pregnant patient. The patient was admitted to the hospital and started on low-molecular-weight heparin. A formal radiology department US performed the next week confirmed the diagnosis of DVT.

Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey.

PubMed

Fleet, Richard; Poitras, Julien; Archambault, Patrick; Tounkara, Fatoumata Korika; Chauny, Jean-Marc; Ouimet, Mathieu; Gauthier, Josée; Dupuis, Gilles; Tanguay, Alain; Lévesque, Jean-Frédéric; Simard-Racine, Geneviève; Haggerty, Jeannie; Légaré, France

2015-12-23

Rural emergency departments (EDs) constitute crucial safety nets for the 20% of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines "the provincial ED management Guide". The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide. We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec's Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements. A total of 23 of Québec's 26 rural EDs (88%) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74%), intensive unit care (78%) and general surgical services (78%), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23% of them have used the guidelines. Furthermore, more than 40% of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30% had air transport access. Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.

Integrated care in the emergency department: a complex adaptive systems perspective.

PubMed

Nugus, Peter; Carroll, Katherine; Hewett, David G; Short, Alison; Forero, Roberto; Braithwaite, Jeffrey

2010-12-01

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a "continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach to be salient to analyzing integrated care in the ED because the processes of categorization, diagnosis and discharge are primarily about the linkages between services, and the communication and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries. Copyright © 2010 Elsevier Ltd. All rights reserved.

Out-of-hours primary care. Implications of organisation on costs

PubMed Central

van Uden, Caro JT; Ament, Andre JHA; Voss, Gemma BWE; Wesseling, Geertjan; Winkens, Ron AG; van Schayck, Onno CP; Crebolder, Harry FJM

2006-01-01

Background To perform out-of-hours primary care, Dutch general practitioners (GPs) have organised themselves in large-scale GP cooperatives. Roughly, two models of out-of-hours care can be distinguished; GP cooperatives working separate from the hospital emergency department (ED) and GP cooperatives integrated with the hospital ED. Research has shown differences in care utilisation between these two models; a significant shift in the integrated model from utilisation of ED care to primary care. These differences may have implications on costs, however, until now this has not been investigated. This study was performed to provide insight in costs of these two different models of out-of-hours care. Methods Annual reports of two GP cooperatives (one separate from and one integrated with a hospital emergency department) in 2003 were analysed on costs and use of out-of-hours care. Costs were calculated per capita. Comparisons were made between the two cooperatives. In addition, a comparison was made between the costs of the hospital ED of the integrated model before and after the set up of the GP cooperative were analysed. Results Costs per capita of the GP cooperative in the integrated model were slightly higher than in the separate model (ε 11.47 and ε 10.54 respectively). Differences were mainly caused by personnel and other costs, including transportation, interest, cleaning, computers and overhead. Despite a significant reduction in patients utilising ED care as a result of the introduction of the GP cooperative integrated within the ED, the costs of the ED remained the same. Conclusion The study results show that the costs of primary care appear to be more dependent on the size of the population the cooperative covers than on the way the GP cooperative is organised, i.e. separated versus integrated. In addition, despite the substantial reduction of patients, locating the GP cooperative at the same site as the ED was found to have little effect on costs of the ED. Sharing more facilities and personnel between the ED and the GP cooperative may improve cost-efficiency. PMID:16674814

Internet Usage by Parents Prior to Seeking Care at a Pediatric Emergency Department: Observational Study

PubMed Central

2017-01-01

Background Little is known about how parents utilize medical information on the Internet prior to an emergency department (ED) visit. Objective The objective of the study was to determine the proportion of parents who accessed the Internet for medical information related to their child’s illness in the 24 hours prior to an ED visit (IPED), to identify the websites used, and to understand how the content contributed to the decision to visit the ED. Methods A 40-question interview was conducted with parents presenting to an ED within a freestanding children’s hospital. If parents reported IPED, the number and names of websites were documented. Parents indicated the helpfulness of Web-based content using a 100-mm visual analog scale and the degree to which it contributed to the decision to visit the ED using 5-point Likert-type responses. Results About 11.8 % (31/262) reported IPED (95% CI 7.3-5.3). Parents who reported IPED were more likely to have at least some college education (P=.04), higher annual household income (P=.001), and older children (P=.04) than those who did not report IPED. About 35% (11/31) could not name any websites used. Mean level of helpfulness of Web-based content was 62 mm (standard deviation, SD=25 mm). After Internet use, some parents (29%, 9/31) were more certain they needed to visit the ED, whereas 19% (6/31) were less certain. A majority (87%, 195/224) of parents who used the Internet stated that they would be somewhat likely or very likely to visit a website recommended by a physician. Conclusions Nearly 1 out of 8 parents presenting to an urban pediatric ED reported using the Internet in the 24 hours prior to the ED visit. Among privately insured, at least one in 5 parents reported using the Internet prior to visiting the ED. Web-based medical information often influences decision making regarding ED utilization. Pediatric providers should provide parents with recommendations for high-quality sources of health information available on the Internet. PMID:28958988

Expanding The INSPIRED COPD Outreach Program™ to the emergency department: a feasibility assessment

PubMed Central

Gillis, Darcy; Demmons, Jillian; Rocker, Graeme

2017-01-01

Background The Halifax-based INSPIRED COPD Outreach Program™ is a facility-to-community home-based novel clinical initiative that through improved care transitions, self-management, and engagement in advance care planning has demonstrated a significant (60%–80%) reduction in health care utilization with substantial cost aversion. By assessing the feasibility of expanding INSPIRED into the emergency department (ED) we anticipated extending reach and potential for positive impact of INSPIRED to those with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who avoid hospital admission. Methods Patients were eligible for the INSPIRED-ED study if >40 years of age, diagnosed with AECOPD and discharged from the ED, willing to be referred, community dwelling with at least one of: previous use of the ED services, admission to Intermediate Care Unit/Intensive Care Unit, or admission to hospital with AECOPD in the past year. We set feasibility objectives for referral rates, completion of action plans, advance care planning participation, and reduction in ED visit frequency. Results Referral rates were 0.5/week. Among eligible patients (n=174) 33 (19%) were referred of whom 15 (M=4, F=11) enrolled in INSPIRED-ED. Mean (SD) age was 68 (7) years, post-bronchdilator FEV1 44.2 (15.5) % predicted, and Medical Research Council (MRC) dyspnea score 3.8 (0.41). We met feasibility objectives for action plan and advance care planning completion. Frequency of subsequent ED visits fell by 54%. Mean (SD) Care Transition Measure (CTM-3) improved from 8.6 (2.0) to 11.3 (1.3), P=0.0004, and of 14 patients responding 12 (86%) found the program very helpful. An additional 34 patients were enrolled to our regular program from those referred but ineligible for INSPIRED-ED (n=27) or unwilling to participate (n=7). Conclusions INSPIRED-ED outcomes were generally positive, however referral and enrollment rates were lower than anticipated. Despite the potential of early self-management education, the ED may not be the ideal recruitment setting for home-based programs. Our findings underline the importance of conducting preliminary work to ascertain best settings for implementing new self-management education initiatives. PMID:28615932

Patient Preferences regarding Shared Decision-making in the Emergency Department: Findings from a multi-site survey.

PubMed

Schoenfeld, Elizabeth M; Kanzaria, Hemal K; Quigley, Denise D; Marie, Peter St; Nayyar, Nikita; Sabbagh, Sarah H; Gress, Kyle L; Probst, Marc A

2018-06-13

As Shared Decision-Making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED. We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale (CPS) and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person. Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85-92%, depending on decision type) expressed a desire for some degree of involvement in decision-making in the ED, while 8-15% preferred to leave decision-making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision-making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved. We found the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision-making. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Antimicrobial Stewardship in the Emergency Department and Guidelines for Development

PubMed Central

May, Larissa; Cosgrove, Sara; L’Archeveque, Michelle; Talan, David A.; Payne, Perry; Rothman, Richard E.

2013-01-01

Antimicrobial resistance is a mounting public health concern. Emergency departments (EDs) represent a particularly important setting for addressing inappropriate antimicrobial prescribing practices, given the frequent use of antibiotics in this setting that sits at the interface of the community and the hospital. This article outlines the importance of antimicrobial stewardship in the ED setting and provides practical recommendations drawn from existing evidence for the application of various strategies and tools that could be implemented in the ED including advancement of clinical guidelines, clinical decision support systems, rapid diagnostics, and expansion of ED pharmacist programs. PMID:23122955

Stress in emergency departments: experiences of nurses and doctors.

PubMed

Healy, Sonya; Tyrrell, Mark

2011-07-01

The effects of stressful incidents on emergency department (ED) staff can be profound. Witnessing aggression, violence or the death of patients, or participating in resuscitation, can be emotionally and physically demanding. Despite the frequency of these events, ED staff do not become immune to the stress they cause, and are often ill prepared and under supported to cope with them. This article reports on a study of nurses' and doctors' attitudes to, and experiences of, workplace stress in three EDs in Ireland, and offers some suggestions on how stress among ED staff can be reduced.

The Emergency Department: Challenges and Opportunities for Suicide Prevention.

PubMed

Asarnow, Joan Rosenbaum; Babeva, Kalina; Horstmann, Elizabeth

2017-10-01

Emergency departments (EDs) can offer life-saving suicide prevention care. This article focuses on the ED and emergency services as service delivery sites for suicide prevention. Characteristics of EDs, models of emergency care, ED screening and brief intervention models, and practice guidelines and parameters are reviewed. A care process model for youths at risk for suicide and self-harm is presented, with guidance for clinicians based on the scientific evidence. Strengthening emergency infrastructure and integrating effective suicide prevention strategies derived from scientific research are critical for advancing suicide prevention objectives. Copyright © 2017 Elsevier Inc. All rights reserved.

Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presentations: findings from a national qualitative study

PubMed Central

2013-01-01

Background Mental health related presentations are common in Australian Emergency Departments (EDs). We sought to better understand ED staff knowledge and levels of confidence in treating people with mental health related problems using qualitative methods. Methods This was a qualitative learning needs analysis of Australian emergency doctors and nurses regarding the assessment and management of mental health presentations. Participants were selected for semi-structured telephone interview using criterion-based sampling. Recruitment was via the Australasian College for Emergency Medicine and College of Emergency Nursing Australasia membership databases. Interviews were audio-recorded and transcribed verbatim. Thematic framework analysis was used to identify perceived knowledge gaps and levels of confidence among participants in assessing and managing patients attending EDs with mental health presentations. Results Thirty-six staff comprising 20 doctors and 16 nurses consented to participate. Data saturation was achieved for four major areas where knowledge gaps were reported. These were: assessment (risk assessment and assessment of mental status), management (psychotherapeutic skills, ongoing management, medication management and behaviour management), training (curriculum and rotations), and application of mental health legislation. Participants’ confidence in assessing mental health patients was affected by environmental, staff, and patient related factors. Clinicians were keen to learn more about evidence based practice to provide better care for this patient group. Areas where clinicians felt the least confident were in the effective assessment and management of high risk behaviours, providing continuity of care, managing people with dual diagnosis, prescribing and effectively managing medications, assessing and managing child and adolescent mental health, and balancing the caseload in ED. Conclusion Participants were most concerned about knowledge gaps in risk assessment, particularly for self-harming patients, violent and aggressive patients and their management, and distinguishing psychiatric from physical illness. Staff confidence was enhanced by better availability of skilled psychiatric support staff to assist in clinical decision-making for complex cases and via the provision of a safe ED environment. Strategies to enhance the care of patients with mental health presentations in Australian emergency departments should address these gaps in knowledge and confidence. PMID:23317351

Emergency Department Utilization Report to Decrease Visits by Pediatric Gastroenterology Patients.

PubMed

Lee, Jarone; Greenspan, Peter T; Israel, Esther; Katz, Aubrey; Fasano, Alessio; Kaafarani, Haytham M A; Linov, Pamela L; Raja, Ali S; Rao, Sandhya K

2016-07-01

Emergency department (ED) utilization is a major driver of health care costs. Specialist physicians have an important role in addressing ED utilization, especially at highly specialized, academic medical centers. We sought to investigate whether reporting of ED utilization to specialist physicians can decrease ED visits. This study analyzed an intervention to reduce ED utilization among ED patients who were followed by pediatric gastroenterologists. In May 2013, each pediatric gastroenterologist began receiving reports with rates of ED use by their patients. The reports generated discussion that resulted in a cultural and process change in which patients with urgent gastrointestinal (GI)-related complaints were preferentially seen in the office. Using control charts, we examined GI-related and all-diagnoses ED use over a 2-year period. The rate of GI-related ED visits decreased by 60% after the intervention, from 4.89 to 1.95 per 1000 office visits (P < .001). Similarly, rates of GI-related ED visits during office hours decreased by 59% from 2.19 to 0.89 per 1000 (P < .001). Rates of all-diagnoses ED visits did not change. Physician-level reporting of ED utilization to pediatric gastroenterologists was associated with physician engagement and a cultural and process change to preferentially treat patients with urgent issues in the office. Copyright © 2016 by the American Academy of Pediatrics.

Associations of work characteristics, employee strain and self-perceived quality of care in Emergency Departments: A cross-sectional study.

PubMed

Weigl, Matthias; Schneider, Anna

2017-01-01

The individual and shared effects of adverse work characteristics on patient care in Emergency Departments (ED) are yet not well understood. We investigated the associations of self-reported ED work characteristics, work-related strain, and perceived quality of care. Questionnaire-based survey with standardized measures among N=53 ED professionals (i.e., nurses, physicians, and administration staff). The study was conducted in the interdisciplinary ED of a German community hospital. A high prevalence of work-related strain was observed: 66.0% of ED professionals showed high levels of emotional exhaustion and 55.6% showed irritation scores above the cut-off value. ED staff reported high supervisor support and autonomy, paired with high time pressure and patient-related stressors. Multivariate analyses revealed that high time pressure and low supervisor support were associated with high work-related strain. Low staffing was related to inferior quality of ED care. ED work systems involve high competing demands for ED professionals with substantial risks for work-related strain. Moreover, adverse ED work characteristics comprise risks for high quality patient care. Our results suggest that promoting work characteristics might foster ED staff functioning on the job as well as improve ED patient care. Copyright © 2016 Elsevier Ltd. All rights reserved.

Medical identity theft in the emergency department: awareness is crucial.

PubMed

Mancini, Michelino

2014-11-01

Medical identity theft in the emergency department (ED) can harm numerous individuals, and many frontline healthcare providers are unaware of this growing concern. The two cases described began as typical ED encounters until red flags were discovered upon validating the patient's identity. Educating all healthcare personnel within and outside the ED regarding the subtle signs of medical identity theft and implementing institutional policies to identify these criminals will discourage further fraudulent behavior.

Presentations to Emergency Departments for COPD: A Time Series Analysis.

PubMed

Rosychuk, Rhonda J; Youngson, Erik; Rowe, Brian H

2016-01-01

Background. Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterized by progressive dyspnea and acute exacerbations which may result in emergency department (ED) presentations. This study examines monthly rates of presentations to EDs in one Canadian province. Methods. Presentations for COPD made by individuals aged ≥55 years during April 1999 to March 2011 were extracted from provincial databases. Data included age, sex, and health zone of residence (North, Central, South, and urban). Crude rates were calculated. Seasonal autoregressive integrated moving average (SARIMA) time series models were developed. Results. ED presentations for COPD totalled 188,824 and the monthly rate of presentation remained relatively stable (from 197.7 to 232.6 per 100,000). Males and seniors (≥65 years) comprised 52.2% and 73.7% of presentations, respectively. The ARIMA(1,0, 0) × (1,0, 1)12 model was appropriate for the overall rate of presentations and for each sex and seniors. Zone specific models showed relatively stable or decreasing rates; the North zone had an increasing trend. Conclusions. ED presentation rates for COPD have been relatively stable in Alberta during the past decade. However, their increases in northern regions deserve further exploration. The SARIMA models quantified the temporal patterns and can help planning future health care service needs.

Evaluation of emergency department performance – a systematic review on recommended performance and quality-in-care measures

PubMed Central

2013-01-01

Background Evaluation of emergency department (ED) performance remains a difficult task due to the lack of consensus on performance measures that reflects high quality, efficiency, and sustainability. Aim To describe, map, and critically evaluate which performance measures that the published literature regard as being most relevant in assessing overall ED performance. Methods Following the PRISMA guidelines, a systematic literature review of review articles reporting accentuated ED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science. Study eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures best reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level performance measures, thus reflecting an overall departmental performance level. Results A number of articles addresses this study’s objective (n = 14 of 46 unique hits). Time intervals and patient-related measures were dominant in the identified performance measures in review articles from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission were highlighted by the majority of articles. Concurrently, “patients left without being seen” (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents were the most highlighted performance measures that related directly to the patient. Performance measures related to employees were only stated in two of the 14 included articles. Conclusions A total of 55 ED performance measures were identified. ED time intervals were the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures were rarely mentioned in the investigated literature. The study’s results allow for advancement towards improved performance measurement and standardised assessment across EDs. PMID:23938117

Association of Positive Responses to Suicide Screening Questions with Hospital Admission and Repeat Emergency Department Visits in Children and Adolescents

PubMed Central

Ballard, Elizabeth D.; Horowitz, Lisa M.; Jobes, David A.; Wagner, Barry M.; Pao, Maryland; Teach, Stephen J.

2013-01-01

Objectives While validated suicide screening tools exist for use among children and adolescents presenting to emergency departments (EDs), the associations between screening positive for suicide risk and immediate psychiatric hospital admission or subsequent ED utilization, stratified by age, have not been examined. Methods A retrospective cohort study of a consecutive case series of patients aged 8–18 years presenting with psychiatric chief complaints over a 9 month period to a single urban tertiary care pediatric ED. Eligible patients were administered a subset of questions from the Risk of Suicide Questionnaire. Outcomes included the odds of psychiatric hospitalization at the index visit and repeat ED visits for psychiatric complaints within the following year, stratified by age. Results Of the 568 patients presenting during the study period, responses to suicide screening questions were available for 442 patients (78%). A total of 159/442 (36%) were hospitalized and 130/442 (29%) had one or more ED visits within the following year. The proportion of patients providing positive responses to one or more suicide screening questions did not differ between patients aged 8–12 years and those aged 13–18 years [77/154 (50%) vs. 137/288 (48%), p = .63]. A positive response to one or more of the questions was significantly associated with increased odds of psychiatric hospitalization in the older age group [adj OR = 3.82 (95% CI 2.24–6.54)] and with repeat visits to the ED in the younger age group [adj OR = 3.55 (95% CI 1.68–7.50)]. Conclusions Positive responses to suicide screening questions were associated with acute psychiatric hospitalization and repeat ED visits. Suicide screening in a pediatric ED may identify children and adolescents with increased need of psychiatric resources. PMID:24076609

Death of a child in the emergency department.

PubMed

O'Malley, Patricia J; Barata, Isabel A; Snow, Sally K

2014-07-01

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Using Lean Management to Reduce Emergency Department Length of Stay for Medicine Admissions.

PubMed

Allaudeen, Nazima; Vashi, Anita; Breckenridge, Julia S; Haji-Sheikhi, Farnoosh; Wagner, Sarah; Posley, Keith A; Asch, Steven M

The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored. To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions. Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016. We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work. The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach. ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites. We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.

A simulated emergency department for medical students.

PubMed

Johnson, Patricia; Brazil, Victoria; Raymond-Dufresne, Éliane; Nielson, Tracy

2017-08-01

During their training, medical students often undertake a rotation in an emergency department (ED), where they are exposed to a wide variety of patient presentations. Simulation can be an effective teaching strategy to help prepare learners for the realities of the clinical environment. Simulating an ED shift can provide students with the opportunity to perform a range of clinical activities, within their scope of practice, in a supervised and supportive learning environment. Medical students often undertake a rotation in an emergency department CONTEXT: There is limited literature describing the structure, syllabus, feasibility and perceived usefulness of simulating a typical ED for medical student training. We developed a simulated ED (simED) teaching session for medical students at our university. Students were informed of the purpose and learning tasks of the session prior to attendance. At the start of their 2-hour simED shift students were allocated 'patients' by the Triage nurse. At the completion of their shift, students attended a debriefing discussion. Student feedback indicated that they felt that the simED: provided a good opportunity to practise skills and apply theory to practice; was realistic and challenging; highlighted the importance of teamwork; and enabled them to identify skills requiring further practise. Suggestions for improvements included a longer time spent in the simED and the opportunity to see more patients. The simED approach seemed to be well received and perceived by medical students as useful preparation for the ED. An overview of the structure, materials and resources used is provided to assist educators seeking to implement similar ED clinical scenarios in their curriculum. © 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Principles of Emergency Department facility design for optimal management of mass-casualty incidents.

PubMed

Halpern, Pinchas; Goldberg, Scott A; Keng, Jimmy G; Koenig, Kristi L

2012-04-01

The Emergency Department (ED) is the triage, stabilization and disposition unit of the hospital during a mass-casualty incident (MCI). With most EDs already functioning at or over capacity, efficient management of an MCI requires optimization of all ED components. While the operational aspects of MCI management have been well described, the architectural/structural principles have not. Further, there are limited reports of the testing of ED design components in actual MCI events. The objective of this study is to outline the important infrastructural design components for optimization of ED response to an MCI, as developed, implemented, and repeatedly tested in one urban medical center. In the authors' experience, the most important aspects of ED design for MCI have included external infrastructure and promoting rapid lockdown of the facility for security purposes; an ambulance bay permitting efficient vehicle flow and casualty discharge; strategic placement of the triage location; patient tracking techniques; planning adequate surge capacity for both patients and staff; sufficient command, control, communications, computers, and information; well-positioned and functional decontamination facilities; adequate, well-located and easily distributed medical supplies; and appropriately built and functioning essential services. Designing the ED to cope well with a large casualty surge during a disaster is not easy, and it may not be feasible for all EDs to implement all the necessary components. However, many of the components of an appropriate infrastructural design add minimal cost to the normal expenditures of building an ED. This study highlights the role of design and infrastructure in MCI preparedness in order to assist planners in improving their ED capabilities. Structural optimization calls for a paradigm shift in the concept of structural and operational ED design, but may be necessary in order to maximize surge capacity, department resilience, and patient and staff safety.

Security, Violent Events, and Anticipated Surge Capabilities of Emergency Departments in Washington State

PubMed Central

Weyand, Jonathan S.; Junck, Emily; Kang, Christopher S.; Heiner, Jason D.

2017-01-01

Introduction Over the past 15 years, violent threats and acts against hospital patients, staff, and providers have increased and escalated. The leading area for violence is the emergency department (ED) given its 24/7 operations, role in patient care, admissions gateway, and center for influxes during acute surge events. This investigation had three objectives: to assess the current security of Washington State EDs; to estimate the prevalence of and response to threats and violence in Washington State EDs; and to appraise the Washington State ED security capability to respond to acute influxes of patients, bystanders, and media during acute surge events. Methods A voluntary, blinded, 28-question Web-based survey developed by emergency physicians was electronically delivered to all 87 Washington State ED directors in January 2013. We evaluated responses by descriptive statistical analyses. Results Analyses occurred after 90% (78/87) of ED directors responded. Annual censuses of the EDs ranged from < 20,000 to 100,000 patients and represented the entire spectrum of practice environments, including critical access hospitals and a regional quaternary referral medical center. Thirty-four of 75 (45%) reported the current level of security was inadequate, based on the general consensus of their ED staff. Nearly two-thirds (63%) of EDs had 24-hour security personnel coverage, while 28% reported no assigned security personnel. Security personnel training was provided by 45% of hospitals or healthcare systems. Sixty-nine of 78 (88%) respondents witnessed or heard about violent threats or acts occurring in their ED. Of these, 93% were directed towards nursing staff, 90% towards physicians, 74% towards security personnel, and 51% towards administrative personnel. Nearly half (48%) noted incidents directed towards another patient, and 50% towards a patient’s family or friend. These events were variably reported to the hospital administration. After an acute surge event, 35% believed the initial additional security response would not be adequate, with 26% reporting no additional security would be available within 15 minutes. Conclusion Our study reveals the variability of ED security staffing and a heterogeneity of capabilities throughout Washington State. These deficiencies and vulnerabilities highlight the need for other EDs and regional emergency preparedness planners to conduct their own readiness assessments. PMID:28435498

An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations

PubMed Central

2014-01-01

Background Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population. Methods This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use—specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures. Results In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits. Conclusions Financial barriers were associated with identifying the ED as one’s usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals. PMID:24507761

Demand for Emergency Services Trends in New South Wales Years 2010-2014 (DESTINY): Age and Clinical Factors Associated with Ambulance Transportation to Emergency Departments.

PubMed

Dinh, Michael M; Muecke, Sandy; Berendsen Russell, Saartje; Chalkley, Dane; Bein, Kendall J; Muscatello, David; Nagaraj, Guruprasad; Paoloni, Richard; Ivers, Rebecca

2016-01-01

The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.

Incorporating Alternative Care Site Characteristics Into Estimates of Substitutable ED Visits.

PubMed

Trueger, Nathan Seth; Chua, Kao-Ping; Hussain, Aamir; Liferidge, Aisha T; Pitts, Stephen R; Pines, Jesse M

2017-07-01

Several recent efforts to improve health care value have focused on reducing emergency department (ED) visits that potentially could be treated in alternative care sites (ie, primary care offices, retail clinics, and urgent care centers). Estimates of the number of these visits may depend on assumptions regarding the operating hours and functional capabilities of alternative care sites. However, methods to account for the variability in these characteristics have not been developed. To develop methods to incorporate the variability in alternative care site characteristics into estimates of ED visit "substitutability." Our approach uses the range of hours and capabilities among alternative care sites to estimate lower and upper bounds of ED visit substitutability. We constructed "basic" and "extended" criteria that captured the plausible degree of variation in each site's hours and capabilities. To illustrate our approach, we analyzed data from 22,697 ED visits by adults in the 2011 National Hospital Ambulatory Medical Care Survey, defining a visit as substitutable if it was treat-and-release and met both the operating hours and functional capabilities criteria. Use of the combined basic hours/basic capabilities criteria and extended hours/extended capabilities generated lower and upper bounds of estimates. Our criteria classified 5.5%-27.1%, 7.6%-20.4%, and 10.6%-46.0% of visits as substitutable in primary care offices, retail clinics, and urgent care centers, respectively. Alternative care sites vary widely in operating hours and functional capabilities. Methods such as ours may help incorporate this variability into estimates of ED visit substitutability.

78 FR 47676 - Agency Information Collection Activities; Comment Request; National Professional Development...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-06

... DEPARTMENT OF EDUCATION [Docket No. ED-2013-ICCD-0100] Agency Information Collection Activities; Comment Request; National Professional Development Program: Grantee Performance Report AGENCY: Office of English Language Acquisition (OLEA), Department of Education (ED). ACTION: Notice. SUMMARY: In accordance...

The Diverse Sources of Federal Financial Support of Schools. School Finance Project. Working Paper.

ERIC Educational Resources Information Center

Miller, Vic

Federal programs outside the Department of Education (ED) provide significant financial support to elementary and secondary education, according to this paper. The authors give capsule descriptions of over two dozen such non-ED programs, compare changes in non-ED funding with shifts in ED aid, evaluate the impact of non-ED aid on different regions…

Regional Energy Deployment System (ReEDS) | Energy Analysis | NREL

Science.gov Websites

System Model The Regional Energy Deployment System (ReEDS) model helps the U.S. Department of model. Visualize Future Capacity Expansion of Renewable Energy Watch this video of the ReEDS model audio. Model Documentation ReEDS Model Documentation: Version 2016 ReEDS Map with Numbered Regions

ED"Facts" Workbook: SY 2013-14. Version 10.1

ERIC Educational Resources Information Center

US Department of Education, 2014

2014-01-01

ED"Facts" is a U.S. Department of Education (ED) initiative to govern, acquire, validate, and use high-quality, kindergarten through grade 12 (K-12) performance data for education planning, policymaking, and management and budget decision making to improve outcomes for students. ED"Facts" centralizes data provided by state…

Emergency department throughput, crowding, and financial outcomes for hospitals.

PubMed

Handel, Daniel A; Hilton, Joshua A; Ward, Michael J; Rabin, Elaine; Zwemer, Frank L; Pines, Jesse M

2010-08-01

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

The organizational culture of emergency departments and the effect on care of older adults: a modified scoping study.

PubMed

Skar, Pål; Bruce, Anne; Sheets, Debra

2015-04-01

How does the organizational micro culture in emergency departments (EDs) impact the care of older adults presenting with a complaint or condition perceived as non-acute? This scoping study reviews the literature and maps three levels of ED culture (artifacts, values and beliefs, and assumptions). Findings on the artifact level indicate that EDs are poorly designed for the needs of older adults. Findings on the ED value and belief level indicate that EDs are for urgent cases (not geriatric care), that older adults do not receive the care and respect they should be given, that older adults require too much time, and that the basic nursing needs of older adults are not a priority for ED nurses. Finally, finding on the assumptions level underpinning ED behaviors suggest that older adults do not belong in the ED, most older adults in the ED are not critically ill and therefore can wait, and staff need to be available for acute cases at all times. A systematic review on the effect of ED micro culture on the quality of geriatric care is warranted. Copyright © 2014. Published by Elsevier Ltd.

Psychiatric emergencies in children and adolescents: an Emergency Department audit.

PubMed

Starling, Jean; Bridgland, Kim; Rose, Donna

2006-12-01

To describe a cohort of children presenting to a paediatric emergency department with mental health problems. An Emergency Department (ED) computerized record system and hospital records were used to obtain data on children who presented to a paediatric ED with mental health problems. There were 291 presentations of 231 children in a 10-month period, about one per day. They were a small (0.8%) but complicated part of the ED workload. Most were first presentations and came voluntarily to ED. There were a wide variety of presenting symptoms including self-harm, suicide attempts, behavioural disorders and medical disorders with associated psychological problems. Acute psychosis was rare. Many children with mental health problems were seen for the first time in ED. With the growing awareness of mental health problems in this age group, it is likely that such presentations will increase. Paediatric and psychiatry services have an opportunity to work together to provide early intervention services for what is potentially a very accessible population.

An automated, broad-based, near real-time public health surveillance system using presentations to hospital Emergency Departments in New South Wales, Australia

PubMed Central

Muscatello, David J; Churches, Tim; Kaldor, Jill; Zheng, Wei; Chiu, Clayton; Correll, Patricia; Jorm, Louisa

2005-01-01

Background In a climate of concern over bioterrorism threats and emergent diseases, public health authorities are trialling more timely surveillance systems. The 2003 Rugby World Cup (RWC) provided an opportunity to test the viability of a near real-time syndromic surveillance system in metropolitan Sydney, Australia. We describe the development and early results of this largely automated system that used data routinely collected in Emergency Departments (EDs). Methods Twelve of 49 EDs in the Sydney metropolitan area automatically transmitted surveillance data from their existing information systems to a central database in near real-time. Information captured for each ED visit included patient demographic details, presenting problem and nursing assessment entered as free-text at triage time, physician-assigned provisional diagnosis codes, and status at departure from the ED. Both diagnoses from the EDs and triage text were used to assign syndrome categories. The text information was automatically classified into one or more of 26 syndrome categories using automated "naïve Bayes" text categorisation techniques. Automated processes were used to analyse both diagnosis and free text-based syndrome data and to produce web-based statistical summaries for daily review. An adjusted cumulative sum (cusum) was used to assess the statistical significance of trends. Results During the RWC the system did not identify any major public health threats associated with the tournament, mass gatherings or the influx of visitors. This was consistent with evidence from other sources, although two known outbreaks were already in progress before the tournament. Limited baseline in early monitoring prevented the system from automatically identifying these ongoing outbreaks. Data capture was invisible to clinical staff in EDs and did not add to their workload. Conclusion We have demonstrated the feasibility and potential utility of syndromic surveillance using routinely collected data from ED information systems. Key features of our system are its nil impact on clinical staff, and its use of statistical methods to assign syndrome categories based on clinical free text information. The system is ongoing, and has expanded to cover 30 EDs. Results of formal evaluations of both the technical efficiency and the public health impacts of the system will be described subsequently. PMID:16372902

Emergency Department Visits by Pediatric Patients for Poisoning by Prescription Opioids

PubMed Central

Tadros, Allison; Layman, Shelley M.; Davis, Stephen M.; Bozeman, Rachel; Davidov, Danielle M.

2016-01-01

Background Prescription medication abuse is an increasingly recognized problem in the United States. As more opioids are being prescribed and abused by adults, there is an increased risk of both accidental and intentional exposure to children and adolescents. The impact of pediatric exposures to prescription pain pills has not been well studied. Objectives We sought to evaluate emergency department (ED) visits for poisoning by prescription opioids in pediatric patients. Methods This retrospective study looked at clinical and demographic data from the Nationwide Emergency Department Sample (NEDS) from 2006 – 2012. Results There were 21,928 pediatric ED visits for prescription opioid poisonings and more than half were unintentional. There was a bimodal age distribution of patients with slightly more than half occurring in females. The majority of patients were discharged from the ED. More visits in the younger age group (0–5 years) were unintentional while the majority of visits in the adolescent age group (15–17 years) were intentional. Mean charge per discharge was $1,840 and $14,235 for admissions and surmounted to over $81 million in total charges. Conclusion Poisonings by prescription opioids largely impact both young children and adolescents. These findings can be used to help target this population for future preventive efforts. PMID:27398815

Prescriptions, Nonmedical Use, and Emergency Department Visits Involving Prescription Stimulants

PubMed Central

Chen, Lian-Yu; Crum, Rosa M.; Strain, Eric C.; CalebAlexander, G.; Kaufmann, Christopher; Mojtabai, Ramin

2018-01-01

Objective Little is known regarding the temporal trends in prescription, nonmedical use and emergency department (ED) visits involving prescription stimulants in the United States. We aimed to examine the three national trends involving dextroamphetamine-amphetamin (Adderall) and methylphenidate in adults and adolescents. Method Three national surveys conducted between 2006-2011 were used: National Disease and Therapeutic Index (NDTI), a survey of office-based practices, National Survey on Drug Use and Health (NSDUH), a population survey of substance use, and Drug Abuse Warning Network (DAWN), a survey of ED visits. Ordinary least square regression was used to examine temporal changes over time and the associations between these three trends. Results In adolescents, treatment visits involving dextroamphetamine-amphetamine and methylphenidate decreased over time; nonmedical dextroamphetamine-amphetamine use remained stable while nonmedical methylphenidate use declined by 54.4% in 6 years. ED visits involving either medication remained stable. In adults, treatment visits involving dextroamphetamine-amphetamine remained unchanged while nonmedical use went up by 67% and ED visits went up by 156%. These three trends involving methylphenidate remained unchanged. The major source for both medications was a friend or relative across age groups; two-thirds of these friends/relatives had obtained the medication from a physician. Conclusions Trends of prescriptions for stimulants do not correspond to trends in reports of nonmedical use and ED visits. Increased nonmedical stimulant use may not be simply attributed to increased prescribing trends. Future studies should focus on deeper understanding of the proportion, risk factors and motivations for drug diversions. PMID:26890573

Prospective evaluation of an automated method to identify patients with severe sepsis or septic shock in the emergency department.

PubMed

Brown, Samuel M; Jones, Jason; Kuttler, Kathryn Gibb; Keddington, Roger K; Allen, Todd L; Haug, Peter

2016-08-22

Sepsis is an often-fatal syndrome resulting from severe infection. Rapid identification and treatment are critical for septic patients. We therefore developed a probabilistic model to identify septic patients in the emergency department (ED). We aimed to produce a model that identifies 80 % of sepsis patients, with no more than 15 false positive alerts per day, within one hour of ED admission, using routine clinical data. We developed the model using retrospective data for 132,748 ED encounters (549 septic), with manual chart review to confirm cases of severe sepsis or septic shock from January 2006 through December 2008. A naïve Bayes model was used to select model features, starting with clinician-proposed candidate variables, which were then used to calculate the probability of sepsis. We evaluated the accuracy of the resulting model in 93,733 ED encounters from April 2009 through June 2010. The final model included mean blood pressure, temperature, age, heart rate, and white blood cell count. The area under the receiver operating characteristic curve (AUC) for the continuous predictor model was 0.953. The binary alert achieved 76.4 % sensitivity with a false positive rate of 4.7 %. We developed and validated a probabilistic model to identify sepsis early in an ED encounter. Despite changes in process, organizational focus, and the H1N1 influenza pandemic, our model performed adequately in our validation cohort, suggesting that it will be generalizable.

Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the Emergency Department

PubMed Central

Drapkin, Jefferson; Likourezos, Antonios; Beals, Tyler; Monfort, Ralph; Fromm, Christian; Marshall, John

2018-01-01

Introduction Our objective was to describe dosing, duration, and pre- and post-infusion analgesic administration of continuous intravenous sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful conditions in the emergency department (ED). Methods We conducted a retrospective chart review of patients aged 18 and older presenting to the ED with acute and chronic painful conditions who received continuous SDK infusion in the ED for a period over six years (2010–2016). Primary data analyses included dosing and duration of infusion, rates of pre- and post-infusion analgesic administration, and final diagnoses. Secondary data included pre- and post-infusion pain scores and rates of side effects. Results A total of 104 patients were enrolled in the study. Average dosing of SDK infusion was 11.26 mg/hr, and the mean duration of infusion was 135.87 minutes. There was a 38% increase in patients not requiring post-infusion analgesia. The average decrease in pain score was 5.04. There were 12 reported adverse effects, with nausea being the most prevalent. Conclusion Continuous intravenous SDK infusion has a role in controlling pain of various etiologies in the ED with a potential to reduce the need for co-analgesics or rescue analgesic administration. There is a need for more robust, prospective, randomized trials that will further evaluate the analgesic efficacy and safety of this modality across a wide range of pain syndromes and different age groups in the ED. PMID:29760856

Explaining transgression in respiratory rate observation methods in the emergency department: A classic grounded theory analysis.

PubMed

Flenady, Tracy; Dwyer, Trudy; Applegarth, Judith

2017-09-01

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often inaccurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs. To develop a substantive theory explaining ED registered nurses' reasoning when they miss or misreport respiratory rate observations. This research project employed a classic grounded theory analysis of qualitative data. Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed responses from individual interviews and open-ended responses from an online questionnaire. Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were employed to code data. This approach facilitated the identification of the main concern of the participants and aided in the generation of theory explaining how the participants processed this issue. The main concern identified is that ED registered nurses do not believe that collecting an accurate respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational requirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The theory 'Rationalising Transgression', explains how participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing strategies that adjust the significance of the organisational requirement. These strategies include; Compensating, when nurses believe they are compensating for errant behaviour by enhancing the patient's outcome; Minimalizing, when nurses believe that the patient's outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy that sanctions negligent behaviour and occurs when nurses 'cut corners' to get the job done. Nurses' use these strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising transgression CONCLUSION: This research reveals that despite continuing education regarding gold standard guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses' understanding of acceptable practice methods. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Brief Report: Factors Associated with Emergency Department Visits for Epilepsy among Children with Autism Spectrum Disorder

ERIC Educational Resources Information Center

Zhang, Wanqing; Baranek, Grace; Boyd, Brian

2018-01-01

We examined how demographic and clinical characteristics differ between emergency department (ED) visits for epilepsy (EP cohort) and ED visits for other reasons (non-EP cohort) in children with ASD. The data were drawn from the 2009 and 2010 Nationwide Emergency Department Sample. We performed both univariate and multivariate analyses to compare…

Development and Validation of the Agency for Healthcare Research and Quality Measures of Potentially Preventable Emergency Department (ED) Visits: The ED Prevention Quality Indicators for General Health Conditions.

PubMed

Davies, Sheryl; Schultz, Ellen; Raven, Maria; Wang, Nancy Ewen; Stocks, Carol L; Delgado, Mucio Kit; McDonald, Kathryn M

2017-10-01

To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008-2010 State Inpatient Databases and State Emergency Department Databases. Empirical analyses and structured panel reviews. Panels of 14-17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county-level poverty, uninsurance, and density of primary care physicians (PCPs). ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end-user panel separately rated the indicators as having strong face validity for most uses evaluated. The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research. © Health Research and Educational Trust.

The impact of unstable housing on emergency department use in a cohort of HIV-positive people in a Canadian setting

PubMed Central

Chan, Keith; Milan, David; Grafstein, Eric; Palmer, Alexis K.; Rhodes, Chelsey; Montaner, Julio S.G.; Hogg, Robert S.

2014-01-01

The social-structural challenges experienced by people living with HIV (PHA) have been shown to contribute to increased use of the Emergency Department (ED). This study identified factors associated with frequent and non-urgent ED use within a cohort of people accessing antiretroviral therapy (ART) in a Canadian setting. Interviewer-administered surveys collected socio-demographic information; clinical variables were obtained through linkages with the provincial drug treatment registry; and ED admission data were abstracted from the Department of Emergency Medicine database. Multivariate logistic regression was used to compute odds of frequent and non-urgent ED use. Unstable housing was independently associated with ED use (adjusted odds ratio [AOR]=1.94, 95% confidence interval [CI] 1.24–3.04]), having three or more ED visits within 6 months of interview date [AOR: 2.03 (95% CI: 1.07–3.83)] and being triaged as non-urgent (AOR=2.71, 95% CI: 1.19–6.17). Frequent and non-urgent use of the ED in this setting is associated with conditions requiring interventions at the social-structural level. Supportive housing may contribute to decreased healthcare costs and improved health outcomes amongst marginalized PHA. PMID:23656484

Oncologic emergencies in a cancer center emergency department and in general emergency departments countywide and nationwide.

PubMed

Yang, Zhi; Yang, Runxiang; Kwak, Min Ji; Qdaisat, Aiham; Lin, Junzhong; Begley, Charles E; Reyes-Gibby, Cielito C; Yeung, Sai-Ching Jim

2018-01-01

Although cancer patients (CPs) are increasingly likely to visit emergency department (ED), no population-based study has compared the characteristics of CPs and non-cancer patients (NCPs) who visit the ED and examined factors associated with hospitalization via the ED. In this study, we (1) compared characteristics and diagnoses between CPs and NCPs who visited the ED in a cancer center or general hospital; (2) compared characteristics and diagnoses between CPs and NCPs who were hospitalized via the ED in a cancer center or general hospital; and (3) investigated important factors associated with such hospitalization. We analyzed patient characteristic and diagnosis [based on International Classification of Diseases-9 (ICD-9) codes] data from the ED of a comprehensive cancer center (MDACC), 24 general EDs in Harris County, Texas (HCED), and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1/1/2007-12/31/2009. Approximately 3.4 million ED visits were analyzed: 47,245, 3,248,973, and 104,566 visits for MDACC, HCED, and NHAMCS, respectively, of which 44,143 (93.4%), 44,583 (1.4%), and 632 (0.6%) were CP visits. CPs were older than NCPs and stayed longer in EDs. Lung, gastrointestinal (excluding colorectal), and genitourinary (excluding prostate) cancers were the three most common diagnoses related to ED visits at general EDs. CPs visiting MDACC were more likely than CPs visiting HCED to be privately insured. CPs were more likely than NCPs to be hospitalized. Pneumonia and influenza, fluid and electrolyte disorders, and fever were important predictive factors for CP hospitalization; coronary artery disease, cerebrovascular disease, and heart failure were important factors for NCP hospitalization. CPs consumed more ED resources than NCPs and had a higher hospitalization rate. Given the differences in characteristics and diagnoses between CPs and NCPs, ED physicians must pay special attention to CPs and be familiar with their unique set of oncologic emergencies.

Study Designs and Evaluation Models for Emergency Department Public Health Research

PubMed Central

Broderick, Kerry B.; Ranney, Megan L.; Vaca, Federico E.; D’Onofrio, Gail; Rothman, Richard E.; Rhodes, Karin V.; Becker, Bruce; Haukoos, Jason S.

2011-01-01

Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled “Public Health in the ED: Screening, Surveillance, and Intervention” and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation. PMID:20053232

Hypovolemic Shock Caused by Angiotensin-Converting Enzyme Inhibitor-Induced Visceral Angioedema: A Case Series and A Simple Method to Diagnose this Complication in the Emergency Department.

PubMed

Myslinski, Joseph; Heiser, Andrew; Kinney, Ashley

2018-03-01

Visceral angioedema is a rarely reported side effect of angiotensin-converting-enzyme inhibitors (ACEI). Because signs and symptoms tend to be nonspecific, the diagnosis is difficult to make, especially in the emergency department (ED). We describe 2 patients presenting with signs of hypovolemic shock, in which the diagnosis of ACEI-induced visceral angioedema was made in the ED. We surmise that patients with abdominal pain, who present with hypovolemic shock and are taking medications that can predispose to angioedema, may have this complication if their hemoglobin level is elevated compared with their previous levels. An abdominal computed tomography scan, if it does not identify any other significant etiology, will increase the probability that ACEI-induced visceral angioedema is the diagnosis when there is nonspecific bowel wall thickening or edema. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Identification of ACEI-induced visceral angioedema in the ED will avoid prolonged admissions, unnecessary procedures, and future recurrences. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical supervision in the emergency department: a critical incident study

PubMed Central

Kilroy, D A

2006-01-01

Objectives To identify the key features of effective clinical supervision in the emergency department (ED) from the perspectives of enthusiastic consultants and specialist registrars. To highlight the importance of clinical supervision within emergency medicine, and identify obstructions to its occurrence in everyday practice. Methods A critical incident study was undertaken consisting of structured interviews, conducted by telephone or in person, with 18 consultants and higher level trainees selected for their interest in supervision. Results Direct clinical supervision of key practical skills and patient management steps was considered to be of paramount importance in providing quality patient care and significantly enhancing professional confidence. The adequacy of supervision varied depending upon patient presentation. Trainees were concerned with the competence and skills of their supervisor; consultants were concerned with wider systemic constraints upon the provision of adequate supervision to juniors. Conclusions The value of supervision extends to all patient presentations in the ED. The study raised questions concerning the appropriate attitudes and qualifications for supervisors. Protected supervisory time for those with trainees is mandatory, and must be incorporated within ED consultant job planning. PMID:16439737

Using the emergency department as a screening site for high blood pressure. A method for improving hypertension detection and appropriate referral.

PubMed

Mamon, J; Green, L; Levine, D M; Gibson, G; Gurley, H T

1987-08-01

This study describes the development and testing of a high blood pressure protocol for use in emergency departments (ED) to enhance detection of those patients appropriate for subsequent referral. The protocol involves two serial blood pressure measurements and a patient interview to determine: 1) previous history of high blood pressure (HBP), 2) treatment in past year for HBP, and 3) usual source of medical care. The accuracy of patient reporting was validated by comparison with the patients' hospital record (reflecting outpatient and inpatient visits). Results indicate that these self-reports have high levels of sensitivity (range 90-100%) and specificity (range 79-96%). Use of the additional patient information increased the sensitivity of the screening protocol in identifying when and where a patient should be referred. Use of this methodology indicates that the protocol is a simple and effective method for HBP screening. The findings also suggest that the ED is an ideal site for screening the "hard-to-reach" hypertensive population.

Medical Identity Theft in the Emergency Department: Awareness is Crucial

PubMed Central

Mancini, Michelino

2014-01-01

Medical Identity theft in the emergency department (ED) can harm numerous individuals, and many frontline healthcare providers are unaware of this growing concern. The two cases described began as typical ED encounters until red flags were discovered upon validating the patient’s identity. Educating all healthcare personnel within and outside the ED regarding the subtle signs of medical identity theft and implementing institutional policies to identify these criminals will discourage further fraudulent behavior. PMID:25493150

78 FR 21119 - Agency Information Collection Activities; Comment Request; Applications for Assistance Section...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-09

... DEPARTMENT OF EDUCATION [Docket No. ED-2013-ICCD-0043] Agency Information Collection Activities; Comment Request; Applications for Assistance Section 8002 Impact Aid Program AGENCY: Department of Education (ED), Office of Elementary and Secondary Education (OESE). ACTION: Notice. SUMMARY: In accordance...

77 FR 73994 - Agency Information Collection Activities; Submission to the Office of Management and Budget for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-12

... DEPARTMENT OF EDUCATION [Docket No. ED-2012-ICCD-0063] Agency Information Collection Activities... Collection of Elementary and Secondary Education Data for EDFacts AGENCY: Office of Planning, Evaluation and Policy Development, Department of Education (ED). [[Page 73995

34 CFR 110.31 - Complaints.

Code of Federal Regulations, 2010 CFR

2010-07-01

... of the Offices of the Department of Education OFFICE FOR CIVIL RIGHTS, DEPARTMENT OF EDUCATION... discrimination. However, for good cause shown, ED may extend this time limit. (b) ED attempts to facilitate the... regulations; (4) Notifying the complainant and the recipient of their rights and obligations under the...

78 FR 44553 - Agency Information Collection Activities; Comment Request; Veterans Upward Bound Annual...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-24

... DEPARTMENT OF EDUCATION [Docket No. ED-2013-ICCD-0095] Agency Information Collection Activities; Comment Request; Veterans Upward Bound Annual Performance Report AGENCY: Office of Postsecondary Education (OPE), Department of Education (ED). ACTION: Notice. SUMMARY: In accordance with the Paperwork...

Self-reported Violence-related Outcomes for Adolescents Within Eight Weeks Of Emergency Department Treatment For Assault Injury

PubMed Central

Blackstone, Mercedes M.; Mollen, Cynthia J.; Culyba, Alison J.; Fein, Joel A.

2011-01-01

Purpose To estimate, using a novel interactive voice response (IVR) survey, the incidence of self-reported violence-related experiences of adolescent assault-injured patients in the weeks following Emergency Department (ED) discharge. Methods In an urban ED, a prospective cohort study with eight week follow-up IVR survey either weekly, bi-weekly or monthly after discharge was conducted with patients aged 12-19 years presenting with assault-related injuries. Survival analysis methods were used to estimate cumulative risks of self-reported violence experience within four and eight weeks. Results Ninety-five patients were enrolled; 42 (44.2%) reported to the IVR survey. As a result of the ED index event, an estimated 18.2% (CI=9.1-34.6%) reported being assaulted (no weapon), 2.9% (CI=0.4-19.1%) had been shot or stabbed, 20.7% (CI=10.9-37.3%) had assaulted someone else (no weapon), and 2.9% (CI=0.4-19.1%) shot or stabbed someone else. Additionally, 54.6% (CI=39.6-70.9%) had avoided going certain places, 47.0% (CI=32.5-64.1%) considered retaliating, 38.1% (CI=24.3-56.3%) had been threatened, and 27.0% (CI=15.4-44.6%) had carried a weapon. Most outcome occurrences happened within four weeks. There was evidence that intent to retaliate when asked at baseline was associated with an elevated risk of several outcomes. Conclusions The risk for subsequent violence among assault-injured adolescent ED patients appears high within weeks of discharge. PMID:22031979

The impact of the TelEmergency program on rural emergency care: An implementation study.

PubMed

Sterling, Sarah A; Seals, Samantha R; Jones, Alan E; King, Melissa H; Galli, Robert L; Isom, Kristen C; Summers, Richard L; Henderson, Kristi A

2017-07-01

Introduction Timely, appropriate intervention is key to improving outcomes in many emergent conditions. In rural areas, it is particularly challenging to assure quality, timely emergency care. The TelEmergency (TE) program, which utilizes a dual nurse practitioner and emergency medicine-trained, board-certified physician model, has the potential to improve access to quality emergency care in rural areas. The objective of this study was to examine how the implementation of the TE program impacts rural hospital Emergency Department (ED) operations. Methods Methods included a before and after study of the effect of the TE program on participating rural hospitals between January 2007 and December 2008. Data on ED and hospital operations were collected one year prior to and one year following the implementation of TE. Data from participating hospitals were combined and compared for the two time periods. Results Nine hospitals met criteria for inclusion and participated in the study. Total ED volumes did not significantly change with TE implementation, but ED admissions to the same rural hospital significantly increased following TE implementation (6.7% to 8.1%, p-value = 0.02). Likewise, discharge rates from the ED declined post-initiation (87.1% to 80.0%, p-value = 0.003). ED deaths and transfer rates showed no significant change, while the rate of patient discharge against medical advice significantly increased with TE use. Discussion In this analysis, we found a significant increase in the rate of ED admissions to rural hospitals with TE use. These findings may have important implications for the quality of emergency care in rural areas and the sustainability of rural hospitals' EDs.

Disruptive Behaviors in an Emergency Department: the Perspective of Physicians and Nurses

PubMed Central

Maddineshat, Maryam; Rosenstein, Alan H; Akaberi, Arash; Tabatabaeichehr, Mahbubeh

2016-01-01

Introduction: Disruptive behaviors cause many problems in the workplace, especially in the emergency department (ED).This study was conducted to assess the physician’s and nurse’s perspective toward disruptive behaviors in the emergency department. Methods: In this cross-sectional study a total of 45 physicians and 110 nurses working in the emergency department of five general hospitals in Bojnurd participated. Data were collected using a translated, changed, and validated questionnaire (25 item). The collected data were analyzed by SPSS ver.13 software. Results: Findings showed that physicians gave more importance to nurse-physician relationships in the ED when compared to nurses’ perspective (90% vs. 70%). In this study, 81% of physicians and 52% of nurses exhibited disruptive behaviors. According to the participants these behaviors could result in adverse outcomes, such as stress (97%), job dissatisfaction and can compromise patient safety (53%), quality of care (72%), and errors (70%). Conclusion: Disruptive behaviors could have a negative effects on relationships and collaboration among medical staffs, and on patients’ quality of care as well. It is essential to provide some practical strategies for prevention of these behaviors. PMID:27752490

Emergency Department Use among Adults with Autism Spectrum Disorders (ASD)

PubMed Central

Vohra, Rini; Madhavan, Suresh; Sambamoorthi, Usha

2016-01-01

A cross-sectional analyses using Nationwide Emergency Department Sample (2006-2011) was conducted to examine the trends, type of ED visits, and mean total ED charges for adults aged 22-64 years with and without ASD (matched 1:3). Around 0.4% ED visits (n = 25,527) were associated with any ASD and rates of such visits more than doubled from 2006 to 2011 (2,549 to 6,087 per 100,000 admissions). Adults with ASD visited ED for: primary psychiatric disorder (15%ASD vs. 4.2%noASD), primary non-psychiatric disorder (16%ASD vs. 14%noASD), and any injury (24%ASD vs. 28%noASD). Mean total ED charges for adults with ASD were 2.3 times higher than adults without ASD. Findings emphasize the need to examine the extent of frequent ED use in this population. PMID:26762115

Patient Preference for Physician Gender in the Emergency Department

PubMed Central

Nolen, Haley A.; Moore, Justin Xavier; Rodgers, Joel B.; Wang, Henry E.; Walter, Lauren A.

2016-01-01

Despite historical gender bias against female physicians, few studies have investigated patients’ physician gender preference in the emergency department (ED) setting. We sought to determine if there is an association between ED patient demographics and physician gender preference. We surveyed patients presenting to an ED to determine association between patient demographics and patient physician gender preference for five ED situations: 1) ‘routine’ visit, 2) emergency visit, 3) ‘sensitive’ medical visit, 4) minor surgical/‘procedural’ visit, and 5) ‘bad news’ delivery. A total of 200 ED patients were surveyed. The majority of ED patients reported no physician gender preference for ‘routine’ visits (89.5 percent), ‘emergent’ visits (89 percent), ‘sensitive’ medical visits (59 percent), ‘procedural’ visits (89 percent) or when receiving ‘bad news’ (82 percent). In the setting of ‘routine’ visits and ‘sensitive’ medical visits, there was a propensity for same-sex physician preference. PMID:27354840

Death of a child in the emergency department.

PubMed

O'Malley, Patricia; Barata, Isabel; Snow, Sally

2014-07-01

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED. Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. Published by Mosby, Inc. All rights reserved.

Death of a child in the emergency department.

PubMed

O'Malley, Patricia; Barata, Isabel; Snow, Sally

2014-07-01

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED. Copyright © 2014 by the American Academy of Pediatrics.

Emergency department presentations in early stage breast cancer patients receiving adjuvant and neoadjuvant chemotherapy.

PubMed

Tang, Monica; Horsley, Patrick; Lewis, Craig R

2018-05-01

(Neo)adjuvant chemotherapy for early stage breast cancer is associated with side-effects, resulting in increased emergency department (ED) presentations. Treatment-related toxicity can affect quality of life, compromise chemotherapy delivery and treatment outcomes, and increase healthcare use. We performed a retrospective study of ED presentations in patients receiving curative chemotherapy for early breast cancer to identify factors contributing to ED presentations. Of 102 patients, 39 (38%) presented to ED within 30 days of chemotherapy, resulting in 63 ED presentations in total. Most common reasons were non-neutropenic fever (17 presentations/27%), neutropenic fever (15/24%), pain (9/14%), drug reaction (6/10%) and infection (4/6%). Factors significantly associated with ED presentation were adjuvant chemotherapy timing compared to neoadjuvant timing (P = 0.031), prophylactic antibiotics (P = 0.045) and docetaxel-containing regimen (P = 0.018). © 2018 Royal Australasian College of Physicians.

Reduction in Hospital-Wide Clinical Laboratory Specimen Identification Errors following Process Interventions: A 10-Year Retrospective Observational Study

PubMed Central

Ning, Hsiao-Chen; Lin, Chia-Ni; Chiu, Daniel Tsun-Yee; Chang, Yung-Ta; Wen, Chiao-Ni; Peng, Shu-Yu; Chu, Tsung-Lan; Yu, Hsin-Ming; Wu, Tsu-Lan

2016-01-01

Background Accurate patient identification and specimen labeling at the time of collection are crucial steps in the prevention of medical errors, thereby improving patient safety. Methods All patient specimen identification errors that occurred in the outpatient department (OPD), emergency department (ED), and inpatient department (IPD) of a 3,800-bed academic medical center in Taiwan were documented and analyzed retrospectively from 2005 to 2014. To reduce such errors, the following series of strategies were implemented: a restrictive specimen acceptance policy for the ED and IPD in 2006; a computer-assisted barcode positive patient identification system for the ED and IPD in 2007 and 2010, and automated sample labeling combined with electronic identification systems introduced to the OPD in 2009. Results Of the 2000345 specimens collected in 2005, 1023 (0.0511%) were identified as having patient identification errors, compared with 58 errors (0.0015%) among 3761238 specimens collected in 2014, after serial interventions; this represents a 97% relative reduction. The total number (rate) of institutional identification errors contributed from the ED, IPD, and OPD over a 10-year period were 423 (0.1058%), 556 (0.0587%), and 44 (0.0067%) errors before the interventions, and 3 (0.0007%), 52 (0.0045%) and 3 (0.0001%) after interventions, representing relative 99%, 92% and 98% reductions, respectively. Conclusions Accurate patient identification is a challenge of patient safety in different health settings. The data collected in our study indicate that a restrictive specimen acceptance policy, computer-generated positive identification systems, and interdisciplinary cooperation can significantly reduce patient identification errors. PMID:27494020

mHealth Tool for Alcohol Use Disorders Among Latinos in Emergency Department.

PubMed

Abujarad, Fuad; Vaca, Federico E

2015-06-01

Latino drinkers experience a disparate number of negative health and social consequences. Emergency Department Alcohol Screening Brief Intervention and Referral to Treatment (ED-SBIRT) is viable and effective at reducing harmful and hazardous drinking. However, barriers (e.g. readily available language translators, provider time burden, resources) to broad implementation remain and account for a major lag in adherence to national guidelines. We describe our approach to the design of a patient-centered bilingual Web-based mobile health ED-SBIRT App that could be integrated into a clinically complex ED environment and used regularly to provide ED-SBIRT for Spanish speaking patients.

mHealth Tool for Alcohol Use Disorders Among Latinos in Emergency Department

PubMed Central

Abujarad, Fuad; Vaca, Federico E.

2015-01-01

Latino drinkers experience a disparate number of negative health and social consequences. Emergency Department Alcohol Screening Brief Intervention and Referral to Treatment (ED-SBIRT) is viable and effective at reducing harmful and hazardous drinking. However, barriers (e.g. readily available language translators, provider time burden, resources) to broad implementation remain and account for a major lag in adherence to national guidelines. We describe our approach to the design of a patient-centered bilingual Web-based mobile health ED-SBIRT App that could be integrated into a clinically complex ED environment and used regularly to provide ED-SBIRT for Spanish speaking patients. PMID:26844234

Violence in the Emergency Department.

PubMed

Stowell, Keith R; Hughes, Nolan P; Rozel, John S

2016-12-01

Violence is common in the emergency department (ED). The ED setting has numerous environmental risk factors for violence, including poor staffing, lack of privacy, overcrowding, and ready availability of nonsecured equipment that can be used as weapons. Strategies can be taken to mitigate the risk of violence toward health care workers, including staff training, changes to the ED layout, appropriate use of security, and policy-level changes. Health care providers in the ED should be familiar with local case law and standards related to the duty to warn third parties when a violent threat is made by a patient. Copyright © 2016 Elsevier Inc. All rights reserved.

Ethics of emergency department triage: SAEM position statement. SAEM Ethics Committee (Society for Academic Emergency Medicine).

PubMed

1995-11-01

Emergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from U.S. EDs. Paradoxically, this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer. The latter regulations view EDs as the safety net for the U.S. health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients out of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.

A Profile of Indian Health Service Emergency Departments.

PubMed

Bernard, Kenneth; Hasegawa, Kohei; Sullivan, Ashley; Camargo, Carlos

2017-06-01

The Indian Health Service provides health care to eligible American Indians and Alaskan Natives. No published data exist on emergency services offered by this unique health care system. We seek to determine the characteristics and capabilities of Indian Health Service emergency departments (EDs). All Indian Health Service EDs were surveyed about demographics and operational characteristics for 2014 with the National Emergency Department Inventory survey (available at http://www.emnet-nedi.org/). Of the forty eligible sites, there were 34 respondents (85% response rate). Respondents reported a total of 637,523 ED encounters, ranging from 521 to 63,200 visits per site. Overall, 85% (95% confidence interval 70% to 94%) had continuous physician coverage. Of all physicians staffing the ED, a median of 13% (interquartile range 0% to 50%) were board certified or board prepared in emergency medicine. Overall, 50% (95% confidence interval 34% to 66%) of respondents reported that their ED was operating over capacity. Indian Health Service EDs varied widely in visit volume, with many operating over capacity. Most were not staffed by board-certified or -prepared emergency physicians. Most lacked access to specialty consultation and telemedicine capabilities. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Barriers and facilitators to ED physician use of the test and treatment for BPPV

PubMed Central

Forman, Jane; Damschroder, Laura; Telian, Steven A.; Fagerlin, Angela; Johnson, Patricia; Brown, Devin L.; An, Lawrence C.; Morgenstern, Lewis B.; Meurer, William J.

2017-01-01

Abstract Background: The test and treatment for benign paroxysmal positional vertigo (BPPV) are evidence-based practices supported by clinical guideline statements. Yet these practices are underutilized in the emergency department (ED) and interventions to promote their use are needed. To inform the development of an intervention, we interviewed ED physicians to explore barriers and facilitators to the current use of the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). Methods: We conducted semi-structured in-person interviews with ED physicians who were recruited at annual ED society meetings in the United States. We analyzed data thematically using qualitative content analysis methods. Results: Based on 50 interviews with ED physicians, barriers that contributed to infrequent use of DHT/CRM that emerged were (1) prior negative experiences or forgetting how to perform them and (2) reliance on the history of present illness to identify BPPV, or using the DHT but misattributing patterns of nystagmus. Based on participants' responses, the principal facilitator of DHT/CRM use was prior positive experiences using these, even if infrequent. When asked which clinical supports would facilitate more frequent use of DHT/CRM, participants agreed supports needed to be brief, readily accessible, and easy to use, and to include well-annotated video examples. Conclusions: Interventions to promote the use of the DHT/CRM in the ED need to overcome prior negative experiences with the DHT/CRM, overreliance on the history of present illness, and the underuse and misattribution of patterns of nystagmus. Future resources need to be sensitive to provider preferences for succinct information and video examples. PMID:28680765

Rapid Assessment of the ED Institutional Eligibility and Compliance Monitoring Systems. Final Report.

ERIC Educational Resources Information Center

Jung, Steven M.

Two U.S. Department of Education (ED) systems for establishing the initial eligibility and monitoring the performance of postsecondary institutions that participate in ED financial assistance programs were assessed. The evaluation was designed to describe and evaluate the eligibility and certification functions of ED's Eligibility and Agency…

Screening Adolescents in the Emergency Department for Weapon Carriage

PubMed Central

Cunningham, Rebecca M.; Resko, Stella M.; Harrison, Stephanie Roahen; Zimmerman, Marc; Stanley, Rachel; Chermack, Stephen T.; Walton, Maureen A.

2010-01-01

Objective To describe prevalence and correlates of past year weapon involvement among adolescents seeking care in an inner-city ED. Methods This cross-sectional study administered a computerized survey to all eligible adolescents (age 14–18), seven days a week seeking care in the ED over an 18 month period in an inner-city Level 1 ED. Validated measures were administered including measures of demographics, sexual activity, substance use, injury, violent behavior and weapon carriage/use. Results Adolescents (N=2069, 86% response rate) completed the computerized survey. 55% were female; 56.5% were African American. In the past year, 20% of adolescents reported knife/razor carriage, 7% reported gun carriage, and 6% pulled a knife/gun on someone; zero-inflated Poisson (ZIP) regression models were used to identify correlates of the occurrence and past year frequency of these weapon variables. Although gun carriage was more frequent among males, females were as likely to carry a knife or pull a weapon in the past year. Conclusions One fifth of all adolescent’s seeking care in this inner city ED have carried a weapon. Understanding weapon carriage among teens seeking ED care is a critical first step to future ED based injury prevention initiatives. PMID:20370746

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland

PubMed Central

Rowland, Sandi; Davidson, Clare; Brady, Joanne; Knudson, Alana

2016-01-01

Objectives. To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDP’s impact on dental-related visits to a regional emergency department (ED). Methods. We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. Results. The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in $215 000 more in charges. Conclusions. Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. Policy Implications. Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed. PMID:27736218

The Impact on Emergency Department Visits for Respiratory Illness During the Southern California Wildfires

PubMed Central

Dohrenwend, Paul B.; Le, Minh V.; Bush, Jeff A.; Thomas, Cyril F.

2013-01-01

Introduction: In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness. Methods: We extracted data from a Kaiser Permanente database for a single metropolitan community ED. We compared the number of visits due to respiratory illness at time intervals of 2 weeks before and during the time when the fires were burning. We counted the total number of patients with chief complaint of dyspnea, cough, and asthma and final international classification of disease 9 coding diagnosis of asthma, bronchitis, chronic obstructive pulmonary disease and respiratory syndrome, and analyzed data for both total number and proportion of ED visits. We evaluated the data using Early Aberration Reporting System software to determine significant single-visit increases compared to expected counts. We also analyzed the average length of ED stay. Data on air quality were extracted from the http://www.airnow.gov site. Results: There were significant differences between pre-fire and fire period average visit counts for the chief complaints of dyspnea and asthma. Dypnea complaints increased by 3.2 visits per day. During the fire the diagnoses of asthma increased significantly by 2.6 patients per day. Air quality reached air quality index values of 300, indicating very unhealthy conditions. Average ED length of stay times remained unchanged during the fire period compared to the pre-fire period. Conclusion: The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur. PMID:23599837

Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department.

PubMed

Goto, Tadahiro; Gibo, Koichiro; Hagiwara, Yusuke; Okubo, Masashi; Brown, David F M; Brown, Calvin A; Hasegawa, Kohei

2016-03-01

The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED). We analyzed the data from two multicenter prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient's age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and intubator's level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children <10 years. A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the analysis. The overall first-pass success rate was 60% (95%CI [54%-66%]). In the multivariable model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23-4.87]), use of RSI (aOR, 2.17; 95% CI [1.31-3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78-5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63-5.70]), and intubation attempt by an emergency physician (aOR, 4.08; 95% CI [1.92-8.63]) were significantly associated with a higher chance of first-pass success. Based on two large multicenter prospective studies of ED airway management, we found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher chance of first-pass success in children. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.

Effect of advanced age and vital signs on admission from an emergency department observation unit

PubMed Central

Caterino, Jeffrey M.; Hoover, Emily; Moseley, Mark G.

2012-01-01

Objectives The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. Methods We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of ≥65 years. Vital signs were examined continuously and at commonly accepted cutoffs. We additionally controlled for demographics, co-morbid conditions, laboratory values, and observation protocol. Results Three hundred patients were enrolled, 12% (n=35) ≥65 years old and 11% (n=33) requiring admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07-14.9%) in older adults and 12.1% (95% CI, 8.4-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR] 0.30, 95% CI 0.05-1.67). Predictors of admission included: systolic pressure ≥180 mmHg (OR 4.19, 95% CI 1.08-16.30), log Charlson co-morbidity score (OR 2.93, 95% CI 1.57-5.46), and white blood cell count ≥14,000/mm3 (OR11.35, 95% CI 3.42-37.72). Conclusions Among patients placed in an ED observation unit, age ≥65 years is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure≥180 mmHg was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. PMID:22386358

Comorbid Parkinson's disease, falls and fractures in the 2010 National Emergency Department Sample

PubMed Central

Beydoun, Hind A.; Beydoun, May A.; Mishra, Nishant K.; Rostant, Ola S.; Zonderman, Alan B.; Eid, Shaker M.

2017-01-01

Introduction Parkinson's disease (PD) is a progressive, neurodegenerative disorder of multifactorial etiology affecting ~1% of older adults. Research focused on linking PD to falls and bone fractures has been limited in Emergency Department (ED) settings, where most injuries are identified. We assessed whether injured U.S. ED admissions with PD diagnoses were more likely to exhibit comorbid fall- or non-fall related bone fractures and whether a PD diagnosis with a concomitant fall or bone fracture is linked to worse prognosis. Methods We performed secondary analyses of 2010 Healthcare Utilization Project National ED Sample from 4,253,987 admissions to U.S. EDs linked to injured elderly patients. ED discharges with ICD-9-CM code (332.0) were identified as PD and those with ICD-9-CM code (800.0–829.0) were used to define bone fracture location. Linear and logistic regression models were constructed to estimate slopes (B) and odds ratios (OR) with 95% confidence intervals (CI). Results PD admissions had 28% increased adjusted prevalence of bone fracture. Non-fall injuries showed stronger relationship between PD and bone fracture (ORadj = 1.33, 95% CI: 1.22–1.45) than fall injuries (ORadj = 1.06, 95% CI: 1.01–1.10). PD had the strongest impact on hospitalization length when bone fracture and fall co-occurred, and total charges were directly associated with PD only for fall injuries. Finally, PD status was not related to in-hospital death in this population. Conclusions Among injured U.S. ED elderly patient visits, those with PD had higher bone fracture prevalence and more resource utilization especially among fall-related injuries. No association of PD with in-hospital death was noted. PMID:27887896

Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department.

PubMed

Wong, Ambrose H; Ruppel, Halley; Crispino, Lauren J; Rosenberg, Alana; Iennaco, Joanne D; Vaca, Federico E

2018-05-01

The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management. Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes. Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy. Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.

Prevalence of alcohol related attendance at an inner city emergency department and its impact: a dual prospective and retrospective cohort study

PubMed Central

Parkinson, Kathryn; Newbury-Birch, Dorothy; Phillipson, Angela; Hindmarch, Paul; Kaner, Eileen; Stamp, Elaine; Vale, Luke; Wright, John; Connolly, Jim

2016-01-01

Background Alcohol related hospital attendances are a potentially avoidable burden on emergency departments (EDs). Understanding the number and type of patients attending EDs with alcohol intoxication is important in estimating the workload and cost implications. We used best practice from previous studies to establish the prevalence of adult alcohol related ED attendances and estimate the costs of clinical management and subsequent health service use. Methods The setting was a large inner city ED in northeast England, UK. Data were collected via (i) retrospective review of hospital records for all ED attendances for four pre-specified weeks in 2010/2011 to identify alcohol related cases along with 12 months of follow-up of the care episode and (ii) prospective 24/7 assessment via breath alcohol concentration testing of patients presenting to the ED in the corresponding weeks in 2012/2013. Results The prevalence rates of alcohol related attendances were 12% and 15% for the retrospective and prospective cohorts, respectively. Prospectively, the rates ranged widely from 4% to 60% across week days, rising to over 70% at weekends. Younger males attending in the early morning hours at weekends made up the largest proportion of alcohol related attendances. The mean cost per attendance was £249 (SD £1064); the mean total cost for those admitted was £851 (SD £2549). The most common reasons for attending were trauma related injuries followed by psychiatric problems. Conclusions Alcohol related attendances are a major and avoidable burden on emergency care. However, targeted interventions at weekends and early morning hours could capture the majority of cases and help prevent future re-attendance. PMID:26698364

Persistent pain after motor vehicle collision: comparative effectiveness of opioids vs nonsteroidal antiinflammatory drugs prescribed from the emergency department-a propensity matched analysis.

PubMed

Beaudoin, Francesca L; Gutman, Roee; Merchant, Roland C; Clark, Melissa A; Swor, Robert A; Jones, Jeffrey S; Lee, David C; Peak, David A; Domeier, Robert M; Rathlev, Niels K; McLean, Samuel A

2017-02-01

Each year millions of Americans present to the emergency department (ED) for care after a motor vehicle collision (MVC); the majority (>90%) are discharged to home after evaluation. Acute musculoskeletal pain is the norm in this population, and such patients are typically discharged to home with prescriptions for oral opioid analgesics or nonsteroidal antiinflammatory drugs (NSAIDs). The influence of acute pain management on subsequent pain outcomes in this common ED population is unknown. We evaluated the effect of opioid analgesics vs NSAIDs initiated from the ED on the presence of moderate to severe musculoskeletal pain and ongoing opioid use at 6 weeks in a large cohort of adult ED patients presenting to the ED after MVC (n = 948). The effect of opioids vs NSAIDs was evaluated using an innovative quasi-experimental design method using propensity scores to account for covariate imbalances between the 2 treatment groups. No difference in risk for moderate to severe musculoskeletal pain at 6 weeks was observed between those discharged with opioid analgesics vs NSAIDs (risk difference = 7.2% [95% confidence interval: -5.2% to 19.5%]). However, at follow-up participants prescribed opioids were more likely than those prescribed NSAIDs to report use of prescription opioids medications at week 6 (risk difference = 17.5% [95% confidence interval: 5.8%-29.3%]). These results suggest that analgesic choice at ED discharge does not influence the development of persistent moderate to severe musculoskeletal pain 6 weeks after an MVC, but may result in continued use of prescription opioids. Supported by NIAMS R01AR056328 and AHRQ 5K12HS022998.

Who Explicitly Requests the Ordering of Computed Tomography for Emergency Department Patients? A Multicenter Prospective Study

PubMed Central

Broder, Joshua Seth; Bhat, Rahul; Boyd, Joshua P.; Ogloblin, Ivan A.; Limkakeng, Alexander; Hocker, Michael Brian; Drake, Weiying Gao; Miller, Taylor; Harringa, John Brian; Repplinger, Michael Dean

2016-01-01

Background Emergency department (ED) computed tomography (CT) use has increased substantially in recent years, resulting in increased radiation exposure for patients. Few studies have assessed which parties contribute to CT ordering in the ED. Objective To determine the proportion of CT scans ordered due to explicit requests by various stakeholders in ED patient care. Methods Prospective, observational study at three university hospital EDs. CT scans ordered during research assistant hours were eligible for inclusion. Attending emergency physicians (EPs) completed standardized data forms to indicate all parties who had explicitly requested that a specific CT be performed. Forms were completed before the CT results were known in order to minimize bias. Results Data were obtained from 77 EPs regarding 944 CTs. The parties most frequently requesting CTs were attending EPs (82.0%, 95% CI 79.4–84.3), resident physicians (28.6%, 95%CI 25.8–31.6), consulting physicians (24.4%, 95%CI 21.7–27.2), and admitting physicians (3.9%, 95%CI 2.9–5.4). In the 168 instances in which the attending EP did not explicitly request the CT, requests most commonly came from consulting physicians (51.2%, 95%CI 43.7–58.6), resident physicians in the ED (39.9%, 95%CI, 32.8–47.4), and admitting physicians (8.9%, 95%CI, 5.5–14.2). EPs were the sole party requesting CT in 46.2% of cases while multiple parties were involved in 39.0%. Patients, families, and radiologists were uncommon sources of such requests. Conclusions Emergency physicians requested the majority of CTs, though nearly 20% were actually not desired by them. Admitting, consulting, and resident physicians in the ED were important contributors to CT utilization. PMID:26873604

All purulence is local – epidemiology and management of skin and soft tissue infections in three urban emergency departments

PubMed Central

2013-01-01

Background Skin and soft tissue infection (SSTIs) are commonly treated in emergency departments (EDs). While the precise role of antibiotics in treating SSTIs remains unclear, most SSTI patients receive empiric antibiotics, often targeted toward methicillin-resistant Staphylococcus aureus (MRSA). The goal of this study was to assess the efficiency with which ED clinicians targeted empiric therapy against MRSA, and to identify factors that may allow ED clinicians to safely target antibiotic use. Methods We performed a retrospective analysis of patient visits for community-acquired SSTIs to three urban, academic EDs in one northeastern US city during the first quarter of 2010. We examined microbiologic patterns among cultured SSTIs, and relationships between clinical and demographic factors and management of SSTIs. Results Antibiotics were prescribed to 86.1% of all patients. Though S. aureus (60% MRSA) was the most common pathogen cultured, antibiotic susceptibility differed between adult and pediatric patients. Susceptibility of S. aureus from ED SSTIs differed from published local antibiograms, with greater trimethoprim resistance and less fluoroquinolone resistance than seen in S. aureus from all hospital sources. Empiric antibiotics covered the resultant pathogen in 85.3% of cases, though coverage was frequently broader than necessary. Conclusions Though S. aureus remained the predominant pathogen in community-acquired SSTIs, ED clinicians did not accurately target therapy toward the causative pathogen. Incomplete local epidemiologic data may contribute to this degree of discordance. Future efforts should seek to identify when antibiotic use can be narrowed or withheld. Local, disease-specific antibiotic resistance patterns should be publicized with the goal of improving antibiotic stewardship. PMID:24359038

The financial impact of health information exchange on emergency department care.

PubMed

Frisse, Mark E; Johnson, Kevin B; Nian, Hui; Davison, Coda L; Gadd, Cynthia S; Unertl, Kim M; Turri, Pat A; Chen, Qingxia

2012-01-01

To examine the financial impact health information exchange (HIE) in emergency departments (EDs). We studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences. HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering. Applied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions. Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

Marginal analysis in assessing factors contributing time to physician in the Emergency Department using operations data.

PubMed

Pathan, Sameer A; Bhutta, Zain A; Moinudheen, Jibin; Jenkins, Dominic; Silva, Ashwin D; Sharma, Yogdutt; Saleh, Warda A; Khudabakhsh, Zeenat; Irfan, Furqan B; Thomas, Stephen H

2016-01-01

Background: Standard Emergency Department (ED) operations goals include minimization of the time interval (tMD) between patients' initial ED presentation and initial physician evaluation. This study assessed factors known (or suspected) to influence tMD with a two-step goal. The first step was generation of a multivariate model identifying parameters associated with prolongation of tMD at a single study center. The second step was the use of a study center-specific multivariate tMD model as a basis for predictive marginal probability analysis; the marginal model allowed for prediction of the degree of ED operations benefit that would be affected with specific ED operations improvements. Methods: The study was conducted using one month (May 2015) of data obtained from an ED administrative database (EDAD) in an urban academic tertiary ED with an annual census of approximately 500,000; during the study month, the ED saw 39,593 cases. The EDAD data were used to generate a multivariate linear regression model assessing the various demographic and operational covariates' effects on the dependent variable tMD. Predictive marginal probability analysis was used to calculate the relative contributions of key covariates as well as demonstrate the likely tMD impact on modifying those covariates with operational improvements. Analyses were conducted with Stata 14MP, with significance defined at p  < 0.05 and confidence intervals (CIs) reported at the 95% level. Results: In an acceptable linear regression model that accounted for just over half of the overall variance in tMD (adjusted r 2 0.51), important contributors to tMD included shift census ( p  = 0.008), shift time of day ( p  = 0.002), and physician coverage n ( p  = 0.004). These strong associations remained even after adjusting for each other and other covariates. Marginal predictive probability analysis was used to predict the overall tMD impact (improvement from 50 to 43 minutes, p  < 0.001) of consistent staffing with 22 physicians. Conclusions: The analysis identified expected variables contributing to tMD with regression demonstrating significance and effect magnitude of alterations in covariates including patient census, shift time of day, and number of physicians. Marginal analysis provided operationally useful demonstration of the need to adjust physician coverage numbers, prompting changes at the study ED. The methods used in this analysis may prove useful in other EDs wishing to analyze operations information with the goal of predicting which interventions may have the most benefit.

Development and Testing of Emergency Department Patient Transfer Communication Measures

ERIC Educational Resources Information Center

Klingner, Jill; Moscovice, Ira

2012-01-01

Purpose: Communication problems are a major contributing factor to adverse events in hospitals. The contextual environment in small rural hospitals increases the importance of emergency department (ED) patient transfer communication quality. This study addresses the communication problems through the development and testing of ED quality…

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Analysis of Hospital-Based Emergency Department Visits for Inflammatory Bowel Disease in the USA.

PubMed

Gajendran, Mahesh; Umapathy, Chandraprakash; Loganathan, Priyadarshini; Hashash, Jana G; Koutroubakis, Ioannis E; Binion, David G

2016-02-01

Inflammatory bowel disease (IBD) is a chronic, debilitating condition with high emergency department (ED) utilization. We aimed to investigate the utilization patterns of ED by IBD patients and measure hospitalization and surgical rates following ED visits. We conducted a cross-sectional study of adults with IBD listed as the primary ED diagnosis from the 2009 to 2011 Nationwide Emergency Department Sample. The characteristics of the IBD-related ED visits in relation to following hospitalizations and surgeries were analyzed. Adult IBD patients constitute 0.09 % of the total ED visits. Crohn's disease (CD) contributed to 69 % of the IBD-ED visits. The hospitalization rate from ED was 59.9 % nationally, ranging from 56 % in west to 69 % in northeast. The most significant factors associated with hospitalization were intra-abdominal abscess [odds ratio (OR) 24.22], bowel obstruction (OR 17.77), anemia (OR 7.54), malnutrition (OR 6.29), hypovolemia/electrolyte abnormalities (OR 5.57), and fever/abnormal white cell count (OR 3.18). Patients with CD (OR 0.66), low-income group (OR 0.90), and female gender (OR 0.87) have a lower odds of getting hospitalized. Age above 65 years (OR 1.63), CD (OR 1.89), bowel obstruction (OR 9.24), and intra-abdominal abscess (OR 18.41) were significantly associated with surgical intervention. The IBD-related ED visits have remained relatively stable from 2009 to 2011. The presence of anemia, malnutrition, hypovolemia, electrolyte abnormalities, fever, abnormal white cell count, bowel obstruction, or intra-abdominal abscess during the ED visit was associated with hospitalization. The presence of bowel obstruction and intra-abdominal abscess was strongly associated with surgical intervention.

Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases.

PubMed

Nikpay, Sayeh; Freedman, Seth; Levy, Helen; Buchmueller, Tom

2017-08-01

We assess whether the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) results in changes in emergency department (ED) visits or ED payer mix. We also test whether the size of the change in ED visits depends on the change in the size of the Medicaid population. Using all-capture, longitudinal, state data from the Agency for Healthcare Research and Quality's Fast Stats program, we implemented a difference-in-difference analysis, which compared changes in ED visits per capita and the share of ED visits by payer (Medicaid, uninsured, and private insurance) in 14 states that did and 11 states that did not expand Medicaid in 2014. Analyses controlled for state-level demographic and economic characteristics. We found that total ED use per 1,000 population increased by 2.5 visits more in Medicaid expansion states than in nonexpansion states after 2014 (95% confidence interval [CI] 1.1 to 3.9). Among the visit types that could be measured, increases in ED visits were largest for injury-related visits and for states with the largest changes in Medicaid enrollment. Compared with nonexpansion states, in expansion states the share of ED visits covered by Medicaid increased 8.8 percentage points (95% CI 5.0 to 12.6), whereas the uninsured share decreased by 5.3 percentage points (95% CI -1.7 to -8.9). The ACA's Medicaid expansion has resulted in changes in payer mix. Contrary to other studies of the ACA's effect on ED visits, our study found that the expansion also increased use of the ED, consistent with polls of emergency physicians. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Nonurgent patients in the emergency department? A French formula to prevent misuse

PubMed Central

2010-01-01

Background Overcrowding in emergency department (EDs) is partly due to the use of EDs by nonurgent patients. In France, the authorities responded to the problem by creating primary care units (PCUs): alternative structures located near hospitals. The aims of the study were to assess the willingness of nonurgent patients to be reoriented to a PCU and to collect the reasons that prompted them to accept or refuse. Methods We carried out a cross sectional survey on patients' use of EDs. The study was conducted in a French hospital ED. Patients were interviewed about their use of health services, ED visits, referrals, activities of daily living, and insurance coverage status. Patients' medical data were also collected. Results 85 patients considered nonurgent by a triage nurse were asked to respond to a questionnaire. Sex ratio was 1.4; mean age was 36.3 +/- 11.7 years. Most patients went to the ED autonomously (76%); one third (31.8%) had consulted a physician. The main reasons for using the ED were difficulty to get an appointment with a general practitioner (22.3%), feelings of pain (68.5%), and the availability of medical services in the ED, like imaging, laboratory tests, and drug prescriptions (37.6%). Traumatisms and wounds were the main medical reasons for going to the ED (43.5%). More than two-thirds of responders (68%) were willing to be reoriented towards PCUs. In the multivariate analysis, only employment and the level of urgency perceived by the patient were associated with the willingness to accept reorientation. Employed persons were 4.5 times more likely to accept reorientation (OR = 4.5 CI (1.6-12.9)). Inversely, persons who perceived a high level of urgency were the least likely to accept reorientation (OR = 0.9 CI (0.8-0.9). Conclusions Our study provides information on the willingness of ED patients to accept reorientation and shows the limits of its feasibility. Alternative structures such as PCUs near the ED seem to respond appropriately to the growing demands of nonurgent patients. Reorientation, however, will be successful only if the new structures adapt their opening hours to the needs of nonurgent patients and if their physicians can perform specific technical skills. PMID:20230602

Emergency Department Use in a Cohort of Older Homeless Adults: Results from the HOPE HOME Study

PubMed Central

Raven, Maria C.; Tieu, Lina; Lee, Christopher T.; Ponath, Claudia; Guzman, David; Kushel, Margot

2018-01-01

Objective The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. Methods We recruited 350 participants who were homeless and 50 or older in Oakland, CA. We interviewed participants about residential history in the prior six months, health status, health-related behaviors, and health services use, and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior six months based on medical record review. We used negative binomial regression to examine factors associated with ED use. Results In the six months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered, 25.1% cycled through multiple institutions including shelters, hospitals and jails, 16.3% primarily stayed with family or friends, and 12.3% had become homeless recently after spending much of the prior six months housed. Half (49.7%) of participants made at least one ED visit in the past six months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08–4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17–4.48) had higher ED use rates than participants who had been housed for most of the prior six months. In addition, having health insurance/coverage (IRR= 2.6; CI = 1.5–4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09–2.99), and severe pain (IRR = 1.72; 95% CI = 1.07–2.76) were associated with higher ED visit rates. Conclusions A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior six months than the general US age-matched population. Within the sample, ED use rates varied based on individuals’ residential histories, suggesting that individuals’ ED use is related to exposure to homelessness. PMID:27520382

Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits

PubMed Central

Sharp, Brian R.; Sharp, Kristen M.; Patterson, Brian; Dooley-Hash, Suzanne

2016-01-01

Introduction Nausea and vomiting in pregnancy (NVP) is a condition that commonly affects women in the first trimester of pregnancy. Despite frequently leading to emergency department (ED) visits, little evidence exists to characterize the nature of ED visits or to guide its treatment in the ED. Our objectives were to evaluate the treatment of NVP in the ED and to identify factors that predict return visits to the ED for NVP. Methods We conducted a retrospective database analysis using the electronic medical record from a single, large academic hospital. Demographic and treatment variables were collected using a chart review of 113 ED patient visits with a billing diagnosis of “nausea and vomiting in pregnancy” or “hyperemesis gravidarum.” Logistic regression analysis was used with a primary outcome of return visit to the ED for the same diagnoses. Results There was wide treatment variability of nausea and vomiting in pregnancy patients in the ED. Of the 113 patient visits, 38 (33.6%) had a return ED visit for NVP. High gravidity (OR 1.31, 95% CI [1.06–1.61]), high parity (OR 1.50 95% CI [1.12–2.00]), and early gestational age (OR 0.74 95% CI [0.60–0.90]) were associated with an increase in return ED visits in univariate logistic regression models, while only early gestational age (OR 0.74 95% CI [0.59–0.91]) was associated with increased return ED visits in a multiple regression model. Admission to the hospital was found to decrease the likelihood of return ED visits (p=0.002). Conclusion NVP can be difficult to manage and has a high ED return visit rate. Optimizing care with aggressive, standardized treatment in the ED and upon discharge, particularly if factors predictive of return ED visits are present, may improve quality of care and reduce ED utilization for this condition. PMID:27625723

Association of emergency department albuterol dispensing with pediatric asthma revisits and readmissions.

PubMed

Hall, A Brad; Novotny, April; Bhisitkul, Donna M; Melton, James; Regan, Tim; Leckie, Maureen

2017-06-01

Although pediatric asthma continues to be a highly studied disease, data to suggest clear strategies to decrease asthma related revisits or readmissions is lacking. The purpose of our study was to assess the effect of emergency department (ED) direct dispensing of beta-agonist metered dose inhalers on pediatric asthma ED revisit and readmission rates. We conducted a retrospective cohort study of pediatric patients discharged from the pediatric ED with a diagnosis of asthma. Our primary outcome measured the rate of asthma revisits to the ED or admissions to the hospital within 28 days. Logistic regression analysis was used to assess ED beta-agonist MDI dispensing and revisit and/or readmission as the outcome. A total of 853 patients met eligibility for inclusion in the study, with 657 enrolled in the Baseline group and 196 enrolled in the ED-MDI group. The Baseline group experienced a revisit and readmission rate of 7.0% (46/657) versus 2.6% (5/196) in the ED-MDI group, (p = 0.026). ED direct dispensing of MDIs was found to be independently associated with a decreased risk of revisit or readmission (odds ratio 0.37; 95% confidence interval 0.14-0.95). In our study, ED direct dispensing of beta-agonist MDIs resulted in a reduction in 28-day revisit and readmission to the hospital. Further studies should be performed to evaluate the economic impact of reducing these revisits and readmissions against the costs of maintaining a dispensing program. Our findings may support modification of asthma programs to include dispensing MDIs from the emergency department.

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.

PubMed

Moy, Ernest; Barrett, Marguerite; Coffey, Rosanna; Hines, Anika L; Newman-Toker, David E

2015-02-01

An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI. We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older. We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses. Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.

Hospital-Based Emergency Department Visits With Dental Conditions: Impact of the Medicaid Reimbursement Fee for Dental Services in New York State, 2009-2013.

PubMed

Rampa, Sankeerth; Wilson, Fernando A; Wang, Hongmei; Wehbi, Nizar K; Smith, Lynette; Allareddy, Veerasathpurush

2018-06-01

Hospital-based emergency department (ED) visits for dental problems have been on the rise. The objectives of this study are to provide estimates of hospital-based ED visits with dental conditions in New York State and to examine the impact of Medicaid reimbursement fee for dental services on the utilization of EDs with dental conditions. New York State Emergency Department Database for the year 2009-2013 and Health Resources and Services Administration's Area Health Resource File were used. All ED visits with diagnosis for dental conditions were selected for analysis. The present study found a total of 325,354 ED visits with dental conditions. The mean age of patient was 32.4 years. A majority of ED visits were made by those aged 25-44 years (49%). Whites comprised 52.1% of ED visits. Proportion of Medicaid increased from 22% (in 2009) to 41.3% (in 2013). For Medicaid patients, the mean ED charges and aggregated ED charges were $811.4 and $88.1 million, respectively. Eleven counties had fewer than 4 dentists per 10,000 population in New York State. High-risk groups identified from the study are those aged 25-44 years, uninsured, covered by Medicaid and private insurance, and residing in low-income areas. The study highlights the need for increased Medicaid reimbursement for dentists and improves access to preventive dental care especially for the vulnerable groups. Copyright © 2017 Elsevier Inc. All rights reserved.

The impact of primary care on emergency department presentation and hospital admission with pneumonia: a case–control study of preschool-aged children

PubMed Central

Emery, Diane P; Milne, Tania; Gilchrist, Catherine A; Gibbons, Megan J; Robinson, Elizabeth; Coster, Gregor D; Forrest, Christopher B; Harnden, Anthony; Mant, David; Grant, Cameron C

2015-01-01

Background: In children, community-acquired pneumonia is a frequent cause of emergency department (ED) presentation and hospital admission. Quality primary care may prevent some of these hospital visits. Aims: The aim of this study was to identify primary care factors associated with ED presentation and hospital admission of preschool-aged children with community-acquired pneumonia. Methods: A case–control study was conducted by enrolling three groups: children presenting to the ED with pneumonia and admitted (n=326), or discharged home (n=179), and well-neighbourhood controls (n=351). Interviews with parents and primary care staff were conducted and health record review was performed. The association of primary care factors with ED presentation and hospital admission, controlling for available confounding factors, was determined using logistic regression. Results: Children were more likely to present to the ED with pneumonia if they did not have a usual general practitioner (GP) (odds ratio (OR)=2.50, 95% confidence interval (CI)=1.67–3.70), their GP worked ⩽20 h/week (OR=1.86, 95% CI=1.10–3.13) or their GP practice lacked an immunisation recall system (OR=5.44, 95% CI=2.26–13.09). Lower parent ratings for continuity (OR=1.63, 95% CI=1.01–2.62), communication (OR=2.01, 95% CI=1.29–3.14) and overall satisfaction (OR=2.16, 95% CI=1.34–3.47) increased the likelihood of ED presentation. Children were more likely to be admitted when antibiotics were prescribed in primary care (OR=2.50, 95% CI=1.43–4.55). Hospital admission was less likely if children did not have a usual GP (OR=0.22, 95% CI=0.11–0.40) or self-referred to the ED (OR=0.48, 95% CI=0.26–0.89). Conclusions: Accessible and continuous primary care is associated with a decreased likelihood of preschool-aged children with pneumonia presenting to the ED and an increased likelihood of hospital admission, implying more appropriate referral. Lower parental satisfaction is associated with an increased likelihood of ED presentation. PMID:25654661

The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study

PubMed Central

2013-01-01

Background Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation. Methods A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes. Results The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance. Conclusions Interpretation of the NPs’ role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required. PMID:24053508

Supporting Patient Care in the Emergency Department with a Computerized Whiteboard System

PubMed Central

Aronsky, Dominik; Jones, Ian; Lanaghan, Kevin; Slovis, Corey M.

2008-01-01

Efficient information management and communication within the emergency department (ED) is essential to providing timely and high-quality patient care. The ED whiteboard (census board) usually serves as an ED’s central access point for operational and patient-related information. This article describes the design, functionality, and experiences with a computerized ED whiteboard, which has the ability to display relevant operational and patient-related information in real time. Embedded functionality, additional whiteboard views, and the integration with ED and institutional information system components, such as the computerized patient record or the provider order entry system, provide rapid access to more detailed information. As an information center, the computerized whiteboard supports our ED environment not only for providing patient care, but also for operational, educational, and research activities. PMID:18096913

Elders' Experiences During Return Visits to the Emergency Department: A Phenomenographic Study in Taiwan.

PubMed

Han, Chin-Yen; Lin, Chun-Chih; Goopy, Suzanne; Hsiao, Ya-Chu; Barnard, Alan

Elders often experience multiple chronic diseases associated with frequent early return visits to emergency departments (EDs). There is limited knowledge of the experiences and concerns of elders during ED return visits. The purpose of the research was to explore the experiences of elders during ED return visits, with a view toward identifying factors that contribute to return visits. The qualitative approach of phenomenography was used. Data were collected at one ED in a 3,000-bed medical center in Taiwan. Inclusion criteria were aged 65 or above and return visits to the ED within 72 hours of discharge from an index ED visit. The seven steps of qualitative data analysis for a phenomenographic study were employed to develop understanding of participants' experiences. Thirty return-visit elders were interviewed in 2014. Four categories of description were established from the participants' accounts. These were "being tricked by ED staff," "doctor shopping," "a sign of impending death," and "feeling fatalistic." The outcome space of elders with early return visits to ED was characterized as "seeking the answer." Index ED visits are linked to return visits for Taiwanese elders through physiological, psychological, and social factors.

Hidden Grief and Lasting Emotions in Emergency Department Nurses.

PubMed

Schwab, Darcie; Napolitano, Nancy; Chevalier, Kelly; Pettorini-D'Amico, Susan

2016-11-01

The emergency department (ED) environment poses unique risks to developing moral distress and posttraumatic stress disorder (PTSD) in nurses. This impacts ED registered nurses' (RNs') ability to remain resilient. The purpose of this article is to explore the benefit of recognizing the signs and symptoms of burnout, introduce interventions to combat PTSD, and improve resiliency in ED RNs. The use of the wounded healer theory provides a framework to help nurse managers develop strategies such as critical incident stress debriefing (CISD) to address emotional distress.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

PubMed Central

Anderson, Eric L.; Nordstrom, Kimberly; Wilson, Michael P.; Peltzer-Jones, Jennifer M.; Zun, Leslie; Ng, Anthony; Allen, Michael H.

2017-01-01

Introduction In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II). Results In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED. Conclusion Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs. PMID:28210358

Smoothing inpatient discharges decreases emergency department congestion: a system dynamics simulation model.

PubMed

Wong, Hannah J; Wu, Robert C; Caesar, Michael; Abrams, Howard; Morra, Dante

2010-08-01

Timely access to emergency patient care is an important quality and efficiency issue. Reduced discharges of inpatients at weekends are a reality to many hospitals and may reduce hospital efficiency and contribute to emergency department (ED) congestion. To evaluate the daily number of ED beds occupied by inpatients after evenly distributing inpatient discharges over the course of the week using a computer simulation model. Simulation modelling study from an academic care hospital in Toronto, Canada. Daily historical data from the general internal medicine (GIM) department between 15 January and 15 December for two years, 2005 and 2006, were used for model building and validation, respectively. There was good agreement between model simulations and historical data for both ED and ward censuses and their respective lengths of stay (LOS), with the greatest difference being +7.8% for GIM ward LOS (model: 9.3 days vs historical: 8.7 days). When discharges were smoothed across the 7 days, the number of ED beds occupied by GIM patients decreased by approximately 27-57% while ED LOS decreased 7-14 hours. The model also demonstrated that patients occupying hospital beds who no longer require acute care have a considerable impact on ED and ward beds. Smoothing out inpatient discharges over the course of a week had a positive effect on decreasing the number of ED beds occupied by inpatients. Despite the particular challenges associated with weekend discharges, simulation experiments suggest that discharges evenly spread across the week may significantly reduce bed requirements and ED LOS.

Randomized Controlled Trial of Mailed Personalized Feedback for Risky Drinkers in the Emergency Department: The Impact on Alcohol Consumption, Alcohol-Related Injuries, and Repeat Emergency Department Presentations.

PubMed

Havard, Alys; Shakeshaft, Anthony P; Conigrave, Katherine M

2015-07-01

Due to the difficulty encountered in disseminating resource-intensive emergency department (ED)-based brief alcohol interventions into real-world settings, this study evaluated the effect of a mailed personalized feedback intervention for problem drinking ED patients. At 6-week follow-up, this intervention was associated with a statistically significant reduction in alcohol consumption among patients with alcohol-involved ED presentations. This study aimed to evaluate the effects of this intervention over time. A randomized controlled trial was conducted among problem drinking ED patients, defined as those scoring 8 or more on the Alcohol Use Disorders Identification Test. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. Follow-up interviews were conducted over the phone, postal survey, or email survey 6 weeks and 6 months after baseline screening, and repeat ED presentations over 12-month follow-up were ascertained via linked ED records. Six-month follow-up interviews were completed with 210 participants (69%), and linked ED records were obtained for 286 participants (94%). The intervention had no effect on alcohol consumption, while findings regarding alcohol-related injuries and repeat ED presentations remain inconclusive. Further research in which the receipt of feedback is improved and a booster intervention is provided is recommended. Copyright © 2015 by the Research Society on Alcoholism.

Applying the Lean principles of the Toyota Production System to reduce wait times in the emergency department.

PubMed

Ng, David; Vail, Gord; Thomas, Sophia; Schmidt, Nicki

2010-01-01

In recognition of patient wait times, and deteriorating patient and staff satisfaction, we set out to improve these measures in our emergency department (ED) without adding any new funding or beds. In 2005 all staff in the ED at Hôtel-Dieu Grace Hospital began a transformation, employing Toyota Lean manufacturing principles to improve ED wait times and quality of care. Lean techniques such as value-stream mapping, just-in-time delivery techniques, workplace organization, reduction of systemic wastes, use of the worker as the source of quality improvement and ongoing refinement of our process steps formed the basis of our project. Our ED has achieved major improvements in departmental flow without adding any additional ED or inpatient beds. The mean registration to physician time has decreased from 111 minutes to 78 minutes. The number of patients who left without being seen has decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients has decreased from a mean of 3.6 to 2.8 hours, with the largest decrease seen in our patients triaged at levels 4 or 5 using the Canadian Emergency Department Triage and Acuity Scale. We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles. Lean manufacturing principles can improve the flow of patients through the ED, resulting in greater patient satisfaction along with reduced time spent by the patient in the ED.

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Diagnostic Coding of Abuse Related Fractures at Two Children's Emergency Departments

ERIC Educational Resources Information Center

Somji, Zeeshanefatema; Plint, Amy; McGahern, Candice; Al-Saleh, Ahmed; Boutis, Kathy

2011-01-01

Objectives: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International…

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The financial consequences of lost demand and reducing boarding in hospital emergency departments.

PubMed

Pines, Jesse M; Batt, Robert J; Hilton, Joshua A; Terwiesch, Christian

2011-10-01

Some have suggested that emergency department (ED) boarding is prevalent because it maximizes revenue as hospitals prioritize non-ED admissions, which reimburse higher than ED admissions. We explore the revenue implications to the overall hospital of reducing boarding in the ED. We quantified the revenue effect of reducing boarding-the balance of higher ED demand and the reduction of non-ED admissions-using financial modeling informed by regression analysis and discrete-event simulation with data from 1 inner-city teaching hospital during 2 years (118,000 ED visits, 22% ED admission rate, 7% left without being seen rate, 36,000 non-ED admissions). Various inpatient bed management policies for reducing non-ED admissions were tested. Non-ED admissions generated more revenue than ED admissions ($4,118 versus $2,268 per inpatient day). A 1-hour reduction in ED boarding time would result in $9,693 to $13,298 of additional daily revenue from capturing left without being seen and diverted ambulance patients. To accommodate this demand, we found that simulated management policies in which non-ED admissions are reduced without consideration to hospital capacity (ie, static policies) mostly did not result in higher revenue. Many dynamic policies requiring cancellation of various proportions of non-ED admissions when the hospital reaches specific trigger points increased revenue. The optimal strategies tested resulted in an estimated $2.7 million and $3.6 in net revenue per year, depending on whether left without being seen patients were assumed to be outpatients or mirrored ambulatory admission rates, respectively. Dynamic inpatient bed management in inner-city teaching hospitals in which non-ED admissions are occasionally reduced to ensure that EDs have reduced boarding times is a financially attractive strategy. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Audit of deaths less than a week after admission through an emergency department: how accurate was the ED diagnosis and were any deaths preventable?

PubMed

Nafsi, Tabassum; Russell, Rob; Reid, Cilla M; Rizvi, Syed M M

2007-10-01

To review the causes of death in patients admitted via the emergency department (ED) who died within 7 days of admission and to identify any ways in which ED care could have been better. The study also aims to compare the diagnosis made in the ED and the mortality diagnosis. A retrospective study; subjects were all patients who attended the ED over 4 months and died within 7 days of admission. The paramedics' notes, ED case cards, inpatient medical notes and details of postmortem findings were examined to identify the time and date of arrival in the ED, presenting complaint, provisional diagnosis made by the ED, treatment plan devised by the ED, diagnosis made in wards, and the cause of death as issued on death certificates or from postmortem findings. Summary sheets of cases where the care provided by the emergency department could have been improved were reviewed, errors were identified and deaths were classified as preventable or unpreventable. Database revealed 3521 admissions via the ED over 4 months, of which 95 cases (2.69%) died within 7 days of admission. 78 patients (82.1% of cases) were appropriately diagnosed and managed whereas 17 (17.87% of cases) were identified with deficiencies in either the diagnosis or the management provided in the ED. We reviewed the quality of care provided in the ED for these cases and rated deaths according to our preventability criteria: 5 (5.26%) deaths were unpreventable despite the deficiency in care provided in the ED; 3 (3.15%) deaths were definitely preventable; 3 (3.15%) were probably preventable; and 6 (6.31%) were possibly preventable deaths. The ED is playing a good role in the management of critically ill patients, with appropriate diagnosis and management in 82% of cases. Training of junior doctors is required to prevent occurrence of errors and thus preventable deaths, but all deaths are not preventable. New guidelines for sepsis management and management of undifferentiated clinical presentations are being introduced and we intend to audit the implications of new guidelines.

Cost of health care utilization among homeless frequent emergency department users.

PubMed

Mitchell, Matthew S; León, Casey L K; Byrne, Thomas H; Lin, Wen-Chieh; Bharel, Monica

2017-05-01

Research demonstrates that homelessness is associated with frequent use of emergency department (ED) services, yet prior studies have not adequately examined the relationship between frequent ED use and utilization of non-ED health care services among those experiencing homelessness. There has also been little effort to assess heterogeneity among homeless individuals who make frequent use of ED services. To address these gaps, the present study used Medicaid claims data from 2010 to estimate the association between the number of ED visits and non-ED health care costs for a cohort of 6,338 Boston Health Care for the Homeless Program patients, and to identify distinct subgroups of persons in this cohort who made frequent use of ED services based on their clinical and demographic characteristics. A series of gamma regression models found more frequent ED use to be associated with higher non-ED costs, even after adjusting for demographic and clinical characteristics. Latent class analysis was used to examine heterogeneity among frequent ED users, and the results identified 6 characteristically distinct subgroups among these persons. The subgroup of persons with trimorbid illness had non-ED costs that far exceeded members of all 5 other subgroups. Study findings reinforce the connection between frequent ED use and high health care costs among homeless individuals and suggest that different groups of homeless frequent ED users may benefit from interventions that vary in terms of their composition and intensity. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States.

PubMed

Schuur, Jeremiah D; Baker, Olesya; Freshman, Jaclyn; Wilson, Michael; Cutler, David M

2017-04-01

We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located. We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED's location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights. We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs. In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Cost-effectiveness analysis and HIV screening: the emergency medicine perspective.

PubMed

Hsu, Heather; Walensky, Rochelle P

2011-07-01

Cost-effectiveness analysis is a useful tool for decisionmakers charged with prioritizing of the myriad medical interventions in the emergency department (ED). This analytic approach may be especially helpful for ranking programs that are competing for scarce resources while attempting to maximize net health benefits. In this article, we review the health economics literature on HIV screening in EDs and introduce the methods of cost-effectiveness analysis for medical interventions. We specifically describe the incremental cost-effectiveness ratio--its calculation, the derivation of ratio components, and the interpretation of these ratios. Copyright © 2011. Published by Mosby, Inc.

Risk Factors for Increased ED Utilization in a Multinational Cohort of Children with Sickle Cell Disease

PubMed Central

Glassberg, Jeffrey A.; Wang, Jason; Cohen, Robyn; Richardson, Lynne D.; DeBaun, Michael R.

2012-01-01

Objectives To identify clinical, social, and environmental risk factors for increased emergency department (ED) use in children with sickle cell disease (SCD). Methods This study was a secondary analysis of ED utilization data from the international multicenter Silent Cerebral Infarct Transfusion (SIT) trial. Between December 2004 and June 2010, baseline demographic, clinical, and laboratory data were collected from children with SCD participating in the trial. The primary outcome was the frequency of ED visits for pain. A secondary outcome was the frequency of ED visits for acute chest syndrome. Results The sample included 985 children from the US, Canada, England, and France, for a total of 2,955 patient-years of data. There were 0.74 ED visits for pain per patient-year. A past medical history of asthma was associated with an increased risk of ED utilization for both pain (RR = 1.28, 95% CI = 1.04 to 1.58) and acute chest syndrome (RR = 1.60, 95% CI = 1.03 to 2.49). Exposure to environmental tobacco smoke in the home was associated with 73% more ED visits for acute chest syndrome (RR 1.73, 95% CI = 1.09 to 2.74). Each $10,000 increase in household income was associated with 5% fewer ED visits for pain (RR 0.95, 95% CI = 0.91 to 1.00, p = 0.05). The association between low income and ED utilization was not significantly different in the USA vs. countries with universal health care (p = 0.51). Conclusions Asthma and exposure to environmental tobacco smoke are potentially modifiable risk factors for greater ED use in children with SCD. Low income is associated with greater ED use for SCD pain in countries with and without universal health care. PMID:22687181

The 'mindless' relationship between nursing homes and emergency departments: what do Bourdieu and Freire have to offer?

PubMed

McCloskey, Rose

2011-06-01

The 'mindless' relationship between nursing homes and emergency departments: what do Bourdieu and Freire have to offer? This paper explicates the long-standing and largely unquestioned adversarial relationship between nurses working in the nursing home (NH) and the emergency department (ED). Drawing on the author's own research on resident ED transfers, this paper reports on the conflict and tension that can arise when residents transfer between the two settings. The theoretical concepts of mindlessness, habitus, social capital and oppression are deployed to understand the contextual nature of the social relations that exist between NH and ED practitioners and between practitioners and residents. This theoretical discussion offers the potential to uncover the social relations that give rise to problematic transfers which may lead to alternative and more productive NH to ED transfers. © 2011 Blackwell Publishing Ltd.

Interdisciplinary Guidelines for Care of Women Presenting to the Emergency Department With Pregnancy Loss.

PubMed

Catlin, Anita

In April 2016, the National Perinatal Association and Kaiser Permanente Northern California Nursing Research Community Benefits Grant sponsored an interdisciplinary summit to explore the needs of women who present with actual or potential pregnancy loss to the emergency department (ED). Thirty-two experts in the field of pregnancy loss, 17 of whom represented their professional organizations, participated. These experts, which included nurses, physicians, social workers, counselors, authors, and parents, worked together to create guidelines for care of women with a pregnancy loss in the ED. Recommendations for ED healthcare providers are included. Emergency department personnel agreed that improvements in care could be offered and were willing to endorse education for their staff. The guidelines delineate how to better provide physical, emotional, and bereavement support at any stage of gestational loss. Administrative support for policies in the ED is essential to ensure the delivery of family-centered, culturally sensitive practices when a pregnancy ends.

Utilization of Hospital Emergency Departments for non-traumatic dental care in New Hampshire, 2001-2008.

PubMed

Anderson, Ludmila; Cherala, Sai; Traore, Elizabeth; Martin, Nancy R

2011-08-01

Hospital Emergency Departments (ED) provide a variety of medical care, some of which is for non-urgent, chronic conditions. We describe the statewide use of hospital ED for selected non-traumatic dental conditions that occurred during 2001-2008 in New Hampshire. Using the administrative hospital discharge dataset for 2001-2007, and provisional 2008 data, we identified all visits for selected dental conditions and calculated age-adjusted rates per 10,000 New Hampshire residents by several socio-demographic characteristics. The Spearman correlation coefficient was used to assess the statistical significance for trend over time. Emergency department visits for non-traumatic dental conditions increased significantly from 11,067 in 2001 to 16,238 visits in 2007 (P < 0.007). There were persistent differences in ED visits by age, county and primary payor, and varying difference by gender. Self-paying individuals and those 15-44 years old were the most frequent ED dental care users. The most frequent dental complains (46%) were diseases of the teeth and supporting structures, diagnostic code ICD-9-CM-525. Dental care associated ED visits have increased in New Hampshire. Individuals seeking dental treatment in ED are not receiving definitive treatment, and they misuse limited resources. Future studies need to determine the specific barriers to timely and effective dental care in dental offices. Ongoing consistent monitoring of ED use for non-traumatic dental conditions is essential.

Epidemiology of Hospital-Treated Injuries Sustained by Fitness Participants

ERIC Educational Resources Information Center

Gray, Shannon E.; Finch, Caroline F.

2015-01-01

Purpose: The purpose of this study was to provide an epidemiological profile of injuries sustained by participants in fitness activities in Victoria, Australia, based on hospital admissions and emergency department (ED) presentations and to identify the most common types, causes, and sites of these injuries. Method: Hospital-treated fitness…

Retrospective observational study of emergency department syndromic surveillance data during air pollution episodes across London and Paris in 2014.

PubMed

Hughes, Helen E; Morbey, Roger; Fouillet, Anne; Caserio-Schönemann, Céline; Dobney, Alec; Hughes, Thomas C; Smith, Gillian E; Elliot, Alex J

2018-04-19

Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014. Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ.Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ. Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0-14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0-14 years), whereas during the second period the increase was greater in adults. This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand. © Crown copyright 2018. Reproduced with the permission of the Controller of Her Majesty’s Stationery Office/Queen’s Printer for Scotland and Public Health England.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol

PubMed Central

Carr, Peter J; Rippey, James C R; Cooke, Marie L; Bharat, Chrianna; Murray, Kevin; Higgins, Niall S; Foale, Aileen; Rickard, Claire M

2016-01-01

Introduction Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency. Methods and analysis We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule. Ethics and dissemination The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used. Trial registration number ACTRN12615000588594; Pre-results. PMID:26868942

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach.

PubMed

Ward, Marie; McAuliffe, Eilish; Wakai, Abel; Geary, Una; Browne, John; Deasy, Conor; Schull, Michael; Boland, Fiona; McDaid, Fiona; Coughlan, Eoin; O'Sullivan, Ronan

2017-01-23

Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED). A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of 'Plan Do Study Act' (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed. Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

Demographic and Treatment Patterns for Infections in Ambulatory Settings in the United States, 2006-2010

PubMed Central

May, Larissa; Mullins, Peter; Pines, Jesse

2013-01-01

Objectives Many factors may influence choice of care setting for treatment of acute infections. The authors evaluated a national sample of U.S. outpatient clinic and emergency department (ED) visits for three common infections (urinary tract infection [UTI], skin and soft tissue infection [SSTI], and upper respiratory infection [URI]), comparing setting, demographics, and care. Methods This was a retrospective analysis of 2006–2010 data from the National Hospital Ambulatory Care Survey (NHAMCS) and National Ambulatory Care Survey (NAMCS). Patients age ≥ 18 years with primary diagnoses of UTI, URI, and SSTI were the visits of interest. Demographics, tests, and prescriptions were compared, divided by ED versus outpatient setting using bivariate statistics. Results Between 2006 and 2010, there were an estimated 40.9 million ambulatory visits for UTI, 168.3 million visits for URI, and 34.8 million visits for SSTI; 24% of UTI, 11% of URI, and 33% of SSTI visits were seen in EDs. Across all groups, ED patients were more commonly younger and black and had Medicaid or no insurance. ED patients had more blood tests (54% vs. 22% for UTI, 21% vs. 14% for URI, and 25% vs. 20% for SSTI) and imaging studies (31% vs. 9% for UTI, 27% vs. 8% for URI, and 16% vs. 5% for SSTI). Pain medications were more frequently used in the ED; over one-fifth of UTI and SSTI visits included narcotics. In both settings, greater than 50% of URI visits received antibiotics; more than 40% of UTI ED visits included broad-spectrum fluoroquinolones. Conclusions Emergency departments treated a considerable proportion of U.S. ambulatory infections from 2006 to 2010. Patient factors, including the presence of acute pain and access to care, appear to influence choice of care setting. Observed antibiotic use in both settings suggests a need for optimizing antibiotic use. PMID:24552520

Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department.

PubMed

Haukoos, Jason S; Campbell, Jonathan D; Conroy, Amy A; Hopkins, Emily; Bucossi, Meggan M; Sasson, Comilla; Al-Tayyib, Alia A; Thrun, Mark W

2013-01-01

The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial. This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated. During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection. Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.

Validation of the Brief Confusion Assessment Method for Screening Delirium in Elderly Medical Patients in a German Emergency Department.

PubMed

Baten, Verena; Busch, Hans-Jörg; Busche, Caroline; Schmid, Bonaventura; Heupel-Reuter, Miriam; Perlov, Evgeniy; Brich, Jochen; Klöppel, Stefan

2018-05-08

Delirium is frequent in elderly patients presenting in the emergency department (ED). Despite the severe prognosis, the majority of delirium cases remain undetected by emergency physicians (EPs). At the time of our study there was no valid delirium screening tool available for EDs in German-speaking regions. We aimed to evaluate the brief Confusion Assessment Method (bCAM) for a German ED during the daily work routine. We implemented the bCAM into practice in a German interdisciplinary high-volume ED and evaluated the bCAM's validity in a convenience sample of medical patients aged ≥ 70 years. The bCAM, which assesses four core features of delirium, was performed by EPs during their daily work routine and compared to a criterion standard based on the criteria for delirium as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Compared to the criterion standard, delirium was found to be present in 46 (16.0%) of the 288 nonsurgical patients enrolled. The bCAM showed 93.8% specificity (95% confidence interval [CI] = 90.0%-96.5%) and 65.2% sensitivity (95% CI = 49.8%-78.7%). Positive and negative likelihood ratios were 10.5 and 0.37, respectively, while the odds ratio was 28.4. Delirium was missed in 10 of 16 cases, since the bCAM did not indicate altered levels of consciousness and disorganized thinking. The level of agreement with the criterion standard increased for patients with low cognitive performance. This was the first study evaluating the bCAM for a German ED and when performed by EPs during routine work. The bCAM showed good specificity, but only moderate sensitivity. Nevertheless, application of the bCAM most likely improves the delirium detection rate in German EDs. However, it should only be applied by trained physicians to maximize diagnostic accuracy and hence improve the bCAM's sensitivity. Future studies should refine the bCAM. © 2018 by the Society for Academic Emergency Medicine.

Low caregiver health literacy is associated with higher pediatric emergency department use and nonurgent visits.

PubMed

Morrison, Andrea K; Schapira, Marilyn M; Gorelick, Marc H; Hoffmann, Raymond G; Brousseau, David C

2014-01-01

We sought to determine the association between low caregiver health literacy and child emergency department (ED) use, both the number and urgency of ED visits. This year long cross-sectional study utilized the Newest Vital Sign questionnaire to measure the health literacy of caregivers accompanying children to a pediatric ED. Prior ED visits were extracted from a regional database. ED visit urgency was classified by resources utilized during the index ED visit. Regression analyses were used to model 2 outcomes-prior ED visits and ED visit urgency-stratified by chronic illness. Analyses were weighted by triage level. Overall, 503 caregivers completed the study; 55% demonstrated low health literacy. Children of caregivers with low health literacy had more prior ED visits (adjusted incidence rate ratio 1.5; 95% confidence interval 1.2, 1.8) and increased odds of a nonurgent index ED visit (adjusted odds ratio 2.4; 95% confidence interval 1.3, 4.4). Among children without chronic illness, low caregiver health literacy was associated with an increased proportion of nonurgent index ED visits (48% vs. 22%; adjusted odds ratio 3.2; 1.8, 5.7). Over half of caregivers presenting with their children to the ED have low health literacy. Low caregiver health literacy is an independent predictor of higher ED use and use of the ED for nonurgent conditions. In children without a chronic illness, low health literate caregivers had more than 3 times greater odds of presenting for a nonurgent condition than those with adequate health literacy. Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Advertising emergency department wait times.

PubMed

Weiner, Scott G

2013-03-01

Advertising emergency department (ED) wait times has become a common practice in the United States. Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED. Opponents worry about the risk to the public health that arises from a patient with an emergent condition self-triaging to a further hospital, problems with inaccuracy and lack of standard definition of the reported time, and directing lower acuity patients to the higher cost ED setting instead to primary care. Three sample cases demonstrating the pitfalls of advertising ED wait times are discussed. Given the lack of rigorous evidence supporting the practice and potential adverse effects to the public health, caution about its use is advised.

An intelligent algorithm for optimizing emergency department job and patient satisfaction.

PubMed

Azadeh, Ali; Yazdanparast, Reza; Abdolhossein Zadeh, Saeed; Keramati, Abbas

2018-06-11

Purpose Resilience engineering, job satisfaction and patient satisfaction were evaluated and analyzed in one Tehran emergency department (ED) to determine ED strengths, weaknesses and opportunities to improve safety, performance, staff and patient satisfaction. The paper aims to discuss these issues. Design/methodology/approach The algorithm included data envelopment analysis (DEA), two artificial neural networks: multilayer perceptron and radial basis function. Data were based on integrated resilience engineering (IRE) and satisfaction indicators. IRE indicators are considered inputs and job and patient satisfaction indicators are considered output variables. Methods were based on mean absolute percentage error analysis. Subsequently, the algorithm was employed for measuring staff and patient satisfaction separately. Each indicator is also identified through sensitivity analysis. Findings The results showed that salary, wage, patient admission and discharge are the crucial factors influencing job and patient satisfaction. The results obtained by the algorithm were validated by comparing them with DEA. Practical implications The approach is a decision-making tool that helps health managers to assess and improve performance and take corrective action. Originality/value This study presents an IRE and intelligent algorithm for analyzing ED job and patient satisfaction - the first study to present an integrated IRE, neural network and mathematical programming approach for optimizing job and patient satisfaction, which simultaneously optimizes job and patient satisfaction, and IRE. The results are validated by DEA through statistical methods.

System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings.

PubMed

Baccei, Steven J; Chinai, Sneha A; Reznek, Martin; Henderson, Scott; Reynolds, Kevin; Brush, D Eric

2018-04-01

The appropriate communication and management of incidental findings on emergency department (ED) radiology studies is an important component of patient safety. Guidelines have been issued by the ACR and other medical associations that best define incidental findings across various modalities and imaging studies. However, there are few examples of health care facilities designing ways to manage incidental findings. Our institution aimed to improve communication and follow-up of incidental radiology findings in ED patients through the collaborative development and implementation of system-level process changes including a standardized loop-closure method. We assembled a multidisciplinary team to address the nature of these incidental findings and designed new workflows and operational pathways for both radiology and ED staff to properly communicate incidental findings. Our results are based on all incidental findings received and acknowledged between November 1, 2016, and May 30, 2017. The total number of incidental findings discovered was 1,409. Our systematic compliance fluctuated between 45% and 95% initially after implementation. However, after overcoming various challenges through optimization, our system reached a compliance rate of 93% to 95%. Through the implementation of our new, standardized communication system, a high degree of compliance with loop closure for ED incidental radiology findings was achieved at our institution. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Mobile and web-based education: delivering emergency department discharge and aftercare instructions.

PubMed

Saidinejad, Mohsen; Zorc, Joseph

2014-03-01

Prior research has identified deficiencies in the standard process of providing instructions for care at discharge from the emergency department (ED). Patients typically receive a brief verbal instruction, along with preformatted written discharge documents. Studies have found that understanding and retention of such information by families are very poor, leading to nonadherence in follow-up care, unnecessary return visit to the ED, and poor health outcomes. The combination of systems factors (information content, delivery methods, and timing) and patient factors (health literacy, language proficiency, and cultural factors) contributes to the challenge of providing successful discharge communication. Internet and mobile devices provide a novel opportunity to better engage families in this process.Mobile health can address both system- and patient-level challenges. By incorporating images, animation, and full Web-based video content, more comprehensible content that is better suited for patients with lower health literacy and today's visual learners can be created. Information can also be delivered both synchronously and asynchronously, enabling the health care providers to deliver health education to the patients electronically to their home, where health care occurs. Furthermore, the providers can track information access by patients, customize content to the individual patients, and reach other caregivers who may not be present during the ED visit. Further research is needed to develop the systems and best practices for incorporating mobile health in the ED setting.

Evaluation of Pharmacist Impact on Culture Review Process for Patients Discharged From the Emergency Department.

PubMed

Santiago, Ruben D; Bazan, Jose A; Brown, Nicole V; Adkins, Eric J; Shirk, Mary Beth

2016-10-01

Background: Accurate and timely review of microbiological test results is a core component of antimicrobial stewardship. There is documented success of these programs in the inpatient setting; however, emergency department (ED) patients are typically not included in these initiatives. Objectives: To assess the impact of an emergency medicine pharmacist (EMP)-facilitated review process of positive microbiological test results from patients discharged from the ED as measured by time to positive result review and number of indicated interventions completed. Methods: This was a retrospective study that compared EMP-facilitated to ED charge nurse (CN)-facilitated physician review of randomly selected positive microbiological test results. Groups were compared concurrently within the time frame of July 1, 2012 through December 31, 2012. Results: One hundred seventy-eight positive microbiological test results were included (EMP, n = 91; CN, n = 87). The median (IQR) time to initial review was 3 (1.0-6.3) hours for the EMP and 2 (0.3-5.5) hours for the CN group ( p = .35). Four percent (1/25) of indicated interventions were not completed in the EMP group versus 47% (14/30) in the CN group ( p = .0004). Conclusion: An EMP was significantly less likely to miss an intervention when indicated with no difference in time to review of positive microbiological results. These findings support the role of the EMP in antimicrobial stewardship in the ED.

Assessing the impact of a radiology information management system in the emergency department

NASA Astrophysics Data System (ADS)

Redfern, Regina O.; Langlotz, Curtis P.; Lowe, Robert A.; Horii, Steven C.; Abbuhl, Stephanie B.; Kundel, Harold L.

1998-07-01

To evaluate a conventional radiology image management system, by investigating information accuracy, and information delivery. To discuss the customization of a picture archival and communication system (PACS), integrated radiology information system (RIS) and hospital information system (HIS) to a high volume emergency department (ED). Materials and Methods: Two data collection periods were completed. After the first data collection period, a change in work rules was implemented to improve the quality of data in the image headers. Data from the RIS, the ED information system, and the HIS as well as observed time motion data were collected for patients admitted to the ED. Data accuracy, patient waiting times, and radiology exam information delivery were compared. Results: The percentage of examinations scheduled in the RIS by the technologists increased from 0% (0 of 213) during the first period to 14% (44 of 317) during the second (p less than 0.001). The percentage of images missing identification numbers decreased from 36% (98 of 272) during the first data collection period to 10% (56 of 562) during the second period (p less than 0.001). Conclusions: Radiologic services in a high-volume ED, requiring rapid service, present important challenges to a PACS system. Strategies can be implemented to improve accuracy and completeness of the data in PACS image headers in such an environment.

Programmatic Cost Evaluation of Nontargeted Opt-Out Rapid HIV Screening in the Emergency Department

PubMed Central

Haukoos, Jason S.; Campbell, Jonathan D.; Conroy, Amy A.; Hopkins, Emily; Bucossi, Meggan M.; Sasson, Comilla; Al-Tayyib, Alia A.; Thrun, Mark W.

2013-01-01

Background The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial. Methods This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated. Results During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%–0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%–4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection. Conclusions Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED. PMID:24391706

Determinants of non-urgent Emergency Department attendance among females in Qatar.

PubMed

Read, Jen'nan Ghazal; Varughese, Shinu; Cameron, Peter A

2014-01-01

The use of emergency department (ED) services for non-urgent conditions is well-studied in many Western countries but much less so in the Middle East and Gulf region. While the consequences are universal-a drain on ED resources and poor patient outcomes-the causes and solutions are likely to be region and country specific. Unique social and economic circumstances also create gender-specific motivations for patient attendance. Alleviating demand on ED services requires understanding these circumstances, as past studies have shown. We undertook this study to understand why female patients with low-acuity conditions choose the emergency department in Qatar over other healthcare options. Prospective study at Hamad General Hospital's (HGH) emergency department female "see-and-treat" unit that treats low-acuity cases. One hundred female patients were purposively recruited to participate in the study. Three trained physicians conducted semi-structured interviews with patients over a three-month period after they had been treated and given informed consent. The study found that motivations for ED attendance were systematically influenced by employment status as an expatriate worker. Forty percent of the sample had been directed to the ED by their employers, and the vast majority (89%) of this group cited employer preference as the primary reason for choosing the ED. The interviews revealed that a major obstacle to workers using alternative facilities was the lack of a government-issued health card, which is available to all citizens and residents at a nominal rate. Reducing the number of low-acuity cases in the emergency department at HGH will require interventions aimed at encouraging patients with non-urgent conditions to use alternative healthcare facilities. Potential interventions include policy changes that require employers to either provide workers with a health card or compel employees to acquire one for themselves.

Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?

PubMed

Chaudhary, Muhammad Ali; Lange, Jeffrey K; Pak, Linda M; Blucher, Justin A; Barton, Lauren B; Sturgeon, Daniel J; Koehlmoos, Tracey; Haider, Adil H; Schoenfeld, Andrew J

2018-05-22

Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%. We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA. An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use. We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use. When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior. Level III, therapeutic study.

ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception.

PubMed

Fee, Christopher; Metlay, Joshua P; Camargo, Carlos A; Maselli, Judith H; Gonzales, Ralph

2010-01-01

The study aimed to determine if emergency department (ED)-administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival. Time series analysis. Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering. Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department-administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100 degrees F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007. Emergency department-administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.

Acute post-disaster medical needs of patients with diabetes: emergency department use in New York City by diabetic adults after Hurricane Sandy

PubMed Central

Lee, David C; Gupta, Vibha K; Carr, Brendan G; Malik, Sidrah; Ferguson, Brandy; Wall, Stephen P; Smith, Silas W; Goldfrank, Lewis R

2016-01-01

Objective To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy. Research design and methods Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012. Results In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions. Conclusions We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks. PMID:27547418

Advancing the Use of Emergency Department Syndromic Surveillance Data, New York City, 2012-2016.

PubMed

Lall, Ramona; Abdelnabi, Jasmine; Ngai, Stephanie; Parton, Hilary B; Saunders, Kelly; Sell, Jessica; Wahnich, Amanda; Weiss, Don; Mathes, Robert W

The use of syndromic surveillance has expanded from its initial purpose of bioterrorism detection. We present 6 use cases from New York City that demonstrate the value of syndromic surveillance for public health response and decision making across a broad range of health outcomes: synthetic cannabinoid drug use, heat-related illness, suspected meningococcal disease, medical needs after severe weather, asthma exacerbation after a building collapse, and Ebola-like illness in travelers returning from West Africa. The New York City syndromic surveillance system receives data on patient visits from all emergency departments (EDs) in the city. The data are used to assign syndrome categories based on the chief complaint and discharge diagnosis, and analytic methods are used to monitor geographic and temporal trends and detect clusters. For all 6 use cases, syndromic surveillance using ED data provided actionable information. Syndromic surveillance helped detect a rise in synthetic cannabinoid-related ED visits, prompting a public health investigation and action. Surveillance of heat-related illness indicated increasing health effects of severe weather and led to more urgent public health messaging. Surveillance of meningitis-related ED visits helped identify unreported cases of culture-negative meningococcal disease. Syndromic surveillance also proved useful for assessing a surge of methadone-related ED visits after Superstorm Sandy, provided reassurance of no localized increases in asthma after a building collapse, and augmented traditional disease reporting during the West African Ebola outbreak. Sharing syndromic surveillance use cases can foster new ideas and build capacity for public health preparedness and response.

Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study.

PubMed

Van Oeveren, Lucas; Donner, Julie; Fantegrossi, Andrea; Mohr, Nicholas M; Brown, Calvin A

2017-04-01

Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance. We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network. Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics. Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia. The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success. Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.

Using an Emergency Department Syndromic Surveillance System to Evaluate Reporting of Potential Rabies Exposures, Illinois, 2013-2015.

PubMed

Bemis, Kelley; Frias, Mabel; Patel, Megan Toth; Christiansen, Demian

Mandatory reporting of potential rabies exposures and initiation of postexposure prophylaxis (PEP) allow local health authorities to monitor PEP administration for errors. Our objectives were to use an emergency department (ED) syndromic surveillance system to (1) estimate reporting compliance for exposure to rabies in suburban Cook County, Illinois, and (2) initiate interventions to improve reporting and reassess compliance. We queried ED records from 45 acute care hospitals in Cook County and surrounding areas from January 1, 2013, through June 30, 2015, for chief complaints or discharge diagnoses pertaining to rabies, PEP, or contact with a wild mammal (eg, bat, raccoon, skunk, fox, or coyote). We matched patients with ≥1 ED visit for potential rabies exposure to people with potential rabies exposure reported to the Cook County Department of Public Health. We considered nonmatches to have unreported exposures. We then initiated active surveillance in July 2015, disseminated education on reporting requirements in August and September 2015, and reassessed reporting completeness from July 2015 through February 2016. Of 248 patients with rabies-related ED visits from January 2013 through June 2015, 63 (25.4%) were reported. After interventions were implemented to increase reporting compliance, 53 of 98 (54.1%) patients with rabies-related ED visits from July 2015 through February 2016 were reported. Patients with ED visits for potential rabies exposure were twice as likely to be reported postintervention than preintervention (risk ratio = 2.1; 95% CI, 1.6-2.8). The volume of potential rabies exposure cases reported to the health department from July 2015 through February 2016 increased by 252% versus the previous year. Potential rabies exposures and PEP initiation are underreported in suburban Cook County. ED syndromic surveillance records can be used to estimate reporting compliance and conduct active surveillance.

Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding.

PubMed

Boyle, Adrian; Coleman, James; Sultan, Yasmin; Dhakshinamoorthy, Vijayasankar; O'Keeffe, Jacqueline; Raut, Pramin; Beniuk, Kathleen

2015-02-01

Emergency department (ED) crowding is recognised as a major public health problem. While there is agreement that ED crowding harms patients, there is less agreement about the best way to measure ED crowding. We have previously derived an eight-point measure of ED crowding by a formal consensus process, the International Crowding Measure in Emergency Departments (ICMED). We aimed to test the feasibility of collecting this measure in real time and to partially validate this measure. We conducted a cross-sectional study in four EDs in England. We conducted independent observations of the measure and compared these with senior clinician's perceptions of crowding and safety. We obtained 84 measurements spread evenly across the four EDs. The measure was feasible to collect in real time except for the 'Left Before Being Seen' variable. Increasing numbers of violations of the measure were associated with increasing clinician concerns. The area under the receiver operating characteristic curve was 0.80 (95% CI 0.72 to 0.90) for predicting crowding and 0.74 (95% CI 0.60 to 0.89) for predicting danger. The optimal number of violations for predicting crowding was three, with a sensitivity of 91.2 (95% CI 85.1 to 97.2) and a specificity of 100.0 (92.9-100). The measure predicted clinician concerns better than individual variables such as occupancy. The ICMED can easily be collected in multiple EDs with different information technology systems. The ICMED seems to predict clinician's concerns about crowding and safety well, but future work is required to validate this before it can be advocated for widespread use. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Emergency Department Telepsychiatry Service Model for a Rural Regional Health System: The First Steps.

PubMed

Meyer, James D; McKean, Alastair J S; Blegen, Rebecca N; Demaerschalk, Bart M

2018-05-09

Emergency departments (EDs) have recognized an increasing number of patients presenting with mental health (MH) concerns. This trend imposes greater demands upon EDs already operating at capacity. Many ED providers do not feel they are optimally prepared to provide the necessary MH care. One consideration in response to this dilemma is to use advanced telemedicine technology for psychiatric consultation. We examined a rural- and community-based health system operating 21 EDs, none of which has direct access to psychiatric consultation. Dedicated beds to MH range from zero (in EDs with only 3 beds) to 6 (in an ED with 38 beds). We conducted a needs assessment of this health system. This included a survey of emergency room providers with a 67% response rate and site visits to directly observe patient flow and communication with ED staff. A visioning workshop provided input from ED staff. Data were also obtained, which reflected ED admissions for the year 2015. The data provide a summary of provider concerns, a summary of MH presentations and diagnosis, and age groupings. The data also provide a time when most MH concerns present to the ED. Based upon these results, a proposed model for delivering comprehensive regional emergency telepsychiatry and behavioral health services is proposed. Emergency telepsychiatry services may be a tenable solution for addressing the shortage of psychiatric consultation to EDs in light of increasing demand for MH treatment in the ED.

Estimating Uncompensated Care Charges at Rural Hospital Emergency Departments

ERIC Educational Resources Information Center

Bennett, Kevin J.; Moore, Charity G.; Probst, Janice C.

2007-01-01

Context: Rural hospitals face multiple financial burdens. Due to federal law, emergency departments (ED) provide a gateway for uninsured and self-pay patients to gain access to treatment. It is unknown how much uncompensated care in rural hospitals is due to ED visits. Purpose: To develop a national estimate of uncompensated care from patients…

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2013-08-30

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Rural Emergency Department Staffing and Participation in Emergency Certification and Training Programs

ERIC Educational Resources Information Center

Casey, Michelle M.; Wholey, Douglas; Moscovice, Ira S.

2008-01-01

Context: The practice of emergency medicine presents many challenges in rural areas. Purpose: We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to…

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2013-06-24

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2012-11-08

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34 CFR 110.1 - What is the purpose of ED's age discrimination regulations?

Code of Federal Regulations, 2010 CFR

2010-07-01

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Effect of an emergency department-based electronic system for musculoskeletal consultation on facilitating care for common injuries.

PubMed

Mears, Simon C; Pantle, Hardin A; Bessman, Edward S; Lifchez, Scott D

2015-05-01

Access to musculoskeletal consultation in the emergency department (ED) is a nationwide problem. In addition, consultation from a subspecialist may be delayed or may not be available, which can slow down the ED flow and reduce patient satisfaction. The purpose of this study was to review the 1-year results of a change in the authors' institutional practice to reduce subspecialty consultation for select musculoskeletal problems while still ensuring adequate patient follow-up in orthopedic or plastic surgery clinics for patients not seen by these services in the ED. The authors hypothesized that select injuries could be safely managed in the ED by using an electronic system to ensure appropriate follow-up care. Using Kaizen methodology, a multidisciplinary group (including ED staff, orthopedics, plastic surgery, pediatrics, nursing, radiology, therapy, and administration) met to improve care for select musculoskeletal injuries. A system was agreed on in which ED providers managed select musculoskeletal injuries without subspecialist consultation. Follow-up was organized using an electronic system, which facilitated communication between the ED staff and the secretarial staff of the subspecialist departments. Over a 1-year period, 150 patients were treated using this system. Charts and radiographs were reviewed for missed injuries. Radiographic review revealed 2 missed injuries. One patient had additional back pain and a lumbar spine fracture was found during the subspecialist follow-up visit; it was treated nonoperatively. Another patient appeared to have scapholunate widening on the injury radiograph that was not appreciated in the ED. Of the 150 patients, 51 were seen in follow-up by a subspecialist at the authors' institution. An electronic system to organize follow-up with a subspecialist allowed the ED providers to deliver safe and effective care for simple musculoskeletal injuries. Copyright 2015, SLACK Incorporated.

The cost of an emergency department visit and its relationship to emergency department volume.

PubMed

Bamezai, Anil; Melnick, Glenn; Nawathe, Amar

2005-05-01

This article addresses 2 questions: (1) to what extent do emergency departments (EDs) exhibit economies of scale; and (2) to what extent do publicly available accounting data understate the marginal cost of an outpatient ED visit? Understanding the appropriate role for EDs in the overall health care system is crucially dependent on answers to these questions. The literature on these issues is sparse and somewhat dated and fails to differentiate between trauma and nontrauma hospitals. We believe a careful review of these questions is necessary because several changes (greater managed care penetration, increased price competition, cost of compliance with Emergency Medical Treatment and Active Labor Act regulations, and so on) may have significantly altered ED economics in recent years. We use a 2-pronged approach, 1 based on descriptive analyses of publicly available accounting data and 1 based on statistical cost models estimated from a 9-year panel of hospital data, to address the above-mentioned questions. Neither the descriptive analyses nor the statistical models support the existence of significant scale economies. Furthermore, the marginal cost of outpatient ED visits, even without the emergency physician component, appear quite high--in 1998 dollars, US295 dollars and US412 dollars for nontrauma and trauma EDs, respectively. These statistical estimates exceed the accounting estimates of per-visit costs by a factor of roughly 2. Our findings suggest that the marginal cost of an outpatient ED visit is higher than is generally believed. Hospitals thus need to carefully review how EDs fit within their overall operations and cost structure and may need to pay special attention to policies and procedures that guide the delivery of nonurgent care through the ED.

Google Flu Trends Spatial Variability Validated Against Emergency Department Influenza-Related Visits.

PubMed

Klembczyk, Joseph Jeffrey; Jalalpour, Mehdi; Levin, Scott; Washington, Raynard E; Pines, Jesse M; Rothman, Richard E; Dugas, Andrea Freyer

2016-06-28

Influenza is a deadly and costly public health problem. Variations in its seasonal patterns cause dangerous surges in emergency department (ED) patient volume. Google Flu Trends (GFT) can provide faster influenza surveillance information than traditional CDC methods, potentially leading to improved public health preparedness. GFT has been found to correlate well with reported influenza and to improve influenza prediction models. However, previous validation studies have focused on isolated clinical locations. The purpose of the study was to measure GFT surveillance effectiveness by correlating GFT with influenza-related ED visits in 19 US cities across seven influenza seasons, and to explore which city characteristics lead to better or worse GFT effectiveness. Using Healthcare Cost and Utilization Project data, we collected weekly counts of ED visits for all patients with diagnosis (International Statistical Classification of Diseases 9) codes for influenza-related visits from 2005-2011 in 19 different US cities. We measured the correlation between weekly volume of GFT searches and influenza-related ED visits (ie, GFT ED surveillance effectiveness) per city. We evaluated the relationship between 15 publically available city indicators (11 sociodemographic, two health care utilization, and two climate) and GFT surveillance effectiveness using univariate linear regression. Correlation between city-level GFT and influenza-related ED visits had a median of .84, ranging from .67 to .93 across 19 cities. Temporal variability was observed, with median correlation ranging from .78 in 2009 to .94 in 2005. City indicators significantly associated (P<.10) with improved GFT surveillance include higher proportion of female population, higher proportion with Medicare coverage, higher ED visits per capita, and lower socioeconomic status. GFT is strongly correlated with ED influenza-related visits at the city level, but unexplained variation over geographic location and time limits its utility as standalone surveillance. GFT is likely most useful as an early signal used in conjunction with other more comprehensive surveillance techniques. City indicators associated with improved GFT surveillance provide some insight into the variability of GFT effectiveness. For example, populations with lower socioeconomic status may have a greater tendency to initially turn to the Internet for health questions, thus leading to increased GFT effectiveness. GFT has the potential to provide valuable information to ED providers for patient care and to administrators for ED surge preparedness.

Predictive score for mortality in patients with COPD exacerbations attending hospital emergency departments

PubMed Central

2014-01-01

Background Limited information is available about predictors of short-term outcomes in patients with exacerbation of chronic obstructive pulmonary disease (eCOPD) attending an emergency department (ED). Such information could help stratify these patients and guide medical decision-making. The aim of this study was to develop a clinical prediction rule for short-term mortality during hospital admission or within a week after the index ED visit. Methods This was a prospective cohort study of patients with eCOPD attending the EDs of 16 participating hospitals. Recruitment started in June 2008 and ended in September 2010. Information on possible predictor variables was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up. Main short-term outcomes were death during hospital admission or within 1 week of discharge to home from the ED, as well as at death within 1 month of the index ED visit. Multivariate logistic regression models were developed in a derivation sample and validated in a validation sample. The score was compared with other published prediction rules for patients with stable COPD. Results In total, 2,487 patients were included in the study. Predictors of death during hospital admission, or within 1 week of discharge to home from the ED were patient age, baseline dyspnea, previous need for long-term home oxygen therapy or non-invasive mechanical ventilation, altered mental status, and use of inspiratory accessory muscles or paradoxical breathing upon ED arrival (area under the curve (AUC) = 0.85). Addition of arterial blood gas parameters (oxygen and carbon dioxide partial pressures (PO2 and PCO2)) and pH) did not improve the model. The same variables were predictors of death at 1 month (AUC = 0.85). Compared with other commonly used tools for predicting the severity of COPD in stable patients, our rule was significantly better. Conclusions Five clinical predictors easily available in the ED, and also in the primary care setting, can be used to create a simple and easily obtained score that allows clinicians to stratify patients with eCOPD upon ED arrival and guide the medical decision-making process. PMID:24758312

Adolescent Female Text Messaging Preferences to Prevent Pregnancy After an Emergency Department Visit: A Qualitative Analysis

PubMed Central

Schnall, Rebecca; Stockwell, Melissa S; Castaño, Paula M; Higgins, Tracy; Westhoff, Carolyn; Santelli, John; Dayan, Peter S

2016-01-01

Background Over 15 million adolescents use the emergency department (ED) each year in the United States. Adolescent females who use the ED for medical care have been found to be at high risk for unintended pregnancy. Given that adolescents represent the largest users of text messaging and are receptive to receiving text messages related to their sexual health, the ED visit represents an opportunity for intervention. Objective The aim of this qualitative study was to explore interest in and preferences for the content, frequency, and timing of an ED-based text message intervention to prevent pregnancy for adolescent females. Methods We conducted semistructured, open-ended interviews in one urban ED in the United States with adolescent females aged 14-19 years. Eligible subjects were adolescents who were sexually active in the past 3 months, presented to the ED for a reproductive health complaint, owned a mobile phone, and did not use effective contraception. Using an interview guide, enrollment continued until saturation of key themes. The investigators designed sample text messages using the Health Beliefs Model and participants viewed these on a mobile phone. The team recorded, transcribed, and coded interviews based on thematic analysis using the qualitative analysis software NVivo and Excel. Results Participants (n=14) were predominantly Hispanic (13/14; 93%), insured (13/14; 93%), ED users in the past year (12/14; 86%), and frequent text users (10/14; 71% had sent or received >30 texts per day). All were interested in receiving text messages from the ED about pregnancy prevention, favoring messages that were “brief,” “professional,” and “nonaccusatory.” Respondents favored texts with links to websites, repeated information regarding places to receive “confidential” care, and focused information on contraception options and misconceptions. Preferences for text message frequency varied from daily to monthly, with random hours of delivery to maintain “surprise.” No participant feared that text messages would violate her privacy. Conclusions Adolescent female patients at high pregnancy risk are interested in ED-based pregnancy prevention provided by texting. Understanding preferences for the content, frequency, and timing of messages can guide in designing future interventions in the ED. PMID:27687855

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

PubMed Central

2014-01-01

Background The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED. Methods We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts. Results The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED. Conclusions There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. Trial registration ClinicalTrials.gov registration number NCT00756704 PMID:24460974

Hospital factors impact variation in emergency department length of stay more than physician factors.

PubMed

Krall, Scott P; Cornelius, Angela P; Addison, J Bruce

2014-03-01

To analyze the correlation between the many different emergency department (ED) treatment metric intervals and determine if the metrics directly impacted by the physician correlate to the "door to room" interval in an ED (interval determined by ED bed availability). Our null hypothesis was that the cause of the variation in delay to receiving a room was multifactorial and does not correlate to any one metric interval. We collected daily interval averages from the ED information system, Meditech©. Patient flow metrics were collected on a 24-hour basis. We analyzed the relationship between the time intervals that make up an ED visit and the "arrival to room" interval using simple correlation (Pearson Correlation coefficients). Summary statistics of industry standard metrics were also done by dividing the intervals into 2 groups, based on the average ED length of stay (LOS) from the National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary. Simple correlation analysis showed that the doctor-to-discharge time interval had no correlation to the interval of "door to room (waiting room time)", correlation coefficient (CC) (CC=0.000, p=0.96). "Room to doctor" had a low correlation to "door to room" CC=0.143, while "decision to admitted patients departing the ED time" had a moderate correlation of 0.29 (p <0.001). "New arrivals" (daily patient census) had a strong correlation to longer "door to room" times, 0.657, p<0.001. The "door to discharge" times had a very strong correlation CC=0.804 (p<0.001), to the extended "door to room" time. Physician-dependent intervals had minimal correlation to the variation in arrival to room time. The "door to room" interval was a significant component to the variation in "door to discharge" i.e. LOS. The hospital-influenced "admit decision to hospital bed" i.e. hospital inpatient capacity, interval had a correlation to delayed "door to room" time. The other major factor affecting department bed availability was the "total patients per day." The correlation to the increasing "door to room" time also reflects the effect of availability of ED resources (beds) on the patient evaluation time. The time that it took for a patient to receive a room appeared more dependent on the system resources, for example, beds in the ED, as well as in the hospital, than on the physician.

Process modeling of emergency department patient flow: effect of patient length of stay on ED diversion.

PubMed

Kolker, Alexander

2008-10-01

A discreet event simulation methodology has been used to establish a quantitative relationship between Emergency Department (ED) performance characteristics, such as percent of time on ambulance diversion and the number of patients in queue in the waiting room, and the upper limits of patient length of stay (LOS). A simulation process model of ED patient flow has been developed that took into account a significant difference between LOS distributions of patients discharged home and patients admitted into the hospital. Using simulation model it has been identified that ED diversion could be negligible (less than approximately 0.5%) if patients discharged home stay in ED not more than 5 h, and patients admitted into the hospital stay in ED not more than 6 h Using full factorial design of experiments with two factors and the model's predicted percent diversion as a response function, other combinations of LOS upper limits have been determined that would result in low ED percent diversion as well. It has also been determined that if the number of patients exceeds 11 in queue in ED waiting room then the diversion percent is rapidly increasing.

Medicaid dental coverage alone may not lower rates of dental emergency department visits.

PubMed

Fingar, Kathryn R; Smith, Mark W; Davies, Sheryl; McDonald, Kathryn M; Stocks, Carol; Raven, Maria C

2015-08-01

Medicaid was expanded to millions of individuals under the Affordable Care Act, but many states do not provide dental coverage for adults under their Medicaid programs. In the absence of dental coverage, patients may resort to costly emergency department (ED) visits for dental conditions. Medicaid coverage of dental benefits could help ease the burden on the ED, but ED use for dental conditions might remain a problem in areas with a scarcity of dentists. We examined county-level rates of ED visits for nontraumatic dental conditions in twenty-nine states in 2010 in relation to dental provider density and Medicaid coverage of nonemergency dental services. Higher density of dental providers was associated with lower rates of dental ED visits by patients with Medicaid in rural counties but not in urban counties, where most dental ED visits occurred. County-level Medicaid-funded dental ED visit rates were lower in states where Medicaid covered nonemergency dental services than in other states, although this difference was not significant after other factors were adjusted for. Providing dental coverage alone might not reduce Medicaid-funded dental ED visits if patients do not have access to dental providers. Project HOPE—The People-to-People Health Foundation, Inc.

Inter-Facility Transfer of Pediatric Burn Patients from U.S. Emergency Departments

PubMed Central

Johnson, Sarah A.; Shi, Junxin; Groner, Jonathan I.; Thakkar, Rajan K.; Fabia, Renata; Besner, Gail E.; Xiang, Huiyun; Wheeler, Krista K.

2016-01-01

Purpose To describe the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) and to determine factors associated with inter-facility transfer. Methods We analyzed data from the 2012 Nationwide Emergency Department Sample. Current American Burn Association (ABA) Guidelines were used to identify children <18 who met criteria for referral to burn centers. Burn patient admission volume was used as a proxy for burn expertise. Logistic models were fitted to examine the odds of transfer from low volume hospitals. Results In 2012, there were an estimated 126,742 (95% CI: 116,104–137,380) pediatric burn ED visits in the U.S. Of the 69,003 (54.4%) meeting referral criteria, 83.2% were in low volume hospitals. Only 8.2% of patients meeting criteria were transferred from low volume hospitals. Of the 52,604 (95% CI: 48,433 – 56,775) not transferred, 98.3% were treated and released and 1.7% were admitted without transfer; 54.7% of burns involved hands. Conclusions Over 90% of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals. Perhaps a portion of the 92% of patients currently receiving definitive care in low volume hospitals are under-referred and would have improved clinical outcomes if transferred at the time of presentation. PMID:27554628

Developing a multidisciplinary approach within the ED towards domestic violence presentations.

PubMed

Basu, Subhashis; Ratcliffe, Giles

2014-03-01

To improve the detection and quality of care of patients who attend the emergency department (ED) with confirmed or suspected domestic abuse (DA). A quality improvement report on the design, implementation and evaluation of a specialised service and structured training programme to detect and manage DA presentations within an emergency medicine department. The study was set in the ED at the Northern General Hospital, Sheffield, UK. Key measures for improvement included introducing a service within the ED to help staff manage DA and coordinate responses; improve staff confidence in detecting DA; develop a structured and consistent process by which to manage DA presentations. An Independent Domestic Violence Advocate service was introduced into the department in July 2011 through a multiagency agreement. A structured training and education programme was delivered to ED staff. A 'communications form' was developed for DA risk assessment and case management. The process was reviewed quarterly. One hundred and seventy-two referrals were made to the service (121 distinct clients) over a 12-month period. Staff reported greater confidence in detecting DA, and community partners highlighted the role the service had in improving DA detection and care quality within the city. Strong leadership and prioritising the issue within the department has facilitated the development of the process and contributed substantially to its success. Support from community partners has been invaluable in tailoring the service and education programme to the needs of staff and patients within the department.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.

PubMed

Ali, Nissa J; McWilliams, J Michael; Epstein, Stephen K; Smulowitz, Peter B

2017-11-01

We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality. Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Pediatric Emergency Department Resource Utilization among Children with Primary Care Clinic Contact in the Preceding 2 Days: A Cross-Sectional Study.

PubMed

Grech, Christina K; Laux, Molly A; Burrows, Heather L; Macy, Michelle L; Pomeranz, Elaine S

2017-09-01

To characterize pediatric patient contacts with their primary care clinic in the 2 days preceding a visit to the emergency department (ED) and explore how the type of clinic contact relates to ED resource use. We conducted a retrospective chart review of 368 pediatric ED visits in the first 7 days of each month, from September 2012 to August 2013. Visits were included if the family contacted their child's general pediatric clinic in the study health system in the 2 days preceding the ED visit. Descriptive statistics were calculated. Primary outcomes were ED resource use (tests, treatments) and disposition (admission or discharge). Outcomes by type of clinic contact were compared with χ 2 statistics. Of 1116 records with ED visits in the 12 study weeks extracted from the electronic medical record, 368 ED visits met inclusion criteria. Most ED visits followed a single clinic contact (78.8%). Of the 474 clinic contacts, 149 were in-person visits, 216 phone calls when clinic was open, and 109 phone calls when clinic was closed. ED visits that followed an in-person clinic contact with advice to go to the ED had significantly greater rates of testing and admission than those advised to go to the ED after phone contact and those never advised to go to the ED. In-person clinic visits with advice to go to the ED were associated with the greatest ED resource use. Limitations include a study of a single health system without a uniform process for triaging patients to the ED across clinics. Copyright © 2017 Elsevier Inc. All rights reserved.

The impact of electronic health records on care of heart failure patients in the emergency room

PubMed Central

Park, Young-Taek; Du, Jing; Theera-Ampornpunt, Nawanan; Gordon, Bradley D; Bershow, Barry A; Gensinger, Raymond A; Shrift, Michael; Routhe, Daniel T; Speedie, Stuart M

2011-01-01

Objective To evaluate if electronic health records (EHR) have observable effects on care outcomes, we examined quality and efficiency measures for patients presenting to emergency departments (ED). Materials and methods We conducted a retrospective study of 5166 adults with heart failure in three metropolitan EDs. Patients were termed internal if prior information was in the EHR upon ED presentation, otherwise external. Associations of internality with hospitalization, mortality, length of stay (LOS), and numbers of tests, procedures, and medications ordered in the ED were examined after adjusting for age, gender, race, marital status, comorbidities and hospitalization as a proxy for acuity level where appropriate. Results At two EDs internals had lower odds of mortality if hospitalized (OR 0.55; 95% CI 0.38 to 0.81 and 0.45; 0.21 to 0.96), fewer laboratory tests during the ED visit (−4.6%; −8.9% to −0.1% and −14.0%; −19.5% to −8.1%) as well as fewer medications (−33.6%; −38.4% to −28.4% and −21.3%; −33.2% to −7.3%). At one of these two EDs, internals had lower odds of hospitalization (0.37; 0.22 to 0.60). At the third ED, internal patients only experienced a prolonged ED LOS (32.3%; 6.3% to 64.8%) but no other differences. There was no association with hospital LOS or number of procedures ordered. Discussion EHR availability was associated with salutary outcomes in two of three ED settings and prolongation of ED LOS at a third, but evidence was mixed and causality remains to be determined. Conclusions An EHR may have the potential to be a valuable adjunct in the care of heart failure patients. PMID:22071528

Rural-urban disparities in child abuse management resources in the emergency department.

PubMed

Choo, Esther K; Spiro, David M; Lowe, Robert A; Newgard, Craig D; Hall, Michael Kennedy; McConnell, Kenneth John

2010-01-01

To characterize differences in child abuse management resources between urban and rural emergency departments (EDs). We surveyed ED directors and nurse managers at hospitals in Oregon to gain information about available abuse-related resources. Chi-square analysis was used to test differences between urban and rural EDs. Multivariate analysis was performed to examine the association between a variety of hospital characteristics, in addition to rural location, and presence of child abuse resources. Fifty-five Oregon hospitals were surveyed. A smaller proportion of rural EDs had written abuse policies (62% vs 95%, P= .006) or on-site child abuse advocates (35% vs 71%, P= .009). Thirty-two percent of rural EDs had none of the examined abuse resources (vs 0% of urban EDs, P= .01). Of hospital characteristics studied in the multivariate model, only rural location was associated with decreased availability of child abuse resources (OR 0.19 [95% CI, 0.05-0.70]). Rural EDs have fewer resources than urban EDs for the management of child abuse. Other studied hospital characteristics were not associated with availability of abuse resources. Further work is needed to identify barriers to resource utilization and to create resources that can be made accessible to all ED settings. © 2010 National Rural Health Association.

A qualitative systematic review of the reasons for parental attendance at the emergency department with children presenting with minor illness.

PubMed

Butun, Ahmet; Hemingway, Pippa

2018-01-01

Over 5 million children attend the Emergency Department (ED) annually in England with an ever-increasing paediatric emergency caseload echoed globally. Approximately 60% of children present with illness and the majority have non-urgent illness creating burgeoning pressures on children's ED and this crisis resonates globally. To date no qualitative systematic review exists that focuses on the parental reasons for childhood attendance at the ED in this sub-group. To identify parental reasons for attending ED for their children presenting with minor illness. A qualitative systematic review was conducted against inclusion/exclusion criteria. Five electronic databases and key journals were searched in June 2015. 471 studies were identified and following study selection, 4 qualitative studies were included. Nine themes were identified e.g. dissatisfaction with family medical services, perceived advantages of ED and 'child suffering' with novel and insightful sub-themes of 'hereditary anxiety', 'taking it off our hands', ED as a 'magical place'. This novel qualitative systematic review examined parental attendance presenting with childhood minor illness of interest to emergency care reformers and clinicians. ED attendance is complex and multifactorial but parents provide vital insight to ED reformers on parental reasons for ED attendance in this sub-group. Copyright © 2017 Elsevier Ltd. All rights reserved.

Verbal abuse and physical assault in the emergency department: Rates of violence, perceptions of safety, and attitudes towards security.

PubMed

Partridge, Bradley; Affleck, Julia

2017-08-01

Emergency Department (ED) workers are prone to occupational violence, however the extent and impact of this may not be evenly felt across all roles in the ED. Explore: 1) the rate of verbal abuse and physical assaults experienced by ED staff, 2) perceptions of safety, 3) attitudes towards security officers, and 4) formal reporting of incidents. 330 ED workers were surveyed at four public hospitals in one metropolitan health service district in Queensland, Australia, including 179 nurses, 83 medical staff, 44 administration staff, 14 allied health, and 9 operational. Nurses were more likely to have been physically assaulted in the last six months and were less likely to feel safe. Most ED staff across all roles experienced verbal abuse. Nurses were better than medical staff at reporting instances of occupational violence although overall reporting across all roles was low. Staff who thought that security officers respond to incidents quickly and are a visible presence in the ED were more likely to feel safe in the ED. Workers in the ED, particularly nurses, experience high rates of verbal abuse and physical aggression and there may be a case for having designated security guards in the ED. Copyright © 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Factors that influence patient satisfaction in the emergency department.

PubMed

Bruce, T A; Bowman, J M; Brown, S T

1998-12-01

This descriptive correlation study examined the satisfaction levels of urgent and nonurgent patients in relation to nursing care, the emergency department (ED) environment, ancillary services, and information received. The sample consisted of 28 subjects, with the majority of patients being very satisfied with nursing care. The primary area of concern was information about the length of waiting time. The satisfaction levels of ED patients with the care they receive has become increasingly important in today's health care environment. ED nurses play an important role in ensuring that patients are satisfied and receive quality care.

The Impact of "ED" on Educational Research.

ERIC Educational Resources Information Center

Florio, David H.

1980-01-01

The purposes, structure, and component parts of the newly formed Department of Education (ED) organizations from which educational research programs will be administered are discussed. As the climate surrounding ED changes, opportunities to take advantage of the elevated status of research will be presented. (Author/RL)

Applying advanced analytics to guide emergency department operational decisions: A proof-of-concept study examining the effects of boarding.

PubMed

Andrew Taylor, R; Venkatesh, Arjun; Parwani, Vivek; Chekijian, Sharon; Shapiro, Marc; Oh, Andrew; Harriman, David; Tarabar, Asim; Ulrich, Andrew

2018-01-04

Emergency Department (ED) leaders are increasingly confronted with large amounts of data with the potential to inform and guide operational decisions. Routine use of advanced analytic methods may provide additional insights. To examine the practical application of available advanced analytic methods to guide operational decision making around patient boarding. Retrospective analysis of the effect of boarding on ED operational metrics from a single site between 1/2015 and 1/2017. Times series were visualized through decompositional techniques accounting for seasonal trends, to determine the effect of boarding on ED performance metrics and to determine the impact of boarding "shocks" to the system on operational metrics over several days. There were 226,461 visits with the mean (IQR) number of visits per day was 273 (258-291). Decomposition of the boarding count time series illustrated an upward trend in the last 2-3 quarters as well as clear seasonal components. All performance metrics were significantly impacted (p<0.05) by boarding count, except for overall Press Ganey scores (p<0.65). For every additional increase in boarder count, overall length-of-stay (LOS) increased by 1.55min (0.68, 1.50). Smaller effects were seen for waiting room LOS and treat and release LOS. The impulse responses indicate that the boarding shocks are characterized by changes in the performance metrics within the first day that fade out after 4-5days. In this study regarding the use of advanced analytics in daily ED operations, time series analysis provided multiple useful insights into boarding and its impact on performance metrics. Copyright © 2018. Published by Elsevier Inc.

Predicting prolonged length of hospital stay in older emergency department users: use of a novel analysis method, the Artificial Neural Network.

PubMed

Launay, C P; Rivière, H; Kabeshova, A; Beauchet, O

2015-09-01

To examine performance criteria (i.e., sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], likelihood ratios [LR], area under receiver operating characteristic curve [AUROC]) of a 10-item brief geriatric assessment (BGA) for the prediction of prolonged length hospital stay (LHS) in older patients hospitalized in acute care wards after an emergency department (ED) visit, using artificial neural networks (ANNs); and to describe the contribution of each BGA item to the predictive accuracy using the AUROC value. A total of 993 geriatric ED users admitted to acute care wards were included in this prospective cohort study. Age >85years, gender male, polypharmacy, non use of formal and/or informal home-help services, history of falls, temporal disorientation, place of living, reasons and nature for ED admission, and use of psychoactive drugs composed the 10 items of BGA and were recorded at the ED admission. The prolonged LHS was defined as the top third of LHS. The ANNs were conducted using two feeds forward (multilayer perceptron [MLP] and modified MLP). The best performance was reported with the modified MLP involving the 10 items (sensitivity=62.7%; specificity=96.6%; PPV=87.1; NPV=87.5; positive LR=18.2; AUC=90.5). In this model, presence of chronic conditions had the highest contributions (51.3%) in AUROC value. The 10-item BGA appears to accurately predict prolonged LHS, using the ANN MLP method, showing the best criteria performance ever reported until now. Presence of chronic conditions was the main contributor for the predictive accuracy. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Trends in Nationwide Herpes Zoster Emergency Department Utilization From 2006 to 2013.

PubMed

Dommasch, Erica D; Joyce, Cara J; Mostaghimi, Arash

2017-09-01

The effect of vaccination on emergency department (ED) utilization for herpes zoster (HZ) has not been examined to date. To determine trends in US ED utilization and costs associated with HZ. The Nationwide Emergency Department Sample data set was examined for temporal trends in the number of visits and costs for treatment of HZ in EDs in the United States from January 1, 2006, through December 31, 2013. Cases of HZ were identified using validated International Classification of Diseases, Ninth Revision-Clinical Modification diagnosis codes. Patients were stratified by age: less than 20 years (varicella vaccine recommended), 20 to 59 years (no vaccine recommended), and 60 years or older (HZ vaccine recommended). Population-based rates were estimated using sampling weights. Population-based incidence rates of HZ-related ED visits, charge for ED services, and total charges. A total of 1 350 957 ED visits for HZ were identified between 2006 and 2013, representing 0.13% of all US ED visits. Of these patients, 563 200 (51.7%) were male; mean (SE) age was 54.0 (0.1) years. Between 2006 and 2013, the percentage of HZ-related ED visits increased from 0.13% to 0.14% (8.3%). This growth was driven by patients aged 20 to 59 years (increase of 22.8% [from 0.12% to 0.14% of ED visits]) while the proportion of ED HZ visits decreased for patients aged less than 20 years and 60 years or older, from 0.03% to 0.02% (-39.6%) and from 0.28% to 0.25% (-10.9%), respectively. For all age groups, there was an increase from 2006 to 2013 in overall adjusted total (from $92.83 to $202.47 million) and mean charges (from $763 to $1262) for HZ-related ED visits. The number of ED visits and total cost associated with HZ increased between 2006 and 2013. Greater use was driven by an increased number of visits by patients aged 20 to 59 years, but populations recommended for vaccination (<20 and ≥60 years) demonstrated decreased ED utilization. Per-visit and total costs increased across all age groups. Vaccination may be associated with a reduction of ED utilization. Further research is required to confirm these results and examine the drivers of increased ED costs.

Radiology response in the emergency department during a mass casualty incident: a retrospective study of the two terrorist attacks on 22 July 2011 in Norway.

PubMed

Young, Victoria Solveig; Eggesbø, Heidi B; Gaarder, Christine; Næss, Pål Aksel; Enden, Tone

2017-07-01

To describe the use of radiology in the emergency department (ED) in a trauma centre during a mass casualty incident, using a minimum acceptable care (MAC) strategy in which CT was restricted to potentially severe head injuries. We retrospectively studied the initial use of imaging on patients triaged to the trauma centre following the twin terrorist attacks in Norway on 22 July 2011. Nine patients from the explosion and 15 from the shooting were included. Fourteen patients had an Injury Severity Score >15. During the first 15 h, 22/24 patients underwent imaging in the ED. All 15 gunshot patients had plain films taken in the ED, compared to three from the explosion. A CT was performed in 18/24 patients; ten of these were completed in the ED and included five non-head CTs, the latter representing deviations from the MAC strategy. No CT referrals were delayed or declined. Mobilisation of radiology personnel resulted in a tripling of the staff. Plain film and CT capacity was never exceeded despite deviations from the MAC strategy. An updated disaster management plan will require the radiologist to cancel non-head CTs performed in the ED until no additional MCI patients are expected. • Minimum acceptable care (MAC) should replace normal routines in mass casualty incidents. • MAC implied reduced use of imaging in the emergency department (ED). • CT in ED was restricted to suspected severe head injuries during MAC. • The radiologist should cancel all non-head CTs in the ED during MAC.

The association between crowding and mortality in admitted pediatric patients from mixed adult-pediatric emergency departments in Korea.

PubMed

Cha, Won Chul; Shin, Sang Do; Cho, Jin Sung; Song, Kyoung Jun; Singer, Adam J; Kwak, Young Ho

2011-12-01

We aimed to investigate the effect of crowding on the hospital mortality of pediatric patients from adult-pediatric mixed emergency departments (EDs). We used the National Emergency Department Information System database, which included demographic, clinical, diagnostic, and procedural information with all emergency patients visiting to 116 EDs from Korea since 2004. We enrolled EDs with mean length of stay of more than 6 hours. Study period was from January 2006 to December 2008. Pediatric patients younger than 15 years admitted from these EDs were study targets. We calculated the mean patient volume (mean number of patients in the ED) over 8-hour shift for each hospital. When the volume reached the highest quartile, the period was considered as crowded. Patients who came during the overcrowded period were defined as the crowded group. We performed a Kaplan-Meier analysis, and hazard ratio and 95% confidence intervals (95% CIs) were calculated using a Cox proportional hazards regression model. A total of 34 EDs and 125,031 admitted pediatric patients were included; 74,152 (59.3%) were male, and the mean age was 3.84 (95% CI, 3.82-3.86) years; 35,924 (28.7%) were determined as the crowded group. The 30-day mortality rates were 0.4% and 0.3% (P = 0.063) for the crowded group and for the noncrowded group, respectively. The hazard ratio for hospital mortality of the crowded group was 1.230 (95% CI, 1.019-1.558). The ED crowding was associated with increased hazard for hospital mortality for pediatric patients in mixed EDs.

"Why Is This Patient Being Sent Here?": Communication from Urgent Care to the Emergency Department.

PubMed

Gardner, Rebekah; Choo, Esther K; Gravenstein, Stefan; Baier, Rosa R

2016-03-01

Despite patients' increasing use of urgent care centers (UCC), little is known about how urgent care clinicians communicate with the emergency department (ED). To assess ED clinicians' perceptions of the quality and consistency of communication when patients are referred from UCCs to EDs. Emergency medicine department chairs distributed a brief, electronic survey to a statewide sample of ED clinicians via e-mail. The survey included multiple-choice and free-text questions focused on types of communication desired and received from UCCs, types of test results available on transfer, and suggestions for improvement. Of 199 ED clinicians, 102 (51.3%) responded. More than four out of five respondents "somewhat" or "strongly agreed" that each of the following would be helpful: a telephone call, the reason for referral, specific concern, a copy of the chart, and UCC contact information. However, ED clinicians reported not consistently receiving these: only a fifth (21.6%) of clinicians reported receiving the specific concern for their last 5 patients transferred from a UCC, and 34.3% recalled receiving a copy of the chart. Overall, 54.9% reported receiving laboratory test results "often or almost always," 49.0% electrocardiograms, and 44.1% imaging reports. Qualitative analysis revealed several themes: incomplete data when patients are referred; barriers to discussion between ED and urgent care clinicians; and possible solutions to improve communication. Our findings highlight variation in communication from UCCs to EDs, indicating a need to improve communication standards and practices. We identify several potential ways to improve this clinical information hand-off. Copyright © 2016 Elsevier Inc. All rights reserved.

Elimination of Emergency Department Medication Errors Due To Estimated Weights.

PubMed

Greenwalt, Mary; Griffen, David; Wilkerson, Jim

2017-01-01

From 7/2014 through 6/2015, 10 emergency department (ED) medication dosing errors were reported through the electronic incident reporting system of an urban academic medical center. Analysis of these medication errors identified inaccurate estimated weight on patients as the root cause. The goal of this project was to reduce weight-based dosing medication errors due to inaccurate estimated weights on patients presenting to the ED. Chart review revealed that 13.8% of estimated weights documented on admitted ED patients varied more than 10% from subsequent actual admission weights recorded. A random sample of 100 charts containing estimated weights revealed 2 previously unreported significant medication dosage errors (.02 significant error rate). Key improvements included removing barriers to weighing ED patients, storytelling to engage staff and change culture, and removal of the estimated weight documentation field from the ED electronic health record (EHR) forms. With these improvements estimated weights on ED patients, and the resulting medication errors, were eliminated.

Learning from Accident and Error: Avoiding the Hazards of Workload, Stress, and Routine Interruptions in the Emergency Department

PubMed Central

Morrison, J. Bradley; Rudolph, Jenny W.

2012-01-01

This article presents a model of how a build-up of interruptions can shift the dynamics of the emergency department (ED) from an adaptive, self-regulating system into a fragile, crisis-prone one. Drawing on case studies of organizational disasters and insights from the theory of high-reliability organizations, the authors use computer simulations to show how the accumulation of small interruptions could have disproportionately large effects in the ED. In the face of a mounting workload created by interruptions, EDs, like other organizational systems, have tipping points, thresholds beyond which a vicious cycle can lead rather quickly to the collapse of normal operating routines and in the extreme to a crisis of organizational paralysis. The authors discuss some possible implications for emergency medicine, emphasizing the potential threat from routine, non-novel demands on EDs and raising the concern that EDs are operating closer to the precipitous edge of crisis as ED crowding exacerbates the problem. PMID:22168187

Multislice coronary computed tomographic angiography in emergency department presentations of unsuspected acute myocardial infarction.

PubMed

Hecht, Harvey S; Bhatti, Tandeep

2009-01-01

Coronary computed tomographic angiography (CCTA) is not indicated in the setting of acute myocardial infarction in the emergency department (ED). Nonetheless, acute coronary syndromes may have atypical presentations, and CCTA may be inadvertently performed in this setting. This study was designed to determine the frequency and characteristics of CCTA imaging of unsuspected acute myocardial infarction in the ED. All CCTAs performed in the ED at Lenox Hill Hospital were reviewed for clinical indications and subsequent course; patients with documented acute myocardial infarction were identified. Of the 500 CCTAs performed on ED patients in the Lenox Hill laboratory, 5 patients (1%) were imaged during the initial phase of an unsuspected acute myocardial infarction; in all cases the CCTAs were key to the diagnosis. The imaging characteristics were (1) total or subtotal occlusion and (2) transmural hypodensity in the infarct area. Although acute myocardial infarction on CCTA in ED patients is an infrequent event, proper and prompt recognition is critical for appropriate patient care, particularly as applications to the ED increase.

Characteristics of the Highest Users of Emergency Services in Veterans Affairs Hospitals: Homeless and Non-Homeless.

PubMed

Gundlapalli, Adi V; Jones, Audrey L; Redd, Andrew; Suo, Ying; Pettey, Warren B P; Mohanty, April; Brignone, Emily; Gawron, Lori; Vanneman, Megan; Samore, Matthew H; Fargo, Jamison D

2017-01-01

Efforts are underway to understand recent increases in emergency department (ED) use and to offer case management to those patients identified as high utilizers. Homeless Veterans are thought to use EDs for non-emergent conditions. This study identifies the highest users of ED services in the Department of Veterans Affairs and provides descriptive analyses of these Veterans, the diagnoses for which they were seen in the ED, and differences based on their homeless status. Homeless Veterans were more likely than non-homeless Veterans to have >10 visits in the 2014 calendar year (12% vs. <1%). Homeless versus non-homeless Veterans with >10 visits were more often male, <age 60, and non-married. Non-homeless Veterans with >10 ED visits were often treated for chest and abdominal pain, and back problems, whereas homeless Veterans were frequently treated for mental health/substance use. Tailored case management approaches may be needed to better link homeless Veterans with high ED use to appropriate outpatient care.

Utilization of and Direct Expenditure for Emergency Medical 
Care in Taiwan: A Population-based Descriptive Study

PubMed Central

Yang, Nan-Ping; Lee, Yi-Hui; Lin, Ching-Heng; Chung, Yuan-Chang; Chen, Wen-Jone; Chou, Pesus

2009-01-01

Background We surveyed the emergency medical system (EMS) in Taiwan to provide information to policymakers responsible for decisions regarding the redistribution of national medical resources. Methods A systematic sampling method was used to randomly sample a representative database from the National Health Insurance (NHI) database in Taiwan, during the period from 2000 to 2004. Results We identified 10,124, 10,408, 11,209, 10,686, and 11,914 emergency room visits in 2000, 2001, 2002, 2003, and 2004, respectively. There were more males than females, and the majority of adults were younger than 50 years. Diagnose of injury/poisoning was the most frequently noted diagnostic category in emergency departments (EDs) in Taiwan. There were 13,196 (24.3%) and 2,952 (5.4%) patients with 2 and 3 concomitant diagnoses, respectively. There was a significant association between advanced age and the existence of multiple diagnoses (P < 0.001). With the exception of the ill-defined symptoms/signs/conditions, the two most frequent diagnoses were diseases of the circulatory system and diseases of the respiratory system in patients aged 65 years or older. On average, treatment-associated expenditure and drug-associated expenditure in Taiwan EDs averaged NT$1,155 ($35.0) and NT$190 ($5.8), respectively, which was equal to 64.5% and 10.6% of the total ED-associated cost. General ED medical expenditure increased with patient age; the increased cost ratio due to age was estimated at 8% per year (P < 0.001). Conclusions The frequency of major health problems diagnosed at ED visits varied by age: more complicated complaints and multiple diagnoses were more frequent in older patients. In Taiwan, the ED system remains overloaded, possibly because of the low cost of an ED visit. PMID:19164870

Emergency department visits of Syrian refugees and the cost of their healthcare.

PubMed

Gulacti, Umut; Lok, Ugur; Polat, Haci

2017-07-01

The aim of this study was to evaluate the demographic and clinical characteristics of Emergency Department (ED) visits made by Syrian refugees and to assess the cost of their healthcare. This retrospective study was conducted in adult Syrians who visited the ED of Adiyaman University Training and Research Hospital, Adiyaman Province, Turkey, between 01 January and 31 December 2015. We evaluated 10,529 Syrian refugees who visited the ED, of whom 9,842 were included in the study. The number of ED visits significantly increased in 2015 compared with 2010; the increase in the proportion of total ED visits was 8% (n = 11,275, dif: 8%, CI 95%: 7.9- 8.2, p < 0.001). Of this 8%, 6.5% were visits made by Syria refugees and the remaining 1.5% accounted for the visits made by other individuals. Upper respiratory tract infections (URTI) were the diseases most frequently presented (n = 4,656; 47.3%), and 68.5% of ED visits were inappropriate (n = 6,749). The median ED length of stay (LOS) of the Syrian refugees was significantly longer than that of the other individuals visiting the ED (p < 0.001). The total cost of the healthcare of the Syrian refugees who visited the ED was calculated as US$ 773,374.63. This study showed that Syrian refugees have increased the proportion of ED visits and the financial healthcare burden. The majority of ED visits made by Syrian refugees were inappropriate. In addition, their ED LOS was longer than that of other individuals making ED visits.

Pharmaceutical advertising in emergency departments.

PubMed

Marco, Catherine A

2004-04-01

Promotion of prescription drugs represents a growing source of pharmaceutical marketing expenditures. This study was undertaken to identify the frequency of items containing pharmaceutical advertising in clinical emergency departments (EDs). In this observational study, emergency physician on-site investigators quantified a variety of items containing pharmaceutical advertising present at specified representative times and days, in clinical EDs. Measurements were obtained by 65 on-site investigators, representing 22 states. Most EDs in this study were community EDs (87% community and 14% university or university affiliate), and most were in urban settings (50% urban, 38% suburban, and 13% rural). Investigators measured 42 items per ED (mean = 42; median = 31; interquartile range of 14-55) containing pharmaceutical advertising in the clinical area. The most commonly observed items included pens (mean 15 per ED; median 10), product brochures (mean 5; median 3), stethoscope labels (mean 4; median 2), drug samples (mean 3; median 0), books (mean 3.4), mugs (mean 2.4), and published literature (mean 3.1). EDs with a policy restricting pharmaceutical representatives in the ED had significantly fewer items containing pharmaceutical advertising (median 7.5; 95% CI = 0 to 27) than EDs without such a policy (median 35; 95% CI = 27 to 47, p = 0.005, nonparametric Wilcoxon two-sample test). There were no differences in quantities of pharmaceutical advertising for EDs in community compared with university settings (p = 0.5), rural compared with urban settings (p = 0.3), or annual ED volumes (p = 0.9). Numerous items containing pharmaceutical advertising are frequently observed in EDs. Policies restricting pharmaceutical representatives in the ED are associated with reduced pharmaceutical advertising.

Appropriate use of red blood cell transfusion in emergency departments: a study in five emergency departments

PubMed Central

Díaz, Manuel Quintana; Borobia, Alberto M.; García Erce, José A.; Maroun-Eid, Charbel; Fabra, Sara; Carcas, Antonio; Frías, Jesus; Muñoz, Manuel

2017-01-01

Background Transfusion of blood components continues to be an important therapeutic resource into the 21st century. Between 5 and 58% of transfusions carried out are estimated to be unnecessary. According to several studies, at least 20% of packed red blood cell transfusions (RBCT) are administered in hospital emergency departments (ED), but few data are available about the appropriateness of RBCT in this setting. This multicentre, cross-sectional observational study aims to assess the appropriateness of RBCT indications and transfused volumes in patients who attend ED. Materials and methods The study cohort is made up of consecutive consenting adult patients (≥18 years old) who received RBCT in ED over a 3-month period and for whom relevant clinical data were collected and analysed. Results Data from 908 RBCT episodes (2±1 units per transfused patient) were analysed. RBCT was considered appropriate in 21.4% (n=195), with significant differences according to RBCT indication (p<0.001), hospital level (p<0.001) and prescribing physician (p=0.002). Pre-transfusion haemoglobin level (Hb) negatively correlated with RBCT appropriateness (r=–0.616; p<0.01). Only 72.4% of appropriate RBCT had a post-transfusion Hb assessment (n=516). Of these, 45% were considered to be over-transfused (n=232), with significant differences according to RBCT indication (p=0.012) and prescribing physician (p=0.047). Overall, 584/1,433 (41%) of evaluable RBC units were unnecessarily transfused. Discussion The appropriateness of RBCT in ED is similar to other hospital departments, but the rate of over-transfusion was high. These data support the need for a reassessment after transfusion of each RBC unit before further units are prescribed. In view of these results, we recommend that physicians should be made more aware of the need to prescribe RBCT appropriately in order to reduce over-transfusion. PMID:27416566

Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan.

PubMed

Krishnan, Jerry A; Martin, Molly A; Lohff, Cortland; Mosnaim, Giselle S; Margellos-Anast, Helen; DeLisa, Julie A; McMahon, Kate; Erwin, Kim; Zun, Leslie S; Berbaum, Michael L; McDermott, Michael; Bracken, Nina E; Kumar, Rajesh; Margaret Paik, S; Nyenhuis, Sharmilee M; Ignoffo, Stacy; Press, Valerie G; Pittsenbarger, Zachary E; Thompson, Trevonne M

2017-06-01

Among children with asthma, black children are two to four times as likely to have an emergency department (ED) visit and die from asthma, respectively, compared to white children in the United States. Despite the availability of evidence-based asthma management guidelines, minority children are less likely than white children to receive or use effective options for asthma care. The CHICAGO Plan is a three-arm multi-center randomized pragmatic trial of children 5 to 11years old presenting to the ED with uncontrolled asthma that compares: [1] an ED-focused intervention to improve the quality of care on discharge to home, [2] the same ED-focused intervention together with a home-based community health worker (CHW)-led intervention, and [3] enhanced usual care. All children receive spacers for the metered dose inhaler and teaching about its use. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale and Satisfaction with Participation in Social Roles at 6months are the primary outcomes in children and in caregivers, respectively. Other patient-reported outcomes and indicators of healthcare utilization are assessed as secondary outcomes. Innovative features of the CHICAGO Plan include early and continuous engagement of children, caregivers, the Chicago Department of Public Health, and other stakeholders to inform the design and implementation of the study and a shared research infrastructure to coordinate study activities. The objective of this report is to describe the development of the CHICAGO Plan, including the methods and rationale for engaging stakeholders, the shared research infrastructure, and other features of the pragmatic clinical trial design. Published by Elsevier Inc.

Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan

PubMed Central

Krishnan, Jerry A.; Martin, Molly A.; Lohff, Cortland; Mosnaim, Giselle S.; Margellos-Anast, Helen; DeLisa, Julie A.; McMahon, Kate; Erwin, Kim; Zun, Leslie S.; Berbaum, Michael L.; McDermott, Michael; Bracken, Nina E.; Kumar, Rajesh; Paik, S. Margaret; Nyenhuis, Sharmilee M.; Ignoffo, Stacy; Press, Valerie G.; Pittsenbarger, Zachary E.; Thompson, Trevonne M.

2017-01-01

Among children with asthma, black children are two to four times as likely to have an emergency department (ED) visit and die from asthma, respectively, compared to white children in the United States. Despite the availability of evidence-based asthma management guidelines, minority children are less likely than white children to receive or use effective options for asthma care. The CHICAGO Plan is a three-arm multi-center randomized pragmatic trial of children 5 to 11 years old presenting to the ED with uncontrolled asthma that compares: (1) an ED-focused intervention to improve the quality of care on discharge to home, (2) the same ED-focused intervention together with a home-based community health worker (CHW)-led intervention, and (3) enhanced usual care. All children receive spacers for the metered dose inhaler and teaching about its use. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale and Satisfaction with Participation in Social Roles at 6 months are the primary outcomes in children and in caregivers, respectively. Other patient-reported outcomes and indicators of healthcare utilization are assessed as secondary outcomes. Innovative features of the CHICAGO Plan include early and continuous engagement of children, caregivers, the Chicago Department of Public Health, and other stakeholders to inform the design and implementation of the study and a shared research infrastructure to coordinate study activities. The objective of this report is to describe the development of the CHICAGO Plan, including the methods and rationale for engaging stakeholders, the shared research infrastructure, and other features of the pragmatic clinical trial design. PMID:28366780

Chaotic genetic algorithm and Adaboost ensemble metamodeling approach for optimum resource planning in emergency departments.

PubMed

Yousefi, Milad; Yousefi, Moslem; Ferreira, Ricardo Poley Martins; Kim, Joong Hoon; Fogliatto, Flavio S

2018-01-01

Long length of stay and overcrowding in emergency departments (EDs) are two common problems in the healthcare industry. To decrease the average length of stay (ALOS) and tackle overcrowding, numerous resources, including the number of doctors, nurses and receptionists need to be adjusted, while a number of constraints are to be considered at the same time. In this study, an efficient method based on agent-based simulation, machine learning and the genetic algorithm (GA) is presented to determine optimum resource allocation in emergency departments. GA can effectively explore the entire domain of all 19 variables and identify the optimum resource allocation through evolution and mimicking the survival of the fittest concept. A chaotic mutation operator is used in this study to boost GA performance. A model of the system needs to be run several thousand times through the GA evolution process to evaluate each solution, hence the process is computationally expensive. To overcome this drawback, a robust metamodel is initially constructed based on an agent-based system simulation. The simulation exhibits ED performance with various resource allocations and trains the metamodel. The metamodel is created with an ensemble of the adaptive neuro-fuzzy inference system (ANFIS), feedforward neural network (FFNN) and recurrent neural network (RNN) using the adaptive boosting (AdaBoost) ensemble algorithm. The proposed GA-based optimization approach is tested in a public ED, and it is shown to decrease the ALOS in this ED case study by 14%. Additionally, the proposed metamodel shows a 26.6% improvement compared to the average results of ANFIS, FFNN and RNN in terms of mean absolute percentage error (MAPE). Copyright © 2017 Elsevier B.V. All rights reserved.

A Comparison of Medication Histories Obtained by a Pharmacy Technician Versus Nurses in the Emergency Department

PubMed Central

Markovic, Marija; Mathis, A. Scott; Ghin, Hoytin Lee; Gardiner, Michelle; Fahim, Germin

2017-01-01

Purpose: To compare the medication history error rate of the emergency department (ED) pharmacy technician with that of nursing staff and to describe the workflow environment. Methods: Fifty medication histories performed by an ED nurse followed by the pharmacy technician were evaluated for discrepancies (RN-PT group). A separate 50 medication histories performed by the pharmacy technician and observed with necessary intervention by the ED pharmacist were evaluated for discrepancies (PT-RPh group). Discrepancies were totaled and categorized by type of error and therapeutic category of the medication. The workflow description was obtained by observation and staff interview. Results: A total of 474 medications in the RN-PT group and 521 in the PT-RPh group were evaluated. Nurses made at least one error in all 50 medication histories (100%), compared to 18 medication histories for the pharmacy technician (36%). In the RN-PT group, 408 medications had at least one error, corresponding to an accuracy rate of 14% for nurses. In the PT-RPh group, 30 medications had an error, corresponding to an accuracy rate of 94.4% for the pharmacy technician (P < 0.0001). The most common error made by nurses was a missing medication (n = 109), while the most common error for the pharmacy technician was a wrong medication frequency (n = 19). The most common drug class with documented errors for ED nurses was cardiovascular medications (n = 100), while the pharmacy technician made the most errors in gastrointestinal medications (n = 11). Conclusion: Medication histories obtained by the pharmacy technician were significantly more accurate than those obtained by nurses in the emergency department. PMID:28090164

Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians' perspectives.

PubMed

Zafar, Waleed

2015-04-01

Emergency departments (ED) are often stressful environments posing unique ethical challenges-issues that primarily raise moral rather than clinical concerns-in patient care. Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work. Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide. The aim of this study was to explore the perspectives of EM residents and physicians regarding the common ethical challenges they face during patient care in one of only two academic EM departments in Pakistan. These challenges could then be addressed in residents' training and departmental practice guidelines. A qualitative research design was employed and in-depth interviews were conducted with ED physicians. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. Transcripts were analysed using grounded theory methods. Thirteen participants were interviewed and they described four key challenges: how to provide highest quality care with limited resources; how to be truthful to patients; what to do when it is not possible to provide or continue treatment to patients; and when (and when not) to offer life-sustaining treatments. Participants' accounts provided important insights into how physicians tried to resolve these challenges in the 'local moral world' of an ED in Pakistan. The study highlights the need for developing systematic and contextually appropriate mechanisms for resolving common ethical challenges in the EDs and for training residents in moral problem solving. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Children's mental health emergencies-part 1: challenges in care: definition of the problem, barriers to care, screening, advocacy, and resources.

PubMed

Baren, Jill M; Mace, Sharon E; Hendry, Phyllis L; Dietrich, Ann M; Grupp-Phelan, Jacqueline; Mullin, Jacqueline

2008-06-01

At a time when there has been a reduction in mental health resources nationwide, the incidence of mental health disorders in children has seen a dramatic increase for many reasons. A review of the literature was done to identify the epidemiology, barriers to care, useful emergency department (ED) screening methods, and resources regarding pediatric mental health disorders in the ED. Although there are many challenges to the provision of care for children with mental health emergencies, some resources are available. Furthermore, ED screening and intervention may be effective in improving patient outcomes. Collaborative efforts with multidisciplinary services can create a continuum of care, promote better identification of children and adolescents with mental health disorders, and promote early recognition and intervention, which are key to effective referral and treatment.

Health Information Technology Adoption in the Emergency Department.

PubMed

Selck, Frederic W; Decker, Sandra L

2016-02-01

To describe the trend in health information technology (IT) systems adoption in hospital emergency departments (EDs) and its effect on ED efficiency and resource use. 2007-2010 National Hospital Ambulatory Medical Care Survey - ED Component. We assessed changes in the percent of visits to EDs with health IT capability and the estimated effect on waiting time to see a provider, visit length, and resource use. The percent of ED visits that took place in an ED with at least a basic health IT or an advanced IT system increased from 25.2 and 3.1 percent in 2007 to 69.1 and 30.6 percent in 2010, respectively (p < .05). Controlling for ED fixed effects, waiting times were reduced by 6.0 minutes in advanced IT-equipped EDs (p < .05), and the number of tests ordered increased by 9 percent (p < .01). In models using a 1-year lag, advanced systems also showed an increase in the number of medications and images ordered per visit. Almost a third of visits now occur in EDs with advanced IT capability. While advanced IT adoption may decrease wait times, resource use during ED visits may also increase depending on how long the system has been in place. We were not able to determine if these changes indicated more appropriate care. © Health Research and Educational Trust.

Barriers and Facilitators to Implementing the HEADS-ED: A Rapid Screening Tool for Pediatric Patients in Emergency Departments.

PubMed

MacWilliams, Kate; Curran, Janet; Racek, Jakub; Cloutier, Paula; Cappelli, Mario

2017-12-01

This study sought to identify barriers and facilitators to the implementation of the HEADS-ED, a screening tool appropriate for use in the emergency department (ED) that facilitates standardized assessments, discharge planning, charting, and linking pediatric mental health patients to appropriate community resources. A qualitative theory-based design was used to identify barriers and facilitators to implementing the HEADS-ED tool. Focus groups were conducted with participants recruited from 6 different ED settings across 2 provinces (Ontario and Nova Scotia). The Theoretical Domains Framework was used as a conceptual framework to guide data collection and to identify themes from focus group discussions. The following themes spanning 12 domains were identified as reflective of participants' beliefs about the barriers and facilitators to implementing the HEADS-ED tool: knowledge, skills, beliefs about capabilities, social professional role and identity, optimism, beliefs about consequences, reinforcement, environmental context and resources, social influences, emotion, behavioral regulation and memory, and attention and decision process. The HEADS-ED has the potential to address the need for better discharge planning, complete charting, and standardized assessments for the increasing population of pediatric mental health patients who present to EDs. This study has identified potential barriers and facilitators, which should be considered when developing an implementation plan for adopting the HEADS-ED tool into practice within EDs.

Managing Law Enforcement Presence in the Emergency Department: Highlighting the Need for New Policy Recommendations.

PubMed

Tahouni, Morsal R; Liscord, Emory; Mowafi, Hani

2015-10-01

The Emergency Department (ED) is the portal of entry to the health care system for a large percentage of patients. This is especially true for victims and perpetrators of interpersonal violence. Frequently, law enforcement personnel (LEP) accompany patients to the ED or seek access to patients during their ED stay or subsequent hospitalization. The time-sensitive nature of both emergency care and criminal investigation motivates both health care personnel and LEP, and can lead to potential conflicts of interest regarding access to patients in the ED. We hope to examine the relationship among patients, providers, and LEP in the ED, and the potential impact these interactions have on patient care. This article presents a review of the relevant literature and policy consideration as well as provides guidance on the development of such policies for EDs. Hospitals, EDs, and trauma resuscitation rooms are highly regulated environments, but LEP largely fall outside the ethical and institutional guidelines of health care institutions. Many potential areas of conflict exist when LEP are present in the ED that can have detrimental effects on patient care, provider liability, and LEP efficacy. Patients' perceptions of collaboration between ED personnel and LEP can compromise emergency patient care. There is a need for hospital policies to govern interactions among patients, emergency health care providers, and LEP in the ED. Copyright © 2015 Elsevier Inc. All rights reserved.

Implementing Data Definition Consistency for Emergency Department Operations Benchmarking and Research.

PubMed

Yiadom, Maame Yaa A B; Scheulen, James; McWade, Conor M; Augustine, James J

2016-07-01

The objective was to obtain a commitment to adopt a common set of definitions for emergency department (ED) demographic, clinical process, and performance metrics among the ED Benchmarking Alliance (EDBA), ED Operations Study Group (EDOSG), and Academy of Academic Administrators of Emergency Medicine (AAAEM) by 2017. A retrospective cross-sectional analysis of available data from three ED operations benchmarking organizations supported a negotiation to use a set of common metrics with identical definitions. During a 1.5-day meeting-structured according to social change theories of information exchange, self-interest, and interdependence-common definitions were identified and negotiated using the EDBA's published definitions as a start for discussion. Methods of process analysis theory were used in the 8 weeks following the meeting to achieve official consensus on definitions. These two lists were submitted to the organizations' leadership for implementation approval. A total of 374 unique measures were identified, of which 57 (15%) were shared by at least two organizations. Fourteen (4%) were common to all three organizations. In addition to agreement on definitions for the 14 measures used by all three organizations, agreement was reached on universal definitions for 17 of the 57 measures shared by at least two organizations. The negotiation outcome was a list of 31 measures with universal definitions to be adopted by each organization by 2017. The use of negotiation, social change, and process analysis theories achieved the adoption of universal definitions among the EDBA, EDOSG, and AAAEM. This will impact performance benchmarking for nearly half of US EDs. It initiates a formal commitment to utilize standardized metrics, and it transitions consistency in reporting ED operations metrics from consensus to implementation. This work advances our ability to more accurately characterize variation in ED care delivery models, resource utilization, and performance. In addition, it permits future aggregation of these three data sets, thus facilitating the creation of more robust ED operations research data sets unified by a universal language. Negotiation, social change, and process analysis principles can be used to advance the adoption of additional definitions. © 2016 by the Society for Academic Emergency Medicine.

An automated, broad-based, near real-time public health surveillance system using presentations to hospital Emergency Departments in New South Wales, Australia.

PubMed

Muscatello, David J; Churches, Tim; Kaldor, Jill; Zheng, Wei; Chiu, Clayton; Correll, Patricia; Jorm, Louisa

2005-12-22

In a climate of concern over bioterrorism threats and emergent diseases, public health authorities are trialling more timely surveillance systems. The 2003 Rugby World Cup (RWC) provided an opportunity to test the viability of a near real-time syndromic surveillance system in metropolitan Sydney, Australia. We describe the development and early results of this largely automated system that used data routinely collected in Emergency Departments (EDs). Twelve of 49 EDs in the Sydney metropolitan area automatically transmitted surveillance data from their existing information systems to a central database in near real-time. Information captured for each ED visit included patient demographic details, presenting problem and nursing assessment entered as free-text at triage time, physician-assigned provisional diagnosis codes, and status at departure from the ED. Both diagnoses from the EDs and triage text were used to assign syndrome categories. The text information was automatically classified into one or more of 26 syndrome categories using automated "naïve Bayes" text categorisation techniques. Automated processes were used to analyse both diagnosis and free text-based syndrome data and to produce web-based statistical summaries for daily review. An adjusted cumulative sum (cusum) was used to assess the statistical significance of trends. During the RWC the system did not identify any major public health threats associated with the tournament, mass gatherings or the influx of visitors. This was consistent with evidence from other sources, although two known outbreaks were already in progress before the tournament. Limited baseline in early monitoring prevented the system from automatically identifying these ongoing outbreaks. Data capture was invisible to clinical staff in EDs and did not add to their workload. We have demonstrated the feasibility and potential utility of syndromic surveillance using routinely collected data from ED information systems. Key features of our system are its nil impact on clinical staff, and its use of statistical methods to assign syndrome categories based on clinical free text information. The system is ongoing, and has expanded to cover 30 EDs. Results of formal evaluations of both the technical efficiency and the public health impacts of the system will be described subsequently.

Improvement in self-reported confidence in nurses’ professional skills in the emergency department

PubMed Central

2013-01-01

Background The aim of this study was to assess nurses’ self-reported confidence in their professional skills before and after an extensive Emergency Department (ED) reform in Kanta-Häme Central Hospital. Methods Emergency nurses participated in transitional training commencing two years before the establishment of the new organization in 2007. Training was followed by weekly practical educational sessions in the new ED. During this process nurses improved their transition skills, defined house rules for the new clinic and improved their knowledge of new technology and instruments. The main processes involving critically ill ED patients were described and modelled with an electronic flow chart software. During the transitional training nurses compiled lists of practical skills and measures needed in the ED. These were updated after feedback from physicians in primary and secondary care and head physicians in Kanta-Häme Central Hospital. The final 189-item list comprised 15 different categories, each containing from 4 to 35 items. Based on the work described above, a questionnaire was developed to reflect ED nurses’ skills in clinical measures but also to estimate the need for professional education and practical training. Nurses working in the ED were asked to fill the questionnaire in January 2007 (response rate 97%) and in January 2011 (response rate 98%). Results Nurses’ self-reported confidence in their professional skills improved significally in eight classes out of fifteen. These classes were cannulations, urinary catheterizations, patient monitoring, cardiac patients, equipment, triage and nurse practising, psychiatric patients as well as infection risk. Best results were noted in urinary catheterizations, patient monitoring and infection risk. When studying the group of nurses participating in both surveys in 2007 and 2011, improvements were observed in all fifteen categories. All but two of these changes were significant (p<0.05). Conclusions During an extensive reform of emergency services, we noted a significant improvement in the professional skills of nurses. This improvement was especially consistent among nurses working in the ED during the whole transition process. Nurses’ education and training program in the ED may be successfully put into practice when based on co-operation between nurses and physicians dedicated to emergency services. PMID:23497683

The stethoscope in the Emergency Department: a vector of infection?

PubMed Central

Núñez, S.; Moreno, A.; Green, K.; Villar, J.

2000-01-01

The purposes of this study were to determine whether microorganisms can be isolated from the membranes of stethoscopes used by clinicians and nurses, and to analyse whether or not the degree of bacterial colonization could be reduced with different cleaning methods. We designed a transversal before-after study in which 122 stethoscopes were examined. Coagulase negative staphylococci (which are also potentially pathogenic microorganisms) were isolated together with 13 other potentially pathogenic microorganisms, including S. aureus, Acinetobacter sp. and Enterobacter agglomerans. The most effective antiseptic was propyl alcohol. Analysis of the cleaning habits of the Emergency Department (ED) staff, showed that 45% cleaned the stethoscope annually or never. The isolation of potentially pathogenic microorganisms suggests that the stethoscope must be considered as a potential vector of infection not only in the ED but also in other hospital wards and out-patient clinics. PMID:10813148

Characteristics of COPD Patients Using United States Emergency Care or Hospitalization

PubMed Central

Kumbhare, Suchit D.; Beiko, Tatsiana; Wilcox, Susan R.; Strange, Charlie

2016-01-01

Rationale: Several chronic obstructive pulmonary disease (COPD) studies have evaluated risk factors for emergency department (ED) visits or hospitalizations, and found insufficient data available about social and demographic factors that drive these behaviors. This U.S. study was designed to describe the characteristics of COPD patients with ED visits or a hospitalization and to investigate how often common COPD comorbidities are present in these individuals. Methods: Data for 7180 COPD patients regarding demographic factors, comorbidities, smoking status, and ED visits or hospitalization was obtained from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. Logistic regression analysis was used to adjust demographic factors and smoking status to model the correlation between patients with ED visits or hospitalizations and morbidities generating odds ratios (OR) and confidence intervals (CI). Results: Among diagnosed COPD patients in the BRFSS, 16.5% had ED visits or hospitalization in the previous year. These individuals were younger, had a lower socio-economic status (lower education, lower income, and more often unemployed) and 23.4% of the individuals could not visit a doctor because of the financial difficulties compared to 16.7% who had no visit (p<0.0001 for all comparisons). The prevalence of comorbidities was higher in those with ED visits or hospitalization compared to those without. Conclusion: In a population representative of COPD patients, lower socio-economic status and higher comorbidities are associated with ED visits or hospitalization. Studies are needed to further elucidate the complex relationship between COPD, comorbidities, and ED visits or hospitalization. PMID:28848878

76 FR 39394 - Notice of Proposed Information Collection Requests

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-06

... within the U.S. Department of Education (ED) has contracted with Decision Information Resources, Inc. and Mathematica Policy Research, Inc. to assess the procedures for collecting and reporting program performance and evaluation data for eleven ED grant programs. These audits and assessments will provide ED with...

Who breaches the four-hour emergency department wait time target? A retrospective analysis of 374,000 emergency department attendances between 2008 and 2013 at a type 1 emergency department in England.

PubMed

Bobrovitz, Niklas; Lasserson, Daniel S; Briggs, Adam D M

2017-11-02

The four-hour target is a key hospital emergency department performance indicator in England and one that drives the physical and organisational design of the ED. Some studies have identified time of presentation as a key factor affecting waiting times. Few studies have investigated other determinants of breaching the four-hour target. Therefore, our objective was to describe patterns of emergency department breaches of the four-hour wait time target and identify patients at highest risk of breaching. This was a retrospective cohort study of a large type 1 Emergency department at an NHS teaching hospital in Oxford, England. We analysed anonymised individual level patient data for 378,873 emergency department attendances, representing all attendances between April 2008 and April 2013. We examined patient characteristics and emergency department presentation circumstances associated with the highest likelihood of breaching the four-hour wait time target. We used 374,459 complete cases for analysis. In total, 8.3% of all patients breached the four-hour wait time target. The main determinants of patients breaching the four-hour wait time target were hour of arrival to the ED, day of the week, patient age, ED referral source, and the types of investigations patients receive (p < 0.01 for all associations). Patients most likely to breach the four-hour target were older, presented at night, presented on Monday, received multiple types of investigation in the emergency department, and were not self-referred (p < 0.01 for all associations). Patients attending from October to February had a higher odds of breaching compared to those attending from March to September (OR 1.63, 95% CI 1.59 to 1.66). There are a number of independent patient and circumstantial factors associated with the probability of breaching the four-hour ED wait time target including patient age, ED referral source, the types of investigations patients receive, as well as the hour, day, and month of arrival to the ED. Efforts to reduce the number of breaches could explore late-evening/overnight staffing, access to diagnostic tests, rapid discharge facilities, and early assessment and input on diagnostic and management strategies from a senior practitioner.

Frequent use of emergency departments by older people: a comparative cohort study of characteristics and outcomes.

PubMed

Street, Maryann; Berry, Debra; Considine, Julie

2018-04-12

To characterise older people who frequently use emergency departments (EDs) and compare patient outcomes with older non-frequent ED attenders. Retrospective comparative cohort study. Logistic regression modelling of patient characteristics and health service usage, comparing older frequent ED attenders (≥4 ED attendances in 12 months) to non-frequent ED attenders. Three Australian public hospital EDs, with a total of 143 327 emergency attendances in the 12 months. People aged ≥65 years attending the ED in financial year 2013/2014. The primary outcome was frequent ED use; secondary outcomes were ED length of stay, discharge destination from ED, hospital length of stay, re-presentation within 48 h, hospital readmission within 30 days and in-hospital mortality. Five percent of older people were frequent attenders (n = 1046/21 073), accounting for 16.9% (n = 5469/32 282) of all attendances by older people. Frequent ED attenders were more likely to be male, aged 75-84 years, arrive by ambulance and have a diagnosis relating to chronic illness. Frequent attenders stayed 0.4 h longer in ED (P < 0.001), were more likely to be admitted to hospital (69.2% vs 67.2%; P = 0.004), and had a 1 day longer hospital stay (P < 0.001). In-hospital mortality for older frequent ED attenders was double that of non-frequent attenders (7.0% vs 3.2%, P < 0.001) over 12 months. Older frequent ED attenders had more chronic disease and care needs requiring hospital admission than non-frequent attenders. A new approach to care planning and coordination is recommended, to optimise the patient journey and improve outcomes.

The association of weather on pediatric emergency department visits in Changwon, Korea (2005-2014).

PubMed

Lee, Hae Jeong; Jin, Mi Hyeon; Lee, Jun Hwa

2016-05-01

It is widely believed that patients are less likely to visit hospitals during bad weather. We hypothesized that weather and emergency department (ED) visits are associated. Thus, we investigated the association between pediatric ED visits and weather, and sought to determine whether admissions to the ED are affected by meteorological factors. We retrospectively analyzed all 87,242 emergency visits to Samsung Changwon Hospital by pediatric patients under 19years of age from January 2005 to December 2014. ED visits were categorized by disease. We used Poisson regression and generalized linear model to examine the relationships between current weather and ED visits. Additionally a distributed lag non-linear model was used to investigate the effect of weather on ED visits. During this 10-year study period, the average temperature and diurnal temperature range (DTR) were 14.7°C and 8.2°C, respectively. There were 1,145days of rain or snow (31.4%) during the 3,652-day study period. The volume of ED visits decreased on days of rain or snow. Additionally ED visits increased 2days after rainy or snowy days. The volume of ED visits increased 1.013 times with every 1°C increase in DTR. The volume of ED visits by patients with trauma, digestive diseases, and respiratory diseases increased when DTR was over 10°C. As rainfall increased to over 25mm, the ward admission rate (23.8%, p=0.018) of ED patients increased significantly. The volume of ED visits decreased on days of rain or snow and the ED visits were increased 2days after rainy or snowy days. The volume of ED visits increased for every 1°C increase in DTR. Copyright © 2016. Published by Elsevier B.V.

A multicenter observational study of US adults with acute asthma: who are the frequent users of the emergency department?

PubMed

Hasegawa, Kohei; Sullivan, Ashley F; Tovar Hirashima, Eva; Gaeta, Theodore J; Fee, Christopher; Turner, Stuart J; Massaro, Susan; Camargo, Carlos A

2014-01-01

Despite the substantial burden of asthma-related emergency department (ED) visits, there have been no recent multicenter efforts to characterize this high-risk population. We aimed to characterize patients with asthma according to their frequency of ED visits and to identify factors associated with frequent ED visits. A multicenter chart review study of 48 EDs across 23 US states. We identified ED patients ages 18 to 54 years with acute asthma during 2011 and 2012. Primary outcome was frequency of ED visits for acute asthma in the past year, excluding the index ED visit. Of the 1890 enrolled patients, 863 patients (46%) had 1 or more (frequent) ED visits in the past year. Specifically, 28% had 1 to 2 visits, 11% had 3 to 5 visits, and 7% had 6 or more visits. Among frequent ED users, guideline-recommended management was suboptimal. For example, of patients with 6 or more ED visits, 85% lacked evidence of prior evaluation by an asthma specialist, and 43% were not treated with inhaled corticosteroids. In a multivariable model, significant predictors of frequent ED visits were public insurance, no insurance, and markers for chronic asthma severity (all P < .05). Stronger associations were found among those with a higher frequency of asthma-related ED visits (eg, 6 or more ED visits). This multicenter study of US adults with acute asthma demonstrated many frequent ED users and suboptimal preventive management in this high-risk population. Future reductions in asthma morbidity and associated health care utilization will require continued efforts to bridge these major gaps in asthma care. Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Patient nonadherence to filling discharge medication prescriptions from the emergency department: Barriers and clinical implications.

PubMed

Farris, Brian; Shakowski, Courtney; Mueller, Scott W; Phong, Suzanne; Kiser, Tyree H; Jacknin, Gabrielle

2018-03-01

Barriers to and clinical implications of patient nonadherence to filling discharge medication prescriptions from the emergency department (ED) were evaluated. This was a retrospective, observational analysis of patients discharged from the ED from April 2013 through May 2015 with medication prescriptions. Patients age 18-89 years who were seen in the ED and did not retrieve discharge medication prescriptions from the onsite, 24-hour ED discharge pharmacy were included in this study. Patients who did not pick up prescriptions were called and asked about barriers to prescription filling. These charts were then retrospectively reviewed and categorized. The primary study outcome was the frequency of nonadherence to filling discharge medications prescribed during the ED visit at the ED outpatient pharmacy. Secondary outcomes included identifying barriers to medication adherence, the rate of return ED visits within 30 days of ED discharge, and the rate of 30-day hospital admissions. Associations between patient and medication variables and the rates of return ED visits within 30 days of discharge and 30-day hospital admissions were analyzed. Of the 4,444 patients discharged from the ED with a prescription to be filled at the satellite pharmacy, 510 were nonadherent. Of these patients, 505 had complete chart information available for evaluation. A large proportion of nonadherent patients revisited the ED within 30 days of ED discharge. Multivariate logistic regression found payer class, ethnicity, and sex were independently associated with return ED visits. The majority of patients who received a prescription during an ED visit filled their discharge medications. Sex, ethnicity, and payer class were independently associated with nonadherence. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Working Together to Connect Care: a metropolitan tertiary emergency department and community care program.

PubMed

Harcourt, Debra; McDonald, Clancy; Cartlidge-Gann, Leonie; Burke, John

2017-03-02

Objective Frequent attendance by people to an emergency department (ED) is a global concern. A collaborative partnership between an ED and the primary and community healthcare sectors has the potential to improve care for the person who frequently attends the ED. The aims of the Working Together to Connect Care program are to decrease the number of presentations by providing focused community support and to integrate all healthcare services with the goal of achieving positive, patient-centred and directed outcomes. Methods A retrospective analysis of ED data for 2014 and 2015 was used to ascertain the characteristics of the potential program cohort. The definition used to identify a 'frequent attendee' was more than four presentations to an ED in 1 month. This analysis was used to develop the processes now known as the Working Together to Connect Care program. This program includes participant identification by applying the definition, flagging of potential participants in the ED IT system, case review and referral to community services by ED staff, case conferencing facilitated within the ED and individualised, patient centred case management provided by government and non-government community services. Results Two months after the date of commencement of the Working Together to Connect Care program there are 31 active participants in the program: 10 are on the Mental Health pathway, and one is on the No Consent pathway. On average there are three people recruited to the program every week. The establishment of a new program for supporting frequent attendees of an ED has had its challenges. Identifying systems that support people in their community has been an early positive outcome of this project. Conclusion It is expected that data regarding the number of ED presentations, potential fiscal savings and client outcomes will be available in 2017. What is known about the topic? Frequent attendance at EDs is a global issue and although the number of 'super users' is small compared with non-frequent users, the presentations are high. People in the frequent attendee group will often seek care from multiple EDs for, in the main, mental health issues and substance abuse. Furthermore, frequent ED users are vulnerable and experience higher mortality, hospital admissions and out-patient visits than non-frequent users. Aggressive and assertive outreach, intense coordination of services by integrated care teams, and the need for non-medical resources, such as supportive housing, have positive outcomes for this group of people. What does this paper add? This study uses international research findings in an Australian setting to provide a testing of the generalisability of an assertive and collaborative ED and community case management approach for supporting people who frequent a metropolitan ED. What are the implications for practitioners? The chronicling of a process undertaken to affect change in a health care setting supports practitioners when developing processes for this cohort across different ED contexts.

Drinking Water Turbidity and Emergency Department Visits for Gastrointestinal Illness in New York City, 2002-2009

PubMed Central

Hsieh, Jennifer L.; Nguyen, Trang Quyen; Matte, Thomas; Ito, Kazuhiko

2015-01-01

Background Studies have examined whether there is a relationship between drinking water turbidity and gastrointestinal (GI) illness indicators, and results have varied possibly due to differences in methods and study settings. Objectives As part of a water security improvement project we conducted a retrospective analysis of the relationship between drinking water turbidity and GI illness in New York City (NYC) based on emergency department chief complaint syndromic data that are available in near-real-time. Methods We used a Poisson time-series model to estimate the relationship of turbidity measured at distribution system and source water sites to diarrhea emergency department (ED) visits in NYC during 2002-2009. The analysis assessed age groups and was stratified by season and adjusted for sub-seasonal temporal trends, year-to-year variation, ambient temperature, day-of-week, and holidays. Results Seasonal variation unrelated to turbidity dominated (~90% deviance) the variation of daily diarrhea ED visits, with an additional 0.4% deviance explained with turbidity. Small yet significant multi-day lagged associations were found between NYC turbidity and diarrhea ED visits in the spring only, with approximately 5% excess risk per inter-quartile-range of NYC turbidity peaking at a 6 day lag. This association was strongest among those aged 0-4 years and was explained by the variation in source water turbidity. Conclusions Integrated analysis of turbidity and syndromic surveillance data, as part of overall drinking water surveillance, may be useful for enhanced situational awareness of possible risk factors that can contribute to GI illness. Elucidating the causes of turbidity-GI illness associations including seasonal and regional variations would be necessary to further inform surveillance needs. PMID:25919375

Developing Syndromic Surveillance to Monitor and Respond to Adverse Health Events Related to Psychoactive Substance Use: Methods and Applications.

PubMed

Nolan, Michelle L; Kunins, Hillary V; Lall, Ramona; Paone, Denise

Recent increases in drug overdose deaths, both in New York City and nationally, highlight the need for timely data on psychoactive drug-related morbidity. We developed drug syndrome definitions for syndromic surveillance to monitor drug-related emergency department (ED) visits in real time. We used 2012 archived syndromic surveillance data from New York City hospitals to develop definitions for psychoactive drug-related syndromes. The dataset contained ED visit-level information that included patients' chief complaints, dates of visits, ZIP codes of residence, discharge diagnoses, and dispositions. After manually reviewing chief complaints, we developed a classification scheme comprising 3 categories (overdose, drug mention, and drug abuse/misuse), which we used to define 25 psychoactive drug syndromes. From July 2013 through December 2015, the New York City Department of Health and Mental Hygiene performed daily syndromic surveillance of psychoactive drug-related ED visits using the 25 syndrome definitions. Syndromic surveillance triggered 4 public health investigations, supported 8 other public health investigations that had been triggered by other mechanisms, and resulted in the identification of 5 psychoactive drug-related outbreaks. Syndromic surveillance also identified a substantial increase in synthetic cannabinoid-related visits (from an average of 3 per week in January 2014 to >300 per week in July 2015) and an increase in heroin overdose visits (from 80 to 171 in the first 3 quarters of 2012 and 2014, respectively) in a single neighborhood. Syndromic surveillance using these novel definitions enabled monitoring of trends in psychoactive drug-related morbidity, initiation and support of public health investigations, and targeting of interventions. Health departments can refine these definitions for their jurisdictions using the described methods and integrate them into existing syndromic surveillance systems.

Overcrowding in emergency departments: A review of strategies to decrease future challenges.

PubMed

Yarmohammadian, Mohammad H; Rezaei, Fatemeh; Haghshenas, Abbas; Tavakoli, Nahid

2017-01-01

Emergency departments (EDs) are the most challenging ward with respect to patient delay. The goal of this study is to present strategies that have proven to reduce delay and overcrowding in EDs. In this review article, initial electronic database search resulted in a total of 1006 articles. Thirty articles were included after reviewing full texts. Inclusion criteria were assessments of real patient flows and implementing strategies inside the hospitals. In this study, we discussed strategies of team triage, point-of-care testing, ideal ED patient journey models, streaming, and fast track. Patients might be directed to different streaming channels depending on clinical status and required practitioners. The most comprehensive strategy is ideal ED patient journey models, in which ten interrelated substrategies are provided. ED leaders should apply strategies that provide a continuous care process without deeply depending on external services.

A proposed simulation optimization model framework for emergency department problems in public hospital

NASA Astrophysics Data System (ADS)

Ibrahim, Ireen Munira; Liong, Choong-Yeun; Bakar, Sakhinah Abu; Ahmad, Norazura; Najmuddin, Ahmad Farid

2015-12-01

The Emergency Department (ED) is a very complex system with limited resources to support increase in demand. ED services are considered as good quality if they can meet the patient's expectation. Long waiting times and length of stay is always the main problem faced by the management. The management of ED should give greater emphasis on their capacity of resources in order to increase the quality of services, which conforms to patient satisfaction. This paper is a review of work in progress of a study being conducted in a government hospital in Selangor, Malaysia. This paper proposed a simulation optimization model framework which is used to study ED operations and problems as well as to find an optimal solution to the problems. The integration of simulation and optimization is hoped can assist management in decision making process regarding their resource capacity planning in order to improve current and future ED operations.

Tricyclic antidepressant overdose: emergency department findings as predictors of clinical course.

PubMed

Foulke, G E; Albertson, T E; Walby, W F

1986-11-01

There is controversy regarding the appropriate utilization of health care resources in the management of tricyclic antidepressant overdosage. Antidepressant overdose patients presenting to the emergency department (ED) are routinely admitted to intensive care units, but only a small proportion develop cardiac arrhythmias or other complications requiring such an environment. The authors reviewed the findings in 165 patients presenting to an ED with antidepressant overdose. They found that major manifestations of toxicity on ED evaluation (altered mental status, seizures, arrhythmias, and conduction defects) were commonly associated with a complicated hospital course. Patients with the isolated findings of sinus tachycardia or QTc prolongation had no complications. No patient experienced a serious toxic event without major evidence of toxicity on ED evaluation and continued evidence of toxicity during the hospital course. These data support the concept that proper ED evaluation can identify a large body of patients with trivial ingestions who may not require hospital observation.

Work-related knee injuries treated in US emergency departments.

PubMed

Chen, Zhiqiang; Chakrabarty, Sangita; Levine, Robert S; Aliyu, Muktar H; Ding, Tan; Jackson, Larry L

2013-09-01

To characterize work-related knee injuries treated in US emergency departments (EDs). We characterized work-related knee injuries treated in EDs in 2007 and examined trends from 1998 to 2007 by using the National Electronic Injury Surveillance System-occupational supplement. In 2007, 184,300 (± 54,000; 95% confidence interval) occupational knee injuries were treated in US EDs, accounting for 5% of the 3.4 (± 0.9) million ED-treated occupational injuries. The ED-treated knee injury rate was 13 (± 4) injuries per 10,000 full-time equivalent workers. Younger workers and older female workers had high rates. Strains/sprains and contusions/abrasions were common-frequently resulting from falls and bodily reaction/overexertion events. Knee injury rates declined from 1998 through 2007. Knee injury prevention should emphasize reducing falls and bodily reaction/overexertion events, particularly among all youth and older women.

Advertising Emergency Department Wait Times

PubMed Central

Weiner, Scott G.

2013-01-01

Advertising emergency department (ED) wait times has become a common practice in the United States. Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED. Opponents worry about the risk to the public health that arises from a patient with an emergent condition self-triaging to a further hospital, problems with inaccuracy and lack of standard definition of the reported time, and directing lower acuity patients to the higher cost ED setting instead to primary care. Three sample cases demonstrating the pitfalls of advertising ED wait times are discussed. Given the lack of rigorous evidence supporting the practice and potential adverse effects to the public health, caution about its use is advised. PMID:23599836

78 FR 61347 - Agency Information Collection Activities; Submission to the Office of Management and Budget for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-03

... DEPARTMENT OF EDUCATION [Docket No.: ED-2013-ICCD-0099] Agency Information Collection Activities... Education (ED). ACTION: Notice. SUMMARY: In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C... Clearance Division, U.S. Department of Education, 400 Maryland Avenue SW., LBJ, Room 2E103,Washington, DC...

Individual-Level and Socio-Structural Characteristics of Violence: An Emergency Department Study

ERIC Educational Resources Information Center

Boyle, Douglas J.; Hassett-Walker, Constance

2008-01-01

In this article, the authors present a data collection system to provide information about assault-related injuries within Newark, New Jersey. In 2001, Emergency Department (ED) staff at the six hospitals providing emergency medical care within the city collected data on all assault-related ED visits. Individual-level (n = 1,204) and…

Epidemiology of Eye-Related Emergency Department Visits.

PubMed

Channa, Roomasa; Zafar, Syed Nabeel; Canner, Joseph K; Haring, R Sterling; Schneider, Eric B; Friedman, David S

2016-03-01

Determining the epidemiology of eye-related emergency department (ED) visits on a national level can assist policymakers in appropriate allocation of resources. To study ED visits related to ocular conditions for all age groups across the United States. Nationally representative data from the US Nationwide Emergency Department Sample (NEDS) were used to analyze ED visits from January 1, 2006, to December 31, 2011 (6 years). All patients with eye problems presenting to EDs across the United States were eligible for inclusion. A weighted count of 11 929 955 ED visits were categorized as possibly emergent (emergent), unlikely to be emergent (nonemergent), or could not be determined. Data were analyzed from March 1 to May 30, 2015. Population-based incidence rates of eye-related ED visits, incidence rates of eye injuries, relative proportions of emergent vs nonemergent eye-related ED visits among different age groups, and independent factors associated with emergent vs nonemergent visits. From 2006 to 2011, 11 929 955 ED visits (male patients, 54.2%; mean [SD] age, 31 [22] years) for ocular problems across the United States were categorized as emergent (41.2%), nonemergent (44.3%), or could not determine (14.5%). Corneal abrasions (13.7%) and foreign body in the external eye (7.5%) were the leading diagnoses in the emergent category. More than 4 million visits were for conjunctivitis (28.0%), subconjunctival hemorrhages (3.0%), and styes (3.8%). Emergent visits were significantly more likely to occur among males (odds ratio [OR], 2.00; 95% CI, 2.00-2.01), patients in the highest income quartile (OR, 1.47; 95% CI, 1.46-1.49), older patients (OR, 2.38; 95% CI, 2.38-2.44), and patients with private insurance (OR, 1.29; 95% CI, 1.28-1.30). Mean annual inflation-adjusted charges for all eye-related ED visits totaled $2.0 billion. Across the United States, nonemergent conditions accounted for almost half of all eye-related ED visits. Interventions to facilitate management of these cases outside the ED could make ED resources more available for truly emergent ophthalmic and medical issues.

Emergency Department Visits by Nursing Home Residents in the United States

PubMed Central

Wang, Henry E.; Shah, Manish N.; Allman, Richard M.; Kilgore, Meredith

2012-01-01

BACKGROUND/OBJECTIVES The Emergency Department (ED) is an important source of health care for nursing home residents. The objective of this study was to characterize ED use by nursing home residents in the United States (US). DESIGN Analysis of the National Hospital Ambulatory Medical Care Survey SETTING US Emergency Departments, 2005-2008 PARTICIPANTS Individuals visiting US EDs, stratified by nursing home and non-nursing home residents. INTERVENTIONS None MEASUREMENTS We identified all ED visits by nursing home residents. We contrasted the demographic and clinical characteristics between nursing home residents and non-nursing home residents. We also compared ED resource utilization, length of stay and outcomes. RESULTS During 2005-2008, nursing home residents accounted for 9,104,735 of 475,077,828 US ED visits (1.9%; 95% CI: 1.8-2.1%). The annualized number of ED visits by nursing home residents was 2,276,184. Most nursing home residents were elderly (mean 76.7 years, 95% CI: 75.8-77.5), female (63.3%), and non-Hispanic White (74.8%). Compared with non-nursing home residents, nursing home residents were more likely have been discharged from the hospital in the prior seven days (adjusted OR 1.4, 95% CI: 1.1-1.9). Nursing home residents were more likely to present with fever (adjusted OR 1.9; 95% CI: 1.5-2.4) or hypotension (systolic blood pressure ≤90 mm Hg, OR 1.8; 95% CI: 1.5-2.2). Nursing home patients were more likely to receive diagnostic test, imaging and procedures in the ED. Almost half of nursing home residents visiting the ED were admitted to the hospital. Compared with non-nursing home residents, nursing home residents were more likely to be admitted to the hospital (adjusted OR 1.8; 95% CI 1.6-2.1) and to die (adjusted OR 2.3; 95% CI 1.6-3.3). CONCLUSIONS Nursing home residents account for over 2.2 million ED visits annually in the US. Compared with other ED patients, nursing home residents have higher medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the US. PMID:22091500

Coping behavior and risk and resilience stress factors in French regional emergency medicine unit workers: a cross-sectional survey.

PubMed

Lala, A I; Sturzu, L M; Picard, J P; Druot, F; Grama, F; Bobirnac, G

2016-01-01

The Emergency Department (ED) has the highest workload in a hospital, offering care to patients in their most acute state of illness, as well as comforting their families and tending to stressful situations of the physical and psychological areal. Method. A cross-sectional survey of 366 Emergency Unit staff members including medical doctors, medical residents, medical nurses and ward aids, was undergone. Study participants came from four periphery hospitals in the Moselle Department of Eastern France with similar workforce and daily patient loads statistics. The instruments used were the Perceived Stress Scale PSS-10 and the Brief COPE questionnaire. Conclusions. Perceived work overload and overall stress is strongly related to work hours and tend to have a stronger influence on doctors than on the nursing staff. Substance use is a common coping method for medical interns, consistent with prior research. The regular assessment of the ED staff perception of stress and stress related factors is essential to support organizational decisions in order to promote a better work environment and better patient care.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits.

PubMed

Martsolf, Grant; Fingar, Kathryn R; Coffey, Rosanna; Kandrack, Ryan; Charland, Tom; Eibner, Christine; Elixhauser, Anne; Steiner, Claudia; Mehrotra, Ateev

2017-04-01

We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low-acuity conditions. We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low-acuity conditions. Retail clinic "penetration" was measured as the percentage of the ED catchment area that overlapped with the 10-minute drive radius of a retail clinic. Rate ratios were calculated for a 10-percentage-point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012. Among all patients, retail clinic penetration was not associated with a reduced rate of low-acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low-acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low-acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter. With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low-acuity ED visits. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Diagnosis of Elder Abuse in U.S. Emergency Departments.

PubMed

Evans, Christopher S; Hunold, Katherine M; Rosen, Tony; Platts-Mills, Timothy F

2017-01-01

To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets. Retrospective cross-sectional analysis. U.S. ED visits recorded in the 2012 Nationwide Emergency Department Sample (NEDS) or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). All ED visits of individuals aged 60 and older. The primary outcome was elder abuse defined according to International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (ORs) were calculated to identify demographic characteristics and common ED diagnoses associated with elder abuse. In 2012, NEDS contained information on 6,723,667 ED visits of older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% confidence interval (CI) = 0.012-0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed greater weighted odds of elder abuse diagnosis in women (odds ratio (OR) = 1.95, 95% CI = 1.68-2.26) and individuals with contusions (OR = 2.91, 95% CI = 2.36-3.57), urinary tract infection (OR = 2.21, 95% CI = 1.84-2.65), and septicemia (OR = 1.92, 95% CI = 1.44-2.55). In the 2011 NHAMCS dataset, no cases of elder abuse were recorded for the 5,965 older adult ED visits. The proportion of U.S. ED visits by older adults receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Diagnosis of Elder Abuse in US Emergency Departments

PubMed Central

Evans, Christopher S.; Hunold, Katherine M.; Rosen, Tony; Platts-Mills, Timothy F.

2016-01-01

OBJECTIVE To estimate the proportion of visits to United States emergency departments (EDs) receiving a diagnosis of elder abuse using two nationally representative datasets. DESIGN Retrospective cross-sectional analysis. SETTING U.S. ED visits recorded in either the 2012 Nationwide Emergency Department Sample (NEDS), or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). PARTICIPANTS All ED visits by patients aged 60 years and older. MEASUREMENTS The primary outcome was elder abuse as defined by ICD-9-CM diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (OR) were calculated to identify patient demographics and common ED diagnoses associated with elder abuse. RESULTS In 2012, NEDS contained 6,723,667 ED visits by older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% Confidence Interval (CI) 0.012– 0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed increased weighted odds of elder abuse diagnosis in females (OR 1.95, 95% CI 1.68–2.26), and patients with contusion (OR 2.91, 95% CI 2.36–3.57), urinary tract infection (OR 2.21, 95% CI 1.84–2.65), or septicemia (OR 1.92, 95% CI 1.44–2.55). In the 2011 NHAMCS dataset, zero cases of elder abuse were recorded among the 5,965 older adult ED visits. CONCLUSION Among US ED visits by older adults, the proportion of visits receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted. PMID:27753066

[Outpatient care in emergency departments and primary care services : A descriptive analysis of secondary data in a rural hospital].

PubMed

Seeger, I; Rupp, P; Naziyok, T; Rölker-Denker, L; Röhrig, R; Hein, A

2017-09-01

The use of emergency departments in German hospitals has been increasing in recent years. Emergency care provided by primary care services ("Bereitschaftsdienstpraxis") or a hospital emergency departments (EDs) is the subject of current discussions. The purpose of this study was to determine the reasons that outpatients with lower treatment urgency consult the ED. Further, the effects of the cooperation between primary care services and the ED will be examined. The study was an exploratory secondary data analysis of data from the hospital information system and a quality management survey of a basic and standard care clinic in a rural area. All patients classified as 4 and 5 according to the emergency severity index (ESI), both four weeks before and after the primary care services and ED visit, were included in the study. During the two survey periods, a total of 1565 outpatient cases were treated, of which 962 cases (61%) were triaged ESI 4 or 5. Of these patients, 324 were surveyed (34%). Overall, 276 cases (85%) visited the ED without contacting a physician beforehand, 161 of the cases (50%) reported an emergency as the reason. In 126 cases (39%) the symptoms lasted more than one day. One-third of all outpatient admissions (537 cases, 34%) visited the ED during the opening hours of the general practitioner. More than 80% of the surviving cases visited the ED without physician contact beforehand. The most common reason for attending the ED was, "It is an emergency." The targeted control of the patients by integrating the primary care service into the ED does not lead to an increased number of cases in the primary care service, but to a subjective relief of the ED staff.

Comparison between B·R·A·H·M·S PCT direct, a new sensitive point-of-care testing device for rapid quantification of procalcitonin in emergency department patients and established reference methods - a prospective multinational trial.

PubMed

Kutz, Alexander; Hausfater, Pierre; Oppert, Michael; Alan, Murat; Grolimund, Eva; Gast, Claire; Alonso, Christine; Wissmann, Christoph; Kuehn, Christian; Bernard, Maguy; Huber, Andreas; Mueller, Beat; Schuetz, Philipp

2016-04-01

Procalcitonin (PCT) is increasingly being used for the diagnostic and prognostic work up of patients with suspected infections in the emergency department (ED). Recently, B·R·A·H·M·S PCT direct, the first high sensitive point-of-care test (POCT), has been developed for fast PCT measurement on capillary or venous blood samples. This is a prospective, international comparison study conducted in three European EDs. Consecutive patients with suspicion of bacterial infection were included. Duplicate determination of PCT was performed in capillary (fingertip) and venous whole blood (EDTA), and compared to the reference method. The diagnostic accuracy was evaluated by correlation and concordance analyses. Three hundred and three patients were included over a 6-month period (60.4% male, median age 65.2 years). The correlation between capillary or venous whole blood and the reference method was excellent: r2=0.96 and 0.97, sensitivity 88.1% and 93.0%, specificity 96.5% and 96.8%, concordance 93% and 95%, respectively at a 0.25 μg/L threshold. No significant bias was observed (-0.04 and -0.02 for capillary and venous whole blood) although there were 6.8% and 5.1% outliers, respectively. B·R·A·H·M·S PCT direct had a shorter time to result as compared to the reference method (25 vs. 144 min, difference 119 min, 95% CI 110-134 min, p<0.0001). This study found a high diagnostic accuracy and a faster time to result of B·R·A·H·M·S PCT direct in the ED setting, allowing shortening time to therapy and a more wide-spread use of PCT.

Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems.

PubMed

Staggs, Lauren; Peek, Meagan; Southard, Gary; Gracely, Ed; Baxendale, Sidney; Cross, Keith P; Kim, In K

2012-01-01

Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI+S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI+S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI+S vs NEB. A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1-18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded. Three hundred and four patients were analyzed: 94 in the MDI+S group and 209 in the NEB group. Mean age in years for the MDI+S group was 9.57 vs 5.07 for the NEB group (p<0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI+S group vs 61.7% in the NEB group (p<0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI+S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p<0.001; 95% CI=3.8-31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of $213,532 annually using MDI+S vs NEB. In mild asthma exacerbations, administering albuterol via MDI+S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput. The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.

Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study

PubMed Central

Hu, Sung-Yuan; Hsieh, Ming-Shun; Lin, Meng-Yu; Hsu, Chiann-Yi; Lin, Tzu-Chieh; How, Chorng-Kuang; Wang, Chen-Yu; Tsai, Jeffrey Che-Hung; Wu, Yu-Hui; Chang, Yan-Zin

2016-01-01

Objectives To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition. Setting A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan. Participants Adult ED visits (aged ≥18 years) during 2009–2013, with or without receiving CT, were enrolled as the study participants. Main outcome measures For all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay. Results In all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013). Conclusions ED CT utilisation rates increased significantly during 2009–2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective. PMID:27279477

Predicting frequent emergency department visits among children with asthma using EHR data.

PubMed

Das, Lala T; Abramson, Erika L; Stone, Anne E; Kondrich, Janienne E; Kern, Lisa M; Grinspan, Zachary M

2017-07-01

For children with asthma, emergency department (ED) visits are common, expensive, and often avoidable. Though several factors are associated with ED use (demographics, comorbidities, insurance, medications), its predictability using electronic health record (EHR) data is understudied. We used a retrospective cohort study design and EHR data from one center to examine the relationship of patient factors in 1 year (2013) and the likelihood of frequent ED use (≥2 visits) in the following year (2014), using bivariate and multivariable statistics. We applied and compared several machine-learning algorithms to predict frequent ED use, then selected a model based on accuracy, parsimony, and interpretability. We identified 2691 children. In bivariate analyses, future frequent ED use was associated with demographics, co-morbidities, insurance status, medication history, and use of healthcare resources. Machine learning algorithms had very good AUC (area under the curve) values [0.66-0.87], though fair PPV (positive predictive value) [48-70%] and poor sensitivity [16-27%]. Our final multivariable logistic regression model contained two variables: insurance status and prior ED use. For publicly insured patients, the odds of frequent ED use were 3.1 [2.2-4.5] times that of privately insured patients. Publicly insured patients with 4+ ED visits and privately insured patients with 6+ ED visits in a year had ≥50% probability of frequent ED use the following year. The model had an AUC of 0.86, PPV of 56%, and sensitivity of 23%. Among children with asthma, prior frequent ED use and insurance status strongly predict future ED use. © 2017 Wiley Periodicals, Inc.

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department.

PubMed

Kantonen, Jarmo; Lloyd, Robert; Mattila, Juho; Kauppila, Timo; Menezes, Ricardo

2015-06-01

To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs). An observational and quasi-experimental study based on before-after comparisons. Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. GPs and nurses from two different primary care EDs. Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.

34 CFR 110.17 - Age distinctions contained in ED's regulations.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 34 Education 1 2013-07-01 2013-07-01 false Age distinctions contained in ED's regulations. 110.17..., DEPARTMENT OF EDUCATION NONDISCRIMINATION ON THE BASIS OF AGE IN PROGRAMS OR ACTIVITIES RECEIVING FEDERAL FINANCIAL ASSISTANCE Standards for Determining Age Discrimination § 110.17 Age distinctions contained in ED...

34 CFR 110.17 - Age distinctions contained in ED's regulations.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 34 Education 1 2014-07-01 2014-07-01 false Age distinctions contained in ED's regulations. 110.17..., DEPARTMENT OF EDUCATION NONDISCRIMINATION ON THE BASIS OF AGE IN PROGRAMS OR ACTIVITIES RECEIVING FEDERAL FINANCIAL ASSISTANCE Standards for Determining Age Discrimination § 110.17 Age distinctions contained in ED...

34 CFR 110.17 - Age distinctions contained in ED's regulations.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 34 Education 1 2010-07-01 2010-07-01 false Age distinctions contained in ED's regulations. 110.17..., DEPARTMENT OF EDUCATION NONDISCRIMINATION ON THE BASIS OF AGE IN PROGRAMS OR ACTIVITIES RECEIVING FEDERAL FINANCIAL ASSISTANCE Standards for Determining Age Discrimination § 110.17 Age distinctions contained in ED...

Cost-effectiveness of oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin in the emergency department.

PubMed

Rudis, Maria I; Touchette, Daniel R; Swadron, Stuart P; Chiu, Amy P; Orlinsky, Michael

2004-03-01

Oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin are all commonly used for loading phenytoin in the emergency department (ED). The cost-effectiveness of each was compared for patients presenting with seizures and subtherapeutic phenytoin concentrations. A simple decision tree was developed to determine the treatment costs associated with each of 3 loading techniques. We determined effectiveness by comparing adverse event rates and by calculating the time to safe ED discharge. Time to safe ED discharge was defined as the time at which therapeutic concentrations of phenytoin (>or=10 mg/L) were achieved with an absence of any adverse events that precluded discharge. The comparative cost-effectiveness of alternatives to oral phenytoin was determined by combining net costs and number of adverse events, expressed as cost per adverse events avoided. Cost-effectiveness was also determined by comparing the net costs of each loading technique required to achieve the time to safe ED discharge, expressed as cost per hour of ED time saved. The outcomes and costs were primarily derived from a prospective, randomized controlled trial, augmented by time-motion studies and alternate-cost sources. Costs included the cost of drugs, supplies, and personnel. Analyses were also performed in scenarios incorporating labor costs and savings from using a lower-urgency area of the ED. The mean number of adverse events per patient for oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin was 1.06, 1.93, and 2.13, respectively. Mean time to safe ED discharge in the 3 groups was 6.4 hours, 1.7 hours, and 1.3 hours. Cost per patient was 2.83 dollars, 21.16 dollars, and 175.19 dollars, respectively, and did not differ substantially in the Labor and Triage (lower-urgency area of ED) scenarios. When the measure of effectiveness was adverse events, oral phenytoin dominated intravenous phenytoin and intravenous fosphenytoin, with a lower cost and number of adverse events. With time to safe ED discharge as the outcome measure, the incremental cost-effectiveness ratios were 3.90 dollars and 387.27 dollars per hour of ED time saved for oral phenytoin versus intravenous phenytoin and for intravenous fosphenytoin versus intravenous phenytoin, respectively. Oral phenytoin is the most cost-effective loading method in most settings. Intravenous phenytoin is preferred if one is willing to pay an additional 20.65 dollars to 44.25 dollars per patient and willing to have more adverse events for a quicker average time to safe ED discharge. It is unlikely that intravenous fosphenytoin is justifiable in any setting.

Adding physical therapy services in the emergency department to prevent immobilization syndrome - a feasibility study in a university hospital.

PubMed

Tousignant-Laflamme, Yannick; Beaudoin, Ann-Marie; Renaud, Anne-Marie; Lauzon, Stephanie; Charest-Bossé, Marie-Catherine; Leblanc, Louise; Grégoire, Maryse

2015-12-03

The association between the functional decline occurring with bedrest and hospitalization in older persons is well-known. A long wait in the emergency department (ED), where patients can be bedridden, is a risk factor for the development of an immobilization syndrome (IS). IS is one of the unwanted consequences of inactivity, which causes pathological changes in most organs and systems. Early mobility interventions, such as physical therapy (PT) delivered in the ED, may prevent its development. To our knowledge, no prior studies have reported on this topic. The goal of this study was to (i) assess the feasibility and (ii) explore the potential clinical value of adding PT services to the ED, in collaboration with nursing staff, to prevent IS. For 12 weeks, PT services were delivered in the ED to older persons (>65 years old) presenting with ≥1 clinical signs associated with the development of IS. Patients were screened by ED nurses and then seen by the physiotherapist. In order to assess feasibility, access to patients, percentage of patients who met eligibility criteria, acceptability of the intervention, and barriers/facilitators to the implementation were measured. To describe the clinical benefits of early PT services, we counted the number of new IS cases among patients after their admission to the ward. After 12 weeks, the ED nurses screened 187 potential patients and 20 received PT services in the ED (before their admission to the ward). Accessibility was not an issue and we observed good acceptability from the milieu. We did not find majors problems or insurmountable obstacles to implementation of the intervention. Clinical outcomes showed that nine patients received PT treatments in the ED and on the ward (after their admission). For the 11 other patients, no PT interventions were done in the ED following the assessment. Follow-up of these 11 patients showed that two of them developed IS during their hospital stay. As for the nine patients who began PT treatments in the ED, none of them developed IS. Based on the results of this feasibility study, it would be likely and potentially beneficial to implement PT services in the ED, which could have a positive impact on preventing the development of IS in older persons presenting risk factors. While only a small proportion of patients (11 %) received PT services, better screening tools/methods should be developed.

The association between pediatric general emergency department visits and post operative adenotonsillectomy hospital return.

PubMed

Bangiyev, John N; Thottam, Prasad J; Christenson, Jennifer R; Metz, Christopher M; Haupert, Michael S

2015-02-01

To define the association between pre-operative general emergency department visits, gender, and pre-operative diagnosis with post-operative emergency department return following adenotonsillectomy. Retrospective chart review of 1468 pediatric patients who underwent adenotonsillectomy at a tertiary pediatric hospital between 2011 and 2013. There was a significant relationship between patients who visited the ED pre-operatively, 25% (N=96) returned to the ED post-procedure, compared to 10% who did not have a pre-operative ED visit. There was an overall significant relation between having a pre-operative visit (χ(2)=53.6, df=1, p<0.001), female gender (female=56.9%; male=43.1%; χ(2)=4.2, df=1, p=0.04), and having a preoperative diagnosis of recurrent strep tonsillitis (OSA and RST=18%; RST=17.5%; OSA=11.8%; χ(2)=12.8, p=0.002) and having a post-operative ED visit. Generalized pre-operative visits along with gender and diagnosis of recurrent streptococcal tonsillitis were found to be positively associated with post-operative ED visits for common post-operative complaints. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Predicting Appropriate Admission of Bronchiolitis Patients in the Emergency Department: Rationale and Methods.

PubMed

Luo, Gang; Stone, Bryan L; Johnson, Michael D; Nkoy, Flory L

2016-03-07

In young children, bronchiolitis is the most common illness resulting in hospitalization. For children less than age 2, bronchiolitis incurs an annual total inpatient cost of $1.73 billion. Each year in the United States, 287,000 emergency department (ED) visits occur because of bronchiolitis, with a hospital admission rate of 32%-40%. Due to a lack of evidence and objective criteria for managing bronchiolitis, ED disposition decisions (hospital admission or discharge to home) are often made subjectively, resulting in significant practice variation. Studies reviewing admission need suggest that up to 29% of admissions from the ED are unnecessary. About 6% of ED discharges for bronchiolitis result in ED returns with admission. These inappropriate dispositions waste limited health care resources, increase patient and parental distress, expose patients to iatrogenic risks, and worsen outcomes. Existing clinical guidelines for bronchiolitis offer limited improvement in patient outcomes. Methodological shortcomings include that the guidelines provide no specific thresholds for ED decisions to admit or to discharge, have an insufficient level of detail, and do not account for differences in patient and illness characteristics including co-morbidities. Predictive models are frequently used to complement clinical guidelines, reduce practice variation, and improve clinicians' decision making. Used in real time, predictive models can present objective criteria supported by historical data for an individualized disease management plan and guide admission decisions. However, existing predictive models for ED patients with bronchiolitis have limitations, including low accuracy and the assumption that the actual ED disposition decision was appropriate. To date, no operational definition of appropriate admission exists. No model has been built based on appropriate admissions, which include both actual admissions that were necessary and actual ED discharges that were unsafe. The goal of this study is to develop a predictive model to guide appropriate hospital admission for ED patients with bronchiolitis. This study will: (1) develop an operational definition of appropriate hospital admission for ED patients with bronchiolitis, (2) develop and test the accuracy of a new model to predict appropriate hospital admission for an ED patient with bronchiolitis, and (3) conduct simulations to estimate the impact of using the model on bronchiolitis outcomes. We are currently extracting administrative and clinical data from the enterprise data warehouse of an integrated health care system. Our goal is to finish this study by the end of 2019. This study will produce a new predictive model that can be operationalized to guide and improve disposition decisions for ED patients with bronchiolitis. Broad use of the model would reduce iatrogenic risk, patient and parental distress, health care use, and costs and improve outcomes for bronchiolitis patients.

Momentary fitting in a fluid environment: A grounded theory of triage nurse decision making.

PubMed

Reay, Gudrun; Rankin, James A; Then, Karen L

2016-05-01

Triage nurses control access to the Emergency Department (ED) and make decisions about patient acuity, patient priority, and placement of the patient in the ED. Understanding the processes and strategies that triage nurses use to make decisions is therefore vital for patient safety and the operation of the ED. The aim of the current study was to generate a substantive grounded theory (GT) of decision making by emergency triage Registered Nurses (RNs). Data collection consisted of seven observations of the triage environment at three tertiary care hospitals where RNs conducted triage and twelve interviews with triage RNs. The data were analyzed by constant comparison in accordance with the classical GT method. In the resultant theory, Momentary Fitting in a Fluid Environment, triage is conceptualized as a process consisting of four categories, determining acuity, anticipating needs, managing space, and creating space. The findings indicate that triage RNs continually strive to achieve fit, while simultaneously considering the individual patient and the ED as a whole entity. Triage RNs require appropriately designed triage environments and computer technology that enable them to secure real time knowledge of the ED to maintain situation awareness. Copyright © 2015 Elsevier Ltd. All rights reserved.

Characteristics of Youth Seeking Emergency Care for Assault Injuries

PubMed Central

Ranney, Megan; Newton, Manya; Woodhull, Whitney; Zimmerman, Marc; Walton, Maureen A.

2014-01-01

OBJECTIVE: To characterize youth seeking care for assault injuries, the context of violence, and previous emergency department (ED) service utilization to inform ED-based injury prevention. METHODS: A consecutive sample of youth (14–24) presenting to an urban ED with an assault injury completed a survey of partner violence, gun/knife victimization, gang membership, and context of the fight. RESULTS: A total of 925 youth entered the ED with an assault injury; 718 completed the survey (15.4% refused); 730 comparison youth were sampled. The fights leading to the ED visit occurred at home (37.6%) or on streets (30.4%), and were commonly with a known person (68.3%). Fights were caused by issues of territory (23.3%) and retaliation (8.9%); 20.8% of youth reported substance use before the fight. The assault-injured group reported more peer/partner violence and more gun experiences. Assault-injured youth reported higher past ED utilization for assault (odds ratio [OR]: 2.16) or mental health reasons (OR: 7.98). Regression analysis found the assault-injured youth had more frequent weapon use (OR: 1.25) and substance misuse (OR: 1.41). CONCLUSIONS: Assault-injured youth seeking ED care report higher levels of previous violence, weapon experience, and substance use compared with a comparison group seeking care for other complaints. Almost 10% of assault-injured youth had another fight-related ED visit in the previous year, and ∼5% had an ED visit for mental health. Most fights were with people known to them and for well-defined reasons, and were therefore likely preventable. The ED is a critical time to interact with youth to prevent future morbidity. PMID:24323994

Predictors of Return Visits Among Insured Emergency Department Mental Health and Substance Abuse Patients, 2005–2013

PubMed Central

Lee, Sangil; Herrin, Jeph; Bobo, William V.; Johnson, Ryan; Sangaralingham, Lindsey R.; Campbell, Ronna L.

2017-01-01

Introduction Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States. Methods We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSA between 2005 and 2013 who were discharged home. Study inclusion required continuous insurance enrollment for the 12 months preceding and the 31 days following the index ED visit. During the study period we included only the first ED visit for each patient. Results A total of 49,672 (14.2%) had a return visit to the ED or had a hospitalization within 30 days following discharge. Mean time to the next ED visit or inpatient admission was 11.7 days. An increased age (age 65+ vs. age <18 years; OR 1.65, 95% CI [1.57 to 1.74]), chronic medical comorbidities (Hwang comorbidity 5+ vs 0; OR 1.31, 95% CI [1.27 to 1.35]), prior ED and inpatient utilization (4+ visits vs 0 visits; OR 5.59, 95% CI [5.41 to 5.78]) were associated with return visits within 30 days following discharge. Conclusion In an analysis of nearly 350,000 ED visits for MHSA, 14.2 % of patients returned to the ED or hospital within 30 days. This study identified a number of factors associated with return visits for acute care. PMID:28874941

Emergency department usage by community step-down facilities--patterns and recommendations.

PubMed

Lee, S W; Goh, C; Chan, Y H

2003-09-01

This study examines the interface between institutional community step-down facilities (CSDFs) and acute hospital's Emergency Department (ED). It also provides a comprehensive description of the usage of an ED's services by CSDFs in its vicinity. This is a prospective 12-week observational study conducted in the Accident and Emergency Department of Changi General Hospital in Singapore. All patients from CSDFs transferred to the department were eligible for the study. Hospital records were used to extract relevant clinical data after admission for the length of stay and final discharge diagnosis. There was a total of 201 referrals to the ED over the 3-month period. The age of the patients ranged from 32 to 107 years, with a median of 83 years. Ninety-two patients (45.8%) were male residents. There were more referrals from CSDF on weekdays than on weekends. In particular, the number of referrals from CSDFs on Mondays were significantly higher (P < 0.05, Poisson regression) than other days of the week. Fifty-one per cent of the ED visits occurred during regular working hours. Eighty-two per cent of the transfers were admitted. The main complaint was shortness of breath with cough, followed by fever and falls. The most common investigation ordered was chest radiograph, followed by electrocardiogram and other radiographs. The most common treatment procedure in the ED was placement of an intravenous line. For those admitted residents, average length of hospital stay was 8.27 +/- 8.19 days (median, 5 days). Seventeen patients (10.3%) died within 3 days of admission, while 31 patients (18.8%) stayed less than 3 days. The admitted residents had an average turnaround time (from time of registration to time of leaving the ED and proceeding to ward) of 97.94 minutes. For patients discharged from the ED, the average turnaround time (time from registration to time of leaving the ED) was 177 minutes. Residents from CSDFs are transferred to the ED for a variety of medical reasons. The most appropriate role of the ED in evaluation of residents of CSDFs is not yet clearly defined. There is increasing need to streamline processes in acute hospitals to cope with an increasing ageing population and to ensure that quality care is delivered to the institutionalised sick.

Forecasting the Emergency Department Patients Flow.

PubMed

Afilal, Mohamed; Yalaoui, Farouk; Dugardin, Frédéric; Amodeo, Lionel; Laplanche, David; Blua, Philippe

2016-07-01

Emergency department (ED) have become the patient's main point of entrance in modern hospitals causing it frequent overcrowding, thus hospital managers are increasingly paying attention to the ED in order to provide better quality service for patients. One of the key elements for a good management strategy is demand forecasting. In this case, forecasting patients flow, which will help decision makers to optimize human (doctors, nurses…) and material(beds, boxs…) resources allocation. The main interest of this research is forecasting daily attendance at an emergency department. The study was conducted on the Emergency Department of Troyes city hospital center, France, in which we propose a new practical ED patients classification that consolidate the CCMU and GEMSA categories into one category and innovative time-series based models to forecast long and short term daily attendance. The models we developed for this case study shows very good performances (up to 91,24 % for the annual Total flow forecast) and robustness to epidemic periods.