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.

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.

Relationship between office-based provider visits and emergency department encounters among publicly-insured adults with epilepsy.

PubMed

Lekoubou, Alain; Bishu, Kinfe G; Ovbiagele, Bruce

2018-03-01

The proportion of adults with epilepsy using the emergency department (ED) is high. Among this patient population, increased frequency of office-based provider visits may be associated with lesser frequency of ED encounters, and key patient features may be linked to more ED encounters. We analyzed the Medical Expenditure Panel Survey Household Component (MEPS-HC) dataset for years 2003-2014, which represents a weighted sample of 842,249 publicly-insured US adults aged ≥18years. The Hurdle Poisson model that accommodates excess zeros was used to estimate the association between office-based and ED visits. Annual mean ED and office-based visits for publicly-insured adults with epilepsy were 0.70 and 10.8 respectively. Probability of at least one ED visit was 0.4% higher for every unit of office-based visit. Individuals in the high income category were less likely to visit the ED at least once while women with epilepsy had a higher likelihood of visiting the ED at least once. Among those who visited the ED at least once, there was a 0.3% higher likelihood of visiting the ED for every unit of office-based visit. Among individuals who visited the ED at least once, being aged 45-64years, residing in the West, and the year 2011/14 were associated with higher ED visits. In this representative sample of publicly-insured adults with epilepsy, higher frequency of office visits was not associated with lower ED utilization, which may be due to underlying greater disease severity or propensity for more treatment complications. Copyright © 2018 Elsevier Inc. All rights reserved.

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma.

PubMed

McGovern, Colleen Marie; Redmond, Margaret; Arcoleo, Kimberly; Stukus, David R

2017-11-01

Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2-18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ 2 = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ 2 = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children. The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.

Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act.

PubMed

Dresden, Scott M; Powell, Emilie S; Kang, Raymond; McHugh, Megan; Cooper, Andrew J; Feinglass, Joe

2017-02-01

We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state. Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI -27,037 to -21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI -11.1 to -6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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

The ED use and non-urgent visits of elderly patients.

PubMed

Gulacti, Umut; Lok, Ugur; Celik, Murat; Aktas, Nurettin; Polat, Haci

2016-12-01

To evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p < 0.001). While the rate of elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p < 0.001). For both genders, the rates of ED visits for patients between 65 and 74 years old was higher than for other elderly age groups (p < 0.001). The prevalence of upper respiratory tract infection (URTI) was the highest within the elderly population (17.5%, CI: 17.1-17.9). The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%), and they were highest in the winter season (25.9%) and in January (10.2%). The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units. The proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries.

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.

Mental Health Services Use Trends in Canadian Veterans: A Population-Based Retrospective Cohort Study in Ontario.

PubMed

Mahar, Alyson L; Aiken, Alice B; Cramm, Heidi; Whitehead, Marlo; Groome, Patti; Kurdyak, Paul

2017-01-01

A substantial evidence base in the peer-reviewed literature exists investigating mental illness in the military, but relatively less is documented about mental illness in veterans. This study uses provincial, administrative data to study the use of mental health services by Canadian veterans in Ontario. This was a retrospective cohort study of Canadian Armed Forces and Royal Canadian Mounted Police veterans who were released between 1990 and 2013 and resided in Ontario. Mental health-related primary care physician, psychiatrist, emergency department (ED) visits, and psychiatric hospitalisations were counted. Repeated measures were presented in 5-year intervals, stratified by age at release. The cohort included 23,818 veterans. In the first 5 years following entry into the health care system, 28.9% of veterans had ≥1 mental health-related primary care physician visit, 5.8% visited a psychiatrist at least once, and 2.4% received acute mental health services at an ED. The use of mental health services was consistent over time. Almost 8% of veterans aged 30 to 39 years saw a psychiatrist in the first 5 years after release, compared to 3.5% of veterans aged ≥50 years at release. The youngest veterans at release (<30 years) were the most frequent users of ED services for a mental health-related reason (5.1% had at least 1 ED visit). Understanding how veterans use the health care system for mental health problems is an important step to ensuring needs are met during the transition to civilian life.

Hospital revisit rate after a diagnosis of conversion disorder.

PubMed

Merkler, Alexander E; Parikh, Neal S; Chaudhry, Simriti; Chait, Alanna; Allen, Nicole C; Navi, Babak B; Kamel, Hooman

2016-04-01

To estimate the hospital revisit rate of patients diagnosed with conversion disorder (CD). Using administrative data, we identified all patients discharged from California, Florida and New York emergency departments (EDs) and acute care hospitals between 2005 and 2011 with a primary discharge diagnosis of CD. Patients discharged with a primary diagnosis of seizure or transient global amnesia (TGA) served as control groups. Our primary outcome was the rate of repeat ED visits and hospital admissions after initial presentation. Poisson regression was used to compare rates between diagnosis groups while adjusting for demographic characteristics. We identified 7946 patients discharged with a primary diagnosis of CD. During a mean follow-up of 3.0 (±1.6) years, patients with CD had a median of three (IQR, 1-9) ED or inpatient revisits, compared with 0 (IQR, 0-2) in patients with TGA and 3 (IQR, 1-7) in those with seizures. Revisit rates were 18.25 (95% CI, 18.10 to 18.40) visits per 100 patients per month in those with CD, 3.90 (95% CI, 3.84 to 3.95) in those with TGA and 17.78 (95% CI, 17.75 to 17.81) in those with seizures. As compared to CD, the incidence rate ratio for repeat ED visits or hospitalisations was 0.89 (95% CI, 0.86 to 0.93) for seizure disorder and 0.32 (95% CI 0.31 to 0.34) for TGA. CD is associated with a substantial hospital revisit rate. Our findings suggest that CD is not an acute, time-limited response to stress, but rather that CD is a manifestation of a broader pattern of chronic neuropsychiatric disease. 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/

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.

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

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

PubMed

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

2017-04-01

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. 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. 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. 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. © 2016 by the Society for Academic Emergency Medicine.

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

Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review.

PubMed

Karam, Grace; Radden, Zoe; Berall, Laura E; Cheng, Catherine; Gruneir, Andrea

2015-09-01

There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re-visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re-visits, hospitalizations, nursing home admissions and death after initial ED discharge. Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral-based interventions, studies that used a validated prediction tool to identify high-risk patients more frequently reported improved outcomes than those that did not use such a tool. Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations. © 2015 The Authors. Geriatrics & Gerontology International published by Wiley Publishing Asia Pty Ltd on behalf of Japan Geriatrics Society.

Efficacy of emergency department‐based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review

PubMed Central

Karam, Grace; Radden, Zoe; Berall, Laura E; Cheng, Catherine

2015-01-01

Aim There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re‐visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. Methods Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re‐visits, hospitalizations, nursing home admissions and death after initial ED discharge. Results Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral‐based interventions, studies that used a validated prediction tool to identify high‐risk patients more frequently reported improved outcomes than those that did not use such a tool. Conclusion Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations. Geriatr Gerontol Int 2015; 15: 1107–1117. PMID:26171554

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.

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

Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability.

PubMed

McDermott, S; Royer, J; Mann, J R; Armour, B S

2018-03-01

Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions. To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied. There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings. Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services. © 2017 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

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

Population-based burden of COPD-related visits in the ED: return ED visits, hospital admissions, and comorbidity risks.

PubMed

Yeatts, Karin B; Lippmann, Steven J; Waller, Anna E; Hassmiller Lich, Kristen; Travers, Debbie; Weinberger, Morris; Donohue, James F

2013-09-01

Little is known about the population-based burden of ED care for COPD. We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions.

National and Regional Representativeness of Hospital Emergency Department Visit Data in the National Syndromic Surveillance Program, United States, 2014

PubMed Central

Coates, Ralph J.; Pérez, Alejandro; Baer, Atar; Zhou, Hong; English, Roseanne; Coletta, Michael; Dey, Achintya

2016-01-01

Objective We examined the representativeness of the nonfederal hospital emergency department (ED) visit data in the National Syndromic Surveillance Program (NSSP). Methods We used the 2012 American Hospital Association Annual Survey Database, other databases, and information from state and local health departments participating in the NSSP about which hospitals submitted data to the NSSP in October 2014. We compared ED visits for hospitals submitting 15 data with all ED visits in all 50 states and Washington, DC. Results Approximately 60.4 million of 134.6 million ED visits nationwide (~45%) were reported to have been submitted to the NSSP. ED visits in 5 of 10 regions and the majority of the states were substantially underrepresented in the NSSP. The NSSP ED visits were similar to national ED visits in terms of many of the characteristics of hospitals and their service areas. However, visits in hospitals with the fewest annual ED visits, in rural trauma centers, and in hospitals serving populations with high percentages of Hispanics and Asians were underrepresented. Conclusions NSSP nonfederal hospital ED visit data were representative for many hospital characteristics and in some geographic areas but were not very representative nationally and in many locations. Representativeness could be improved by increasing participation in more states and among specific types of hospitals. PMID:26883318

Constipation-Related Emergency Department Use, and Associated Office Visits and Payments Among Commercially Insured Children.

PubMed

MacGeorge, Claire A; Simpson, Kit N; Basco, William T; Bundy, David G

2018-04-16

Pediatric constipation is common, costly, and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographic characteristics associated with these office visits, and the ED-associated payments. Data were extracted from the Truven MarketScan database for commercially insured children from 2012 to 2013. Data on the presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex, and region of the country. In a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least 1 setting, with 65,163 (14.5%) having an ED visit for constipation. Of all children with a constipation-related ED visit, 45% had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit. One in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged. Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

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

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

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

PubMed

Chiou, Shang-Jyh; Campbell, Claudia; Horswell, Ronald; Myers, Leann; Culbertson, Richard

2009-12-07

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). 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. 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. 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.

Optimizing financial effects of HIE: a multi-party linear programming approach.

PubMed

Sridhar, Srikrishna; Brennan, Patricia Flatley; Wright, Stephen J; Robinson, Stephen M

2012-01-01

To describe an analytical framework for quantifying the societal savings and financial consequences of a health information exchange (HIE), and to demonstrate its use in designing pricing policies for sustainable HIEs. We developed a linear programming model to (1) quantify the financial worth of HIE information to each of its participating institutions and (2) evaluate three HIE pricing policies: fixed-rate annual, charge per visit, and charge per look-up. We considered three desired outcomes of HIE-related emergency care (modeled as parameters): preventing unrequired hospitalizations, reducing duplicate tests, and avoiding emergency department (ED) visits. We applied this framework to 4639 ED encounters over a 12-month period in three large EDs in Milwaukee, Wisconsin, using Medicare/Medicaid claims data, public reports of hospital admissions, published payer mix data, and use data from a not-for-profit regional HIE. For this HIE, data accesses produced net financial gains for all providers and payers. Gains, due to HIE, were more significant for providers with more health maintenance organizations patients. Reducing unrequired hospitalizations and avoiding repeat ED visits were responsible for more than 70% of the savings. The results showed that fixed annual subscriptions can sustain this HIE, while ensuring financial gains to all participants. Sensitivity analysis revealed that the results were robust to uncertainties in modeling parameters. Our specific HIE pricing recommendations depend on the unique characteristics of this study population. However, our main contribution is the modeling approach, which is broadly applicable to other populations.

Effect of inhaled corticosteroid use on weight (BMI) in pediatric patients with moderate-severe asthma.

PubMed

Han, Jennifer; Nguyen, John; Kim, Yuna; Geng, Bob; Romanowski, Gale; Alejandro, Lawrence; Proudfoot, James; Xu, Ronghui; Leibel, Sydney

2018-04-19

Assess the relationship between inhaled corticosteroid use (ICS) and weight (BMI) in pediatric patients with moderate-severe asthma. Assess if the number of emergency department (ED) visits correlates with overall BMI trajectory. Assess the trend of prescribing biologic therapy in pediatric patients with moderate-severe asthma and determine its relationship with weight (BMI). A retrospective chart review was performed on 93 pediatric patients with moderate-severe asthma to determine the relationship between ICS use and weight (BMI), biologic therapy and BMI, and number of ED visits and BMI trajectory. A mixed effects model was employed with the correlation between repeated measures accounted for through the random effects. There is a statistically significant increase of 0.369 kg/m 2 in BMI trajectory per year in subjects on high-dose steroids compared to an increase of 0.195 kg/m 2 in the low dose group (p < 0.05). The BMI of subjects initiated on biologic therapy (omalizumab or mepolizumab) had a statistically significant decrease in BMI trajectory of 0.818 kg/m 2 per year (p < 0.05). Subjects with ≥5 ED visits due to asthma exacerbations had a significantly higher BMI trajectory (p < 0.05). The potency of ICS use in pediatric patients with moderate-severe asthma affects BMI trajectory; the higher the dose, the greater the projected BMI increase per year. Initiation of biologic therapy decreased BMI trajectory over time. Lastly, those with frequent ED visits had a higher BMI trend. Future prospective studies are warranted that further evaluate the potential metabolic impacts of ICS and assess the effects of biologic therapy on BMI.

Lack of long-term benefits of a 6-month heart failure disease management program.

PubMed

Nguyen, Viviane; Ducharme, Anique; White, Michel; Racine, Normand; O'Meara, Eileen; Zhang, Bin; Rouleau, Jean L; Brophy, James

2007-05-01

Heart failure (HF) represents a major burden on the health care system, causing repeated hospitalizations and numerous emergency department (ED) visits. In a 6-month randomized study of a multidisciplinary HF clinic, we have previously shown decreased hospital readmissions and improved quality of life. Despite these encouraging results, it is unknown if these beneficial effects are sustained. To assess long-term recurrent ED visits, readmissions, and mortality among HF patients who were discharged after a 6-month intensive HF management program (HFMP). Of the 230 subjects (New York Heart Association Class II-IV) who were initially randomized to standard follow-up care or to a HFMP for 6 months, 190 were studied retrospectively for long-term evaluation. Long-term data was obtained from the Quebec administrative health databases. We compared the intervention and control groups for the number of recurrent ED visits, hospital readmissions, and all-cause deaths. After a mean follow-up of 2.8 +/- 1.7 years, there was no difference in the composite end point of all-cause death, hospital admissions, and ED visits between those patients initially in the HFMP group and the controls. After multivariable adjustment, there was no difference in the composite primary endpoint (HR 1.01, 95% CI: 0.75-1.37) or in the secondary end point of all-cause death alone (HR 1.09, 95%CI:0.69-1.72) between those initially assigned to the HF clinic and those receiving usual care. For severely ill patients, the clinical and resource benefits of a 6-month HFMP are not sustained upon program cessation. Further research into the benefits of long-term HFMP is required.

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.

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.

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

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.

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

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

The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study.

PubMed

Balakrishnan, Meenakshi P; Herndon, Jill Boylston; Zhang, Jingnan; Payton, Thomas; Shuster, Jonathan; Carden, Donna L

2017-09-01

Policymakers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor, and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown. The objective was to determine the association of health literacy with preventable ED visits. We conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the 2 years before the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61) versus adequate (REALM ≥ 61) health literacy after adjusting for covariates. Of 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat and release. After covariates were adjusted for, patients with limited literacy had 2.3 (95% confidence interval [CI] = 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95% CI = 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI = 1.5-2.4) times the number of total preventable ED visits. Our results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system. © 2017 by the Society for Academic Emergency Medicine.

Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States.

PubMed

Burke, Robert E; Rooks, Sean P; Levy, Cari; Schwartz, Robert; Ginde, Adit A

2015-05-01

To identify and describe potentially preventable emergency department (ED) visits by nursing home (NH) residents in the United States. These visits are important because they are common, frequently lead to hospitalization, and can be associated with significant cost to the patient and the health care system. Retrospective analysis of the 2005-2010 National Hospital Ambulatory Care Survey (NHAMCS), comparing ED visits by nursing home residents that did not lead to hospital admission (potentially preventable) with those that led to admission (less likely preventable). Nationally representative sample of US EDs; federal hospitals and hospitals with fewer than 6 beds were excluded. Older (age ≥65 years) NH residents with an ED visit during this time period. Patient demographics, ED visit information including testing performed, interventions (both procedures and medications) provided, and diagnoses treated. Older NH residents accounted for 3857 of 208,956 ED visits during the time period of interest (1.8%). When weighted to be nationally representative, these represent 13.97 million ED visits, equivalent to 1.8 ED visits annually per NH resident in the United States. More than half of visits (53.5%) did not lead to hospital admission; of those discharged from the ED, 62.8% had normal vital signs on presentation and 18.9% did not have any diagnostic testing before ED discharge. Injuries were 1.78 times more likely to be discharged than admitted (44.8% versus 25.3%, respectively, P < .001), whereas infections were 2.06 times as likely to be admitted as discharged (22.9% versus 11.1%, respectively). Computed tomography (CT) scans were performed in 25.4% and 30.1% of older NH residents who were discharged from the ED and admitted to the hospital, respectively, and more than 70% of these were CTs of the head. NH residents received centrally acting, sedating medications before ED discharge in 9.4% of visits. This nationally representative sample of older NH residents suggests ED visits for injury, those that are associated with normal triage vital signs, and those that are not associated with any diagnostic testing are potentially preventable. Those discharged from the ED often undergo important testing and receive medications that may alter their physical examination on return to the nursing facility, highlighting the need for seamless communication of the ED course to NHs. Published by Elsevier Inc.

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.

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.

Trends in diabetes-related visits to US EDs from 1997 to 2007.

PubMed

Menchine, Michael D; Wiechmann, Warren; Peters, Anne L; Arora, Sanjay

2012-06-01

The aims of the study were to describe temporal trends in the number, proportion, and per capita use of diabetes-related emergency department (ED) visits and to examine any racial/ethnic disparity in ED use for diabetes-related reasons. We analyzed the ED portion of the National Hospital Ambulatory Medical Care Survey from 1997 through 2007. Diabetes-related ED visits were identified by International Classification of Diseases, Ninth Revision codes. Descriptive statistics were developed. Weighted linear and logistic regression models were used to determine significance of temporal trends, and multivariate logistic regression was used to examine racial/ethnic disparities. A total of 20.2 million (1.69%; 95% confidence interval [CI], 1.59%-1.78%) ED visits were diabetes-related during the study period. We observed significant increases in the number and proportion of diabetes-related ED visits. Overall, there was a 5.6% relative annual increase in the proportion of ED visits that were diabetes-related during the study period. However, the per capita ED use among the population with diabetes did not change over time (P>.05 for trend). On multivariate analysis, black race (odds ratio, 1.8; 95% CI, 1.7-2.0), Hispanic ethnicity (odds ratio, 1.6; 95% CI, 1.4-1.8), and advancing age were associated with significantly higher odds of having a diabetes-related visit. Despite a marked increase in number and proportion of diabetes-related ED visits during the study period, the per capita use of ED services for diabetes-related visits among the diabetic population remained stable. Copyright © 2012 Elsevier Inc. All rights reserved.

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.

Population-Based Burden of COPD-Related Visits in the ED

PubMed Central

Lippmann, Steven J.; Waller, Anna E.; Hassmiller Lich, Kristen; Travers, Debbie; Weinberger, Morris; Donohue, James F.

2013-01-01

Background: Little is known about the population-based burden of ED care for COPD. Methods: We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. Results: In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. Conclusions: The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions. PMID:23579283

After laparoscopic Heller myotomy, do emergency department visits or readmissions predict poor long-term outcomes?

PubMed

Ross, Sharona; Villadolid, Desiree; Al-Saadi, Sam; Boyle, Robert; Cowgill, Sarah M; Rosemurgy, Alexander

2008-12-01

Laparoscopic Heller myotomy is a first-line treatment for achalasia. To improve outcomes after myotomy and to determine if poor early results predict later outcomes, emergency department (ED) visits and readmissions within 60 days following laparoscopic Heller myotomy were studied. Since 1992, 352 patients have undergone laparoscopic Heller myotomy and are followed through a prospectively maintained registry. Causes of ED visits and readmissions within 60 days after myotomy were determined. Patients scored their symptoms of achalasia before myotomy and at last follow-up; scores were compared to determine if the reasons leading to ED visits and/or readmissions impacted long-term outcome after myotomy. Fourteen (4%) patients had ED visits, and 18 (5%) patients had readmissions within 60 days following myotomy. Sixty-four percent of ED visits were for dysphagia/vomiting and 36% were for abdominal/chest pain, while 37% of readmissions were for dysphagia/vomiting. Pneumonia was complicated by empyema in four patients, all without leaks; two patients expired. Despite ED visits/readmissions, achalasia symptom (e.g., dysphagia, regurgitation, choking, heartburn, and chest pain) frequency and severity scores improved after myotomy (p < 0.05 for all). ED visits and readmissions are infrequent following laparoscopic Heller myotomy. ED visits were generally due to complaints related to achalasia or edema after myotomy, while readmissions were generally related to complications of operative intervention or chronic ill health. Despite ED visits or readmissions early after myotomy, symptoms of achalasia are well palliated by myotomy long-term.

Dental visits to a North Carolina emergency department: a painful problem.

PubMed

Hocker, Michael B; Villani, John J; Borawski, Joseph B; Evans, Christopher S; Nelson, Scott M; Gerardo, Charles J; Limkakeng, Alex T

2012-01-01

Emergency departments (EDs) act as the safety net and alternative care site for patients without insurance who have dental pain. We conducted a retrospective chart review of visits to an urban teaching hospital ED over a 12-month period, looking at patients who presented with a chief complaint or ICD code indicating dental pain, toothache, or dental abscess. The number of visits to this ED by patients with a dental complaint was 1,013, representing approximately 1.3% of all visits to this ED. Dental patients had a mean age of 32 (+/- 13) years, and 60% of all dental visits were made by African Americans. Dental patients were more likely to be self-pay than all other ED patients (61% versus 22%, P < 0.001). At the vast majority of dental ED visits (97%), the patient was treated and discharged; at most visits (90%) no dental procedure was performed. ED treatment typically consisted of pain control and antibiotics; at 81% of visits, the patient received an opiate prescription on discharge, and at 69% of visits, the patient received an antibiotic prescription on discharge. This retrospective chart review covered a limited period of time, included only patients at a large urban academic medical center, and did not incorporate follow-up analysis. Although they make up a small percentage of all ED visits, dental ED visits are more common among the uninsured, seldom result in definitive care or hospital admission, and often result in prescription of an opioid or antibiotic. These findings are cause for concern and have implications for public policy.

A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization.

PubMed

Raven, Maria C; Steiner, Faye

2018-06-01

Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits. We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization. Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31). Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Travel distances by Wisconsin Medicaid enrollees who visit emergency departments for dental care.

PubMed

Okunseri, Christopher; Vanevenhoven, Rabeea; Chelius, Thomas; Beyer, Kirsten M M; Okunseri, Elaye; Lobb, William K; Szabo, Aniko

2016-06-01

Prior studies document increased numbers of nontraumatic dental condition (NTDC) visits to U.S. emergency departments (EDs). However, the influence of travel distance on ED use for NTDCs, particularly for Medicaid enrollees has hitherto received little attention. The authors examined the effect of travel distance on Wisconsin Medicaid enrollees' NTDC visits to EDs after adjustment for covariates. NTDC-related visits claims data for Wisconsin Medicaid (2001-2009) was analyzed. For each enrollee, travel distance to the nearest of 130 EDs in Wisconsin was determined. The number of NTDC visits per person-year was aggregated by ZIP+4 of residence. Negative binomial regression adjusting for the expected number of visits based on race, sex, age of the residents and calendar year was used to evaluate the effect of travel distance, urbanicity, and dentist-population ratio on rate of visits. Enrollees residing in rural counties, entire dental health professional shortage areas, areas with dentist population ratios >20,000: 1 and non-Hispanic Whites travelled the furthest, compared to nearest mean ED distance of 2.9 miles. Enrollees residing 3 miles away or further had significantly lower rates of NTDC visits to EDs. This study demonstrates that distance is a barrier to making NTDC-related visits to EDs. Rates of NTDC visits decreased as travel distance to the nearest ED increased for Medicaid enrollees. © 2016 American Association of Public Health Dentistry.

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.

Changes in Emergency Department Utilization After Early Medicaid Expansion in California.

PubMed

Sabik, Lindsay M; Cunningham, Peter J; Tehrani, Ali Bonakdar

2017-06-01

Medicaid expansions aim to improve access to primary care, which could reduce nonemergent (NE) use of the emergency department (ED). In contrast, Medicaid enrollees use the ED more than other groups, including the uninsured. Thus, the expected impact of Medicaid expansion on ED use is unclear. To estimate changes in total and NE ED visits as a result of California's early Medicaid expansion under the Affordable Care Act. In addition to overall changes in the number of visits, changes by payer and safety net hospital status are examined. We used a quasi-experimental approach to examine changes in ED utilization, comparing California expansion counties to comparison counties from California and 2 other states in the same region that did not implement Medicaid expansion during the study period. Regression estimates show no significant change in total number of ED visits following expansion. Medicaid visits increased by 145 visits per hospital-quarter in the first year following expansion and 242 visits subsequent to the first year, whereas visits among uninsured patients decreased by 129 visits per hospital-quarter in the first year and 175 visits in subsequent years, driven by changes at safety net hospitals. We also observe an increase in NE visits per hospital-quarter paid for by Medicaid, and a significant decrease in uninsured NE visits. Medicaid expansions in California were associated with increases in ED visits paid for by Medicaid and declines in uninsured visits. Expansion was also associated with changes in NE visits among Medicaid enrollees and the uninsured.

Factors Associated With Natriuretic Peptide Testing in Patients Presenting to Emergency Departments With Suspected Heart Failure.

PubMed

Sepehrvand, Nariman; Bakal, Jeffrey A; Lin, Meng; McAlister, Finlay; Wesenberg, James C; Ezekowitz, Justin A

2016-08-01

Testing for natriuretic peptides (NPs) such as brain natriuretic peptide (BNP) or N-terminal prohormone brain natriuretic peptide (NT-proBNP) in the emergency department (ED) assists in the evaluation of patients with acute heart failure (HF). The aim of this study was to investigate factors related to the use of NP testing in the ED in a large population-based sample in Canada. This was a retrospective cohort study using linked administrative data from Alberta in 2012. Patients were included if they had testing for an NP in the ED; a comparator group with HF but without NP testing was also included. Of the 16,223 patients in the cohort, 5793 were patients with HF (n = 3148 tested and n = 2645 not tested for NPs) and 10,430 were patients without HF but who were tested for NPs. Patients without HF who were tested for NPs had respiratory disease (34%), non-HF cardiovascular diseases (13%), and other conditions (52%). Patients with HF who were tested had a higher rate of hospital admission from the ED (78.4% vs 62.2%; P < 0.001) and lower 7-day and 90-day repeated ED visit rates compared with those who were not tested. Among patients with HF, male sex, being an urban resident, being seen by an emergency medicine or cardiology specialist, and being seen in hospitals with medium ED visit volumes were associated with increased likelihood of testing for NPs. Several factors, including the type of provider and ED clinical volume, influenced the use of NP testing in routine ED practice. Standardization of an NP testing strategy in clinical practice would be useful for health care systems. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Trends in Emergency Department Resource Utilization for Poisoning-Related Visits, 2003-2011.

PubMed

Mazer-Amirshahi, Maryann; Sun, Christie; Mullins, Peter; Perrone, Jeanmarie; Nelson, Lewis; Pines, Jesse M

2016-09-01

In recent years, there has been an increase in poisoning-related emergency department (ED) visits. This study examines trends in ED resource utilization for poisoning-related visits over time. A retrospective review of data from the National Hospital Ambulatory Medical Care Survey, 2003-2011, was conducted. All ED visits with a reason for visit or ICD-9 code related to poisoning were included. We examined the number of ED visits and resources used including diagnostic studies and procedures performed, medications provided, admission rates, and length of stay. The proportion of visits involving resource use was tabulated and trends analyzed using survey-weighted logistic regression, grouping into 2-year periods to ensure adequate sample size. Of an estimated 843 million ED visits between 2003 and 2011, 8 million (0.9 %) were related to poisoning. Visits increased from 1.8 million (0.8 %) visits in 2003-2004 to 2.9 million (1.1 %) visits in 2010-2011, p = 0.001. Use of laboratory studies, EKGs, plain radiographs, and procedures remained stable across the study period. CT use was more than doubled, increasing from 5.2 to 13.7 % of visits, p = 0.001. ED length of stay increased by 35.5 % from 254 to 344 min, p = 0.001. Admission rates increased by 45.3 %, from 15.0 to 21.8 %, p = 0.046. Over the entire study period, 52.0 % of poisoned patients arrived via ambulance, and 3.0 % of patients had been discharged from the hospital within the previous 7 days. Poisoning-related ED visits increased over the 8-year study period; poisonings are resource-intensive visits and require increasingly longer lengths of ED stay or hospital admission.

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.

How do ED patients with criminal justice contact compare with other ED users? A retrospective analysis of ED visits in California.

PubMed

McConville, Shannon; Mooney, Alyssa C; Williams, Brie A; Hsia, Renee Y

2018-06-21

To assess the patterns of emergency department (ED) utilisation among those with and without criminal justice contact in California in 2014, comparing variation in ED use, visit frequency, diagnoses and insurance coverage. Retrospective, cross-sectional study. Analyses included ED visits to all licensed hospitals in California using statewide data on all ED encounters in 2014. Study participants included 3 757 870 non-elderly adult ED patients who made at least one ED visit in 2014. We assessed the patterns and characteristics of ED visits among those with criminal justice contact-patients who were either admitted to or discharged from the ED by a correctional institution-with patients who did not have criminal justice contact recorded during an ED visit. ED patients with criminal justice contact had higher proportions of frequent ED users (27.2% vs 9.4%), were at higher risk of an ED visit resulting in hospitalisation (26.6% vs 15.2%) and had higher prevalence of mental health conditions (52.8% vs 30.4%) compared with patients with no criminal justice contact recorded during an ED visit. Of the top 10, four primary diagnoses among patients with criminal justice contact were related to behavioural health conditions, accounting for 19.0% of all primary diagnoses in this population. In contrast, behavioural health conditions were absent from the top 10 primary diagnoses in ED patients with no observed criminal justice contact. Despite a high burden of disease, a lack of health insurance coverage was more common among those with criminal justice contact than those without (41.3% vs 14.1%). Given that a large proportion of ED patients with criminal justice contact are frequent users with considerable mental health conditions, current efforts in California's Medicaid programme to identify individuals in need of coordinated services could reduce costly ED utilisation among this group. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

PubMed Central

Shibuya, Naohiro; Patel, Himani; Graney, Colin; Jupiter, Daniel C.

2018-01-01

ABSTRACT The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED. PMID:29706806

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries.

PubMed

Shibuya, Naohiro; Patel, Himani; Graney, Colin; Jupiter, Daniel C

2018-04-01

The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED.

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.

Bacteremia in nonneutropenic pediatric oncology patients with central venous catheters in the ED.

PubMed

Moskalewicz, Risha L; Isenalumhe, Leidy L; Luu, Cindy; Wee, Choo Phei; Nager, Alan L

2017-01-01

To examine clinical characteristics associated with bacteremia in febrile nonneutropenic pediatric oncology patients with central venous catheters (CVCs) in the emergency department (ED). Fever is the primary reason pediatric oncology patients present to the ED. The literature states that 0.9% to 39% of febrile nonneutropenic oncology patients are bacteremic, yet few studies have investigated infectious risk factors in this population. This was a retrospective cohort study in a pediatric ED, reviewing medical records from 2002 to 2014. Inclusion criteria were patients with cancer, temperature at least 38°C, presence of a CVC, absolute neutrophil count greater than 500 cells/μL, and age less than 22 years. Exclusion criteria were repeat ED visits within 72 hours, bloodwork results not reported by the laboratory, and patients without oncologic history documented at the study hospital. The primary outcome measure is a positive blood culture (+BC). Other variables include age, sex, CVC type, cancer diagnosis, absolute neutrophil count, vital signs, upper respiratory infection (URI) symptoms, and amount of intravenous (IV) normal saline (NS) administered in the ED. Data were analyzed using descriptive statistics and a multiple logistic regression model. A total of 1322 ED visits were sampled, with 534 enrolled, and 39 visits had +BC (7.3%). Variables associated with an increased risk of +BC included the following: absence of URI symptoms (odds ratio [OR], 2.30; 95% CI, 1.13-4.69), neuroblastoma (OR, 3.65; 95% CI, 1.47-9.09), "other" cancer diagnosis (OR, 4.56; 95% CI, 1.93-10.76), tunneled externalized CVC (OR, 5.04; 95% CI, 2.25-11.28), and receiving at least 20 mL/kg IV NS (OR, 2.34; 95% CI, 1.2-4.55). The results of a multiple logistic regression model also showed these variables to be associated with +BC. The absence of URI symptoms, presence of an externalized CVC, neuroblastoma or other cancer diagnosis, and receiving at least 20 mL/kg IV NS in the ED are associated with increased risk of bacteremia in nonneutropenic pediatric oncology patients with a CVC. Copyright © 2016 Elsevier Inc. All rights reserved.

Impact of an emergency department pain management protocol on the pattern of visits by patients with sickle cell disease.

PubMed

Givens, Melissa; Rutherford, Cynthia; Joshi, Girish; Delaney, Kathleen

2007-04-01

This study explores how implementation of pain management guidelines in concert with clinic case management affected emergency department (ED) utilization, clinic visits, and hospital admissions for patients with sickle cell disease. A pain management guideline that eliminated meperidine and encouraged timely use of morphine or hydromorphone for pain control in sickle cell crisis was introduced as a quality improvement project. This study is a retrospective review of ED visits, clinic visits, and admissions from 1 year before and 3 years after the guideline implementation. Working with the ED, the Hematology Clinic began to proactively seek the return of their patients for clinic follow-up. A formal case management program for sickle cell patients was initiated in June 2003. A total of 1584 visits by 223 patients were collected, 1097 to the ED and 487 to the Hematology Clinic. Total hospital visits did not change significantly in any of the 4 years, p > 0.10 for each comparison. Total ED visits decreased significantly over the 4-year study period (p < 0.001), whereas clinic visits steadily increased (p < 0.001). Return visits to the ED within 30 days also declined significantly, p < 0.001. Both the absolute number of admissions per year and the total admissions per hospital visit per year declined significantly over the study period, p = 0.001. Although total admissions per hospital visit did not change, the proportion of ED visits that resulted in admission in year 1 (29%) was significantly lower than the proportion admitted in year 2 (43%), p = 0.04. A pain protocol using morphine or hydromorphone coupled with increased access to outpatient clinics decreased ED visits, hospitalizations, and increased utilization of a more stable primary care clinic setting by patients with sickle cell disease.

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

Paid sick leave is associated with fewer ED visits among US private sector working adults.

PubMed

Bhuyan, Soumitra S; Wang, Yang; Bhatt, Jay; Dismuke, S Edward; Carlton, Erik L; Gentry, Dan; LaGrange, Chad; Chang, Cyril F

2016-05-01

The United States (US) is the only developed country that does not guarantee short-term or longer-term paid sick leave. This study used a multiyear nationally representative database to examine the association between availability of paid sick leave and frequency of emergency department (ED) use among US private sector employees. We used the National Health Interview Survey data (2012-2014). The final study sample consists of 42,460 US adults between 18 and 64years of age and working in nongovernmental private sector. Our results suggest that availability of paid sick leave is significantly associated with lower likelihood of ED use, for both moderate (1-3 times/year) and repeated users (4 or more times/year). After controlling for confounding factors, respondents with paid sick leave are 14% less likely to be moderate ED users (adjusted odds ratio, 0.86; 95% CI, 0.79-0.93) and 32% less likely to be repeated ED users (adjusted odds ratio, 0.68; 95% CI, 0.50-0.91). Although expansion of health insurance coverage under the Affordable Care Act has not been shown to reduce utilization of high cost health care services such as the ED, our study suggests other factors such as the availability of paid sick leave may do so, by allowing patients to seek care through other more cost-effective mechanisms (eg, primary care providers). To reduce ED utilization, health policymakers should consider alternative reforms including paid sick leave. Copyright © 2016 Elsevier Inc. All rights reserved.

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.

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

Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents.

PubMed

Seow, Hsien; Barbera, Lisa; Pataky, Reka; Lawson, Beverley; O'Leary, Erin; Fassbender, Konrad; McGrail, Kim; Burge, Fred; Brouwers, Melissa; Sutradhar, Rinku

2016-02-01

Despite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life. To examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. Our cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week. Our study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Parental Language and Return Visits to the Emergency Department After Discharge.

PubMed

Samuels-Kalow, Margaret E; Stack, Anne M; Amico, Kendra; Porter, Stephen C

2017-06-01

Return visits to the emergency department (ED) are used as a marker of quality of care. Limited English proficiency, along with other demographic and disease-specific factors, has been associated with increased risk of return visit, but the relationship between language, short-term return visits, and overall ED use has not been well characterized. This is a planned secondary analysis of a prospective cohort examining the ED discharge process for English- or Spanish-speaking parents of children aged 2 months to 2 years with fever and/or respiratory illness. At 1 year after the index visit, a standardized chart review was performed. The primary outcome was the number of ED visits within 72 hours of the index visit. Multivariable logistic regression was used to examine the relative importance of predictor variables and adjust for confounders. There were 202 parents eligible for inclusion, of whom 23% were Spanish speaking. In addition, 6.9% of the sample had a return visit within 72 hours. After adjustment for confounders, Spanish language was associated with return visit within 72 hours (odds ratio, 3.49; 95% confidence interval, 1.02-11.90) but decreased risk of a second visit within the year (odds ratio, 0.28; 95% confidence interval, 0.12-0.66). Spanish-speaking parents are at an increased risk of 72-hour return ED visit but do not seem to be at increased risk of ED use during the year after their ED visit.

A 5-year comparison of ED visits by homeless and nonhomeless patients.

PubMed

Tadros, Allison; Layman, Shelley M; Brewer, Marissa Pantaleone; Davis, Stephen M

2016-05-01

A 2005 study examined emergency department (ED) utilization by homeless patients in the United States. Within the following 5 years, unemployment increased by 5%. The objective was to analyze changes in ED utilization between 2005 and 2010 by homeless patients and compare with nonhomeless visits. Data from the 2010 National Hospital Ambulatory Medical Care Survey were evaluated. Approximately 679854 visits were made by homeless patients, the majority of which were made by men (72.3%) and patients between the ages of 45 and 64 (50.5%). Homeless patients were twice as likely to be uninsured. ED visits by homeless patients had increased by 44% during the 5-year period. Arrival to the ED by ambulance increased by 14% between the study years, and homeless patients were less likely to be admitted. The number of visits by homeless patients in the ED increased proportionally to an overall increase in ED visits between 2005 and 2010. Copyright © 2016 Elsevier Inc. All rights reserved.

The Burden of Inappropriate Emergency Department Pediatric Visits: Why Italy Needs an Urgent Reform

PubMed Central

Vedovetto, Alessio; Soriani, Nicola; Merlo, Emanuela; Gregori, Dario

2014-01-01

Objective To better understand the issue of inappropriate pediatric Emergency Department (ED) visits in Italy, including the impact of the last National Health System reform. Study Design A retrospective cohort study was conducted with five health care providers in the Veneto region (Italy) in a 2-year period (2010–2011). ED visits were considered “inappropriate” by evaluating both nursing triage and resource utilization, as addressed by the Italian Ministry of Health in 2007. Factors associated with inappropriate ED visits were identified. The cost of each visit was calculated. Principal Findings In total, 134,358 ED visits with 455,650 performed procedures were recorded in the 2-year period; of these, 76,680 (57.1 percent) were considered inappropriate ED visits. Patients likely to make inappropriate ED visits were younger, female, visiting the ED during night or holiday, when the primary care provider (PCP) is not available. Conclusion The National Health System reform aims to improve efficiency, effectiveness, and costs by opening PCP offices 24 hours a day and 7 days a week. This study highlights the need for a deep reorganization of the Italian Primary Care System not only providing a larger time availability but also treating the parents' lack of education on children's health. PMID:24495258

The burden of inappropriate emergency department pediatric visits: why Italy needs an urgent reform.

PubMed

Vedovetto, Alessio; Soriani, Nicola; Merlo, Emanuela; Gregori, Dario

2014-08-01

To better understand the issue of inappropriate pediatric Emergency Department (ED) visits in Italy, including the impact of the last National Health System reform. A retrospective cohort study was conducted with five health care providers in the Veneto region (Italy) in a 2-year period (2010-2011). ED visits were considered "inappropriate" by evaluating both nursing triage and resource utilization, as addressed by the Italian Ministry of Health in 2007. Factors associated with inappropriate ED visits were identified. The cost of each visit was calculated. In total, 134,358 ED visits with 455,650 performed procedures were recorded in the 2-year period; of these, 76,680 (57.1 percent) were considered inappropriate ED visits. Patients likely to make inappropriate ED visits were younger, female, visiting the ED during night or holiday, when the primary care provider (PCP) is not available. The National Health System reform aims to improve efficiency, effectiveness, and costs by opening PCP offices 24 hours a day and 7 days a week. This study highlights the need for a deep reorganization of the Italian Primary Care System not only providing a larger time availability but also treating the parents' lack of education on children's health. © Health Research and Educational Trust.

Using Google Flu Trends data in forecasting influenza-like-illness related ED visits in Omaha, Nebraska.

PubMed

Araz, Ozgur M; Bentley, Dan; Muelleman, Robert L

2014-09-01

Emergency department (ED) visits increase during the influenza seasons. It is essential to identify statistically significant correlates in order to develop an accurate forecasting model for ED visits. Forecasting influenza-like-illness (ILI)-related ED visits can significantly help in developing robust resource management strategies at the EDs. We first performed correlation analyses to understand temporal correlations between several predictors of ILI-related ED visits. We used the data available for Douglas County, the biggest county in Nebraska, for Omaha, the biggest city in the state, and for a major hospital in Omaha. The data set included total and positive influenza test results from the hospital (ie, Antigen rapid (Ag) and Respiratory Syncytial Virus Infection (RSV) tests); an Internet-based influenza surveillance system data, that is, Google Flu Trends, for both Nebraska and Omaha; total ED visits in Douglas County attributable to ILI; and ILI surveillance network data for Douglas County and Nebraska as the predictors and data for the hospital's ILI-related ED visits as the dependent variable. We used Seasonal Autoregressive Integrated Moving Average and Holt Winters methods with3 linear regression models to forecast ILI-related ED visits at the hospital and evaluated model performances by comparing the root means square errors (RMSEs). Because of strong positive correlations with ILI-related ED visits between 2008 and 2012, we validated the use of Google Flu Trends data as a predictor in an ED influenza surveillance tool. Of the 5 forecasting models we have tested, linear regression models performed significantly better when Google Flu Trends data were included as a predictor. Regression models including Google Flu Trends data as a predictor variable have lower RMSE, and the lowest is achieved when all other variables are also included in the model in our forecasting experiments for the first 5 weeks of 2013 (with RMSE = 57.61). Google Flu Trends data statistically improve the performance of predicting ILI-related ED visits in Douglas County, and this result can be generalized to other communities. Timely and accurate estimates of ED volume during the influenza season, as well as during pandemic outbreaks, can help hospitals plan their ED resources accordingly and lower their costs by optimizing supplies and staffing and can improve service quality by decreasing ED wait times and overcrowding. Copyright © 2014 Elsevier Inc. All rights reserved.

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.

Mental Health-related Emergency Department Visits Associated With Cannabis in Colorado.

PubMed

Hall, Katelyn E; Monte, Andrew A; Chang, Tae; Fox, Jacob; Brevik, Cody; Vigil, Daniel I; Van Dyke, Mike; James, Katherine A

2018-02-24

Cannabis legalization in Colorado resulted in increased cannabis-associated health care utilization. Our objective was to examine cooccurrence of cannabis and mental health diagnostic coding in Colorado emergency department (ED) discharges and replicate the study in a subpopulation of ED visits where cannabis involvement and psychiatric diagnosis were confirmed through medical review. We collected statewide ED International Classification of Diseases, 9th Revision, Clinical Modification diagnoses from the Colorado Hospital Association and a subpopulation of ED visits from a large, academic hospital from 2012 to 2014. Diagnosis codes identified visits associated with mental health and cannabis. Codes for mental health conditions and cannabis were confirmed by manual records review in the academic hospital subpopulation. Prevalence ratios (PRs) of mental health ED discharges were calculated to compare cannabis-associated visits to those without cannabis. Rates of mental health and cannabis-associated ED discharges were examined over time. Statewide data demonstrated a fivefold higher prevalence of mental health diagnoses in cannabis-associated ED visits (PR = 5.35, 95% confidence interval [CI], 5.27-5.43) compared to visits without cannabis. The hospital subpopulation supported this finding with a fourfold higher prevalence of psychiatric complaints in cannabis attributable ED visits (PR = 4.87, 95% CI = 4.36-5.44) compared to visits not attributable to cannabis. Statewide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p < 0.0001). In Colorado, the prevalence of mental health conditions in ED visits with cannabis-associated diagnostic codes is higher than in those without cannabis. There is a need for further research determining if these findings are truly attributed to cannabis or merely coincident with concurrent increased use and availability. © 2018 by the Society for Academic Emergency Medicine.

Alcohol-related emergency department visits associated with collegiate football games.

PubMed

Shook, Janice; Hiestand, Brian C

2011-01-01

In 2003, after several post-college football game riots, multiple strategies including strict enforcement of open container laws were instituted by the authors' city and university. The authors compared alcohol-related visits to the on-campus emergency department (ED) associated with home football games in 2002 and 2006, hypothesizing that alcohol-related visits should decline. ED patients during home game weekends. Retrospective cohort study comparing the 2002 and 2006 home games-similar seasons wherein the team went undefeated. Logistic regression assessed the impact of environmental and patient characteristics on the likelihood of an ED visit being alcohol related. In total 2,220 visits in 2002 and 2,146 visits in 2006 were reviewed. Alcohol-related visits increased from 2002 (7.9%) to 2006 (9.5%, p = .06). Despite community interventions, the odds of an ED visit being alcohol related increased (odds ratio [OR] 1.3, 95% confidence interval [CI₉₅] 1.06-1.64). Community measures did not reduce alcohol-related visits to the ED.

Differentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university.

PubMed

Ngo, Duc Anh; Ait-Daoud, Nassima; Rege, Saumitra V; Ding, Christopher; Gallion, Lauren; Davis, Susan; Holstege, Christopher P

2018-02-01

Few studies have explored the epidemiology of students presenting to the emergency department (ED) as a consequence of hazardous drinking. This study examined differentials and trends in ED visits following alcohol intoxication and co-occurring conditions among students presenting to a major U.S. university health system. The ED electronic medical records from academic years 2010-2015 were queried for student visits and their records were linked to the university's student admission datasets. Student alcohol-related visits were identified based on ICD-9 codes. Student characteristics and trends in the rate of alcohol intoxication per 100 ED student visits were analyzed. A random sample of 600 student clinical records were reviewed to validate diagnostic codes. There were 9616 student ED visits (48% males) to the ED of which 1001 (10.4%) visits involved alcohol intoxication. Two thirds of ED visits with alcohol intoxication had a co-occurring diagnosis, with injuries (24%) being the most common condition. The rate of alcohol intoxication varied greatly by student demographics and campus-related factors. There was a linear increase in the rate of alcohol intoxication from 7.9% in 2009-10 to 12.3% in 2014-15 (p<0.01). The increase was greater among female students, students below 20 years of age, Asian students, and student athletes. In the sample reviewed, only two thirds of ED visits with alcohol intoxication were recorded by diagnostic codes. The rate of ED visits following alcohol intoxication varied by student demographic characteristics and campus-related factors with a rising trend over the study period. Copyright © 2017 Elsevier B.V. All rights reserved.

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

Benchmarks for Reducing Emergency Department Visits and Hospitalizations Through Community Health Workers Integrated Into Primary Care: A Cost-Benefit Analysis.

PubMed

Basu, Sanjay; Jack, Helen E; Arabadjis, Sophia D; Phillips, Russell S

2017-02-01

Uncertainty about the financial costs and benefits of community health worker (CHW) programs remains a barrier to their adoption. To determine how much CHWs would need to reduce emergency department (ED) visits and associated hospitalizations among their assigned patients to be cost-neutral from a payer's perspective. Using a microsimulation of patient health care utilization, costs, and revenues, we estimated what portion of ED visits and hospitalizations for different conditions would need to be prevented by a CHW program to fully pay for the program's expenses. The model simulated CHW programs enrolling patients with a history of at least 1 ED visit for a chronic condition in the prior year, utilizing data on utilization and cost from national sources. CHWs assigned to patients with uncontrolled hypertension and congestive heart failure, as compared with other common conditions, achieve cost-neutrality with the lowest number of averted visits to the ED. To achieve cost-neutrality, 4-5 visits to the ED would need to be averted per year by a CHW assigned a panel of 70 patients with uncontrolled hypertension or congestive heart failure-approximately 3%-4% of typical ED visits among such patients, respectively. Most other chronic conditions would require between 7% and 12% of ED visits to be averted to achieve cost-savings. Offsetting costs of a CHW program is theoretically feasible for many common conditions. Yet the benchmark for reducing ED visits and associated hospitalizations varies substantially by a patient's primary diagnosis.

Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study

PubMed Central

Chi, Donald L.; Schwarz, Eli; Milgrom, Peter; Yagapen, Annick; Malveau, Susan; Chen, Zunqui; Chan, Ben; Danner, Sankirtana; Owen, Erin; Morton, Vickie; Lowe, Robert A.

2015-01-01

Objectives. We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits. Methods. We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon’s All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities. Results. Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [CI] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% CI = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% CI = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education. Conclusions. Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits. PMID:25790415

Health outcomes associated with smoke exposure in Albuquerque, New Mexico, during the 2011 Wallow fire.

PubMed

Resnick, Adam; Woods, Brian; Krapfl, Heidi; Toth, Barbara

2015-01-01

This study examined the association between PM2.5 levels and emergency department (ED) visits for selected health outcomes in Albuquerque, New Mexico, during the Wallow fire of 2011. Measurements of 24-hour average concentrations of PM2.5 obtained from the City of Albuquerque were used to calculate wildfire smoke exposure in Albuquerque. Daily ED visits were collected by the New Mexico Department of Health from individual nonfederal licensed facilities in the Albuquerque area. Poisson regression was used to assess the relationship between ED visits for selected respiratory and cardiovascular conditions and varying levels of PM2.5 exposure. Albuquerque, New Mexico. Patients visiting an ED for select conditions before, during, and after the wildfire. Relative increase in ED visits for selected conditions during the wildfire period. Analysis of PM2.5 exposure data and ED visits in Albuquerque before and during the Wallow fire indicated that compared with the period prior to the fire, there was an increased risk of ED visits for some respiratory and cardiovascular conditions during heavy smoke conditions, and risk varied by age and sex. The population of 65+ years was especially at risk for increased ED visits. There was a significantly increased risk of ED visits among the 65+ population for asthma (RR [relative rate] = 1.73, 95% confidence interval [CI] = 1.03-2.93) and for diseases of the veins, lymphatic and circulatory system (RR = 1.56, 95% CI = 1.00-2.43). For the age group of 20 to 64 years, there was a statistically significant increase in ED visits for diseases of pulmonary circulation (RR = 2.64, 95% CI = 1.42-4.9) and for cerebrovascular disease (RR = 1.69, 95% CI = 1.03-2.77). High levels of PM2.5 exposure due to the Wallow fire were associated with increased ED visits for respiratory and cardiovascular conditions in Albuquerque. More effective and targeted preventive measures are necessary to reduce morbidity rates associated with wildfire smoke exposure among vulnerable populations.

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

PubMed

Shippee, Nathan D; Shippee, Tetyana P; Hess, Erik P; Beebe, Timothy J

2014-02-08

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. 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. 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. 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.

Emergency department burden of constipation in the United States from 2006 to 2011.

PubMed

Sommers, Thomas; Corban, Caroline; Sengupta, Neil; Jones, Michael; Cheng, Vivian; Bollom, Andrea; Nurko, Samuel; Kelley, John; Lembo, Anthony

2015-04-01

Although constipation is typically managed in an outpatient setting, there is an increasing trend in the frequency of constipation-related hospital visits. The aim of this study was to analyze trends related to chronic constipation (CC) in the United States with respect to emergency department (ED) visits, patient and hospital characteristics, and associated costs. Data from 2006 to 2011, in which constipation (The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes 564.00-564.09) was the primary discharge diagnosis, were obtained from the National Emergency Department Sample (NEDS). Between 2006 and 2011, the frequency of constipation-related ED visits increased by 41.5%, from 497,034 visits to 703,391 visits, whereas the mean cost per patient rose by 56.4%, from $1,474 in 2006 to $2,306 in 2011. The aggregate national cost of constipation-related ED visits increased by 121.4%, from $732,886,977 in 2006 to $1,622,624,341 in 2011. All cost data were adjusted for inflation and reported in 2014 dollars. Infants (<1 year old) had the highest rate of constipation-related ED visits in both 2006 and 2011. The late elders (85+ years) had the second highest constipation-related ED visit rate in 2006; however, the 1- to 17-year-old age group experienced a 50.7% increase in constipation-related ED visit rate from 2006 to 2011 and had the second highest constipation-related ED visit rate in 2011. The frequency of and the associated costs of ED visits for constipation are significant and have increased notably from 2006 to 2011.

Quantifying Emergency Department Visits From Sport and Recreation: Focus on the Lower Extremity and Knee, 1997–2009

PubMed Central

Tenan, Matthew S.

2016-01-01

Context:  Few authors have reported nationally representative data on the number of sport and recreation (SR) injuries resulting in emergency department (ED) visitation. The existing studies have only provided 1 or 2 years of data and are not longitudinal in nature. Objective:  To use a novel algorithmic approach to determine if ED visitation is due to SR, resulting in a substantially larger longitudinal dataset. Design:  Descriptive epidemiology study. Setting:  Hospital. Patients or Other Participants:  The National Hospital Ambulatory Medical Care Survey, a stratified random-sample survey of US hospital EDs was combined for years 1997–2009. There were 15 699 unweighted patient visits determined to be from SR. Main Outcome Measure(s):  A custom algorithm classified SR visits based on the International Classification of Diseases, Ninth Revision, Clinical Modification E-code and pattern recognition of narrative text. Sport and recreation visits were assessed by age and categorized according to broad injury classifications. Additional quantification was performed on SR visits for lower extremity and knee-specific injuries. Sample weights were applied to provide national annual estimates. Results:  Annually, 4 243 000 ED visits resulted from SR. The largest classification of injury from SR was sprains and strains (896 000/y). Males had substantially more SR-related ED visits than females (2 929 000/y versus 1 314 000/y). For patients 10–49 years old, 1 093 000 lower extremity and 169 000 knee-specific injury visits annually were from SR. For both injury types, males had a higher rate of ED visitation; however, females had 25% and 39% greater odds of visitation for lower extremity and knee-specific injury, respectively. Conclusions:  The burden on the health system of ED visits from SR was substantial. Males presented in the ED at a higher rate for SR injury, though females had a higher proportion of lower extremity and knee-specific injury ED visitations from SR. This longitudinal analysis of population-level data provides the information to target research on specific subpopulations to mitigate SR injury. PMID:27075528

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

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments.

PubMed

Klein, Eili Y; Levin, Scott; Toerper, Matthew F; Makowsky, Michael D; Xu, Tim; Cole, Gai; Kelen, Gabor D

2017-11-01

A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland. We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015). The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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 Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

PubMed

Finnegan, Micaela A; Shaffer, Robyn; Remington, Austin; Kwong, Jereen; Curtin, Catherine; Hernandez-Boussard, Tina

2017-06-21

Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Elevated Steady State WBC and Platelet Counts Are Associated with Frequent Emergency Room Use in Adults with Sickle Cell Anemia

PubMed Central

Danda, Neeraja; Etzion, Zipora

2015-01-01

Introduction Sickle cell anemia has many sequelae that result in emergency department (ED) use, but a minority of patients with sickle cell disease are frequent utilizers and make up the majority of ED visits. If patients who are likely to be frequent ED can be identified in steady state, they can be treated with disease modifying agents in an attempt to reduce ED use frequency. We sought to identify steady state markers for frequent ED use. Methods We identified all patients with SS/Sβ0 seen at our facilities in 2012. Health care utilization over the entire year was calculated and ED visit numbers categorized as either 0–1, 2–5, or 6 or more visits a year. Steady state and acutely active laboratory parameters were collected and analyzed using analysis of variance models and odds ratios. Results 432 adult sickle cell patients were identified, ages 18–87, 54% female, and 38% had been prescribed hydroxyurea. Of the 432 patients,192 had 0–1 visits in the year, 144 had 2–5 visits in the year, and 96 had >6 visits for a total of 2259 visits. Those who had >6 visits accounted for 1750 (77%) of the total visits for the year. When steady state laboratory markers were examined, each additional 50x109/L platelets was associated with 22% greater risk (p < .001); each 1x109/L of WBC was associated with 11% greater risk (p = .003), and each 1g/dL Hb was associated with 23% lower risk (p = .007) of >6 ED visits/year. We did not observe a relationship between baseline HbF, LDH or reticulocyte count with >6 ED visits. Conclusion Patients with elevated white blood cell counts, elevated platelet counts, and low hemoglobin levels exhibited higher risk for frequent ED utilization and could be candidates for early and aggressive therapy with disease modifying agents. PMID:26248283

Characterization of Young Adult Emergency Department Users: Evidence to Guide Policy.

PubMed

Burns, Carson; Wang, N Ewen; Goldstein, Benjamin A; Hernandez-Boussard, Tina

2016-12-01

The purpose of this study was to characterize young adult patients aged 19-25 years who are emergency department (ED) frequent users and study factors associated with frequent ED use. ED visits among 19- to 25-year olds were identified from administrative records in California, Florida, Iowa, Massachusetts, and New York, 2010. Patients were analyzed for 12 months to study the frequency of their ED utilization. ED visits were categorized according to primary diagnosis. Patients were stratified by frequency of ED use: one visit (single users), two to four visits (infrequent users), and five or more visits (frequent users) in a 1-year period. We identified 1,711,774 young adult patients who made 3,650,966 ED visits. Sixty-six percent of patients were single users, 29% were infrequent users, and 4.6% were frequent users. Frequent users accounted for a disproportionate 28.8% of visits within the population studied. Frequent users had the largest proportion of visits for complications of pregnancy (13.6%) compared to single users (6.1%) and Medicaid (42.6%) compared to private insurance (17.3%). There was an increased risk of frequent ED use associated with females (odds ratio [OR]: 1.77), Medicaid (OR: 3.21), and Medicare insurance (OR: 4.22) compared to private insurance, and diseases of the blood (OR: 3.36) and mental illness (OR: 1.99) compared to injury and poisoning. Frequent users comprise a significant portion of the young adult ED population and present with a large proportion of visits for complications of pregnancy. Policies targeting this population might focus on improved access to primary and urgent care, acute obstetric care, and better coordination of care. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Use of emergency department services by women victims of violence in Lazio region, Italy.

PubMed

Farchi, Sara; Polo, Arianna; Asole, Simona; Ruggieri, Maria Pia; Di Lallo, Domenico

2013-07-19

Violence against women is a significant health problem and a hidden phenomenon, in Italy that about 31% of the women have been victims of violence once in life. Aims of this study are to describe characteristics of women victims of violence (VV) attending the EDs in the Lazio region in 2008 and to illustrate the frequency and characteristics of previous ED visits. Using the Emergency Information System, visits of women, (15-49 years), in the 60 EDs, for a violent trauma have been analysed. For each VV identified, we considered the last episode and searched for ED attendances in a six year period (2003-08) in order to identify other visits. We performed descriptive analyses of socio-demographic and clinical factors of VV and we analyzed the impact previous ED visits. We compared ED utilization of women VV with a random sample of women with the same age distribution who gave birth in 2008. In 2008, 7,725 ED attendances of women VV were found (1.1% of the ED visits) corresponding to 6,936 women (prevalence = 52.0x10,000). The mean number of ED visits for each woman in five years was 5.0 (1-190). Prevalent diagnoses were contusions (45.8%), neurotic disorders (5.4%) complications of medical care (6.3%). The women were young, approximately 70% were residents in Rome or the surrounding areas. Foreign women were three times more likely to visit the ED for intentional injuries than were Italian women (114.1 vs 44.4 per 10.000). This study shows high prevalence of violence against women in Lazio region, Italy. Most of the women have been visited by the ED several times before the violent episode, often with traumas. ED medical and nursing staff should be prepared and trained to successfully manage victims of violence.

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.

The characteristics of hospital emergency department visits made by people with mental health conditions who had dental problems.

PubMed

Nalliah, Romesh P; Da Silva, John D; Allareddy, Veerasathpurush

2013-06-01

There is a paucity of knowledge regarding nationally representative estimates of hospital-based emergency department (ED) visits for dental problems made by people with mental health conditions. The authors conducted a study to provide nationwide estimates of hospital-based ED visits attributed to dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess made by people with mental health conditions. The authors used the Nationwide Emergency Department Sample, which is a component of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. ED visits attributable to dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess were identified by the emergency care provider by using diagnostic codes in International Classification of Diseases, Ninth Revision, Clinical Modification. The authors examined outcomes, including hospital charges. They used simple descriptive statistics to summarize the data. In 2008, people with mental health conditions made 15,635,253 visits to hospital-based ED in the United States. A diagnosis of dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess represented 63,164 of these ED visits. The breakdown of the ED visits was 34,574 with dental caries, 25,352 with pulpal and periapical lesions, 9,657 with gingival and periodontal lesions, and 2,776 with mouth cellulitis/abscess. The total charge for ED visits in the United States was $55.46 million in 2008. In 2008, people with mental health conditions made 63,164 visits to hospital-based EDs and received a diagnosis of dental caries, pulpal and periapical lesions, gingival and periodontal lesions or mouth cellulitis/abscess. These ED visits incurred substantial hospital charges. Programs designed to reduce the number of ED visits made by this population for common dental problems could have a substantial impact in reducing the use of hospital resources. Practical Implications. Clinicians should implement preventive practices for patients with mental health conditions. The authors identified combinations of mental health conditions and dental problems that led to patients with mental health conditions making visits to hospital-based EDs for dental problems more frequently than did patients in the general population.

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.

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

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.

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

Revisit rates and associated costs after an emergency department encounter: a multistate analysis.

PubMed

Duseja, Reena; Bardach, Naomi S; Lin, Grace A; Yazdany, Jinoos; Dean, Mitzi L; Clay, Theodore H; Boscardin, W John; Dudley, R Adams

2015-06-02

Return visits to the emergency department (ED) or hospital after an index ED visit strain the health system, but information about rates and determinants of revisits is limited. To describe revisit rates, variation in revisit rates by diagnosis and state, and associated costs. Observational study using the Healthcare Cost and Utilization Project databases. 6 U.S. states. Adults with ED visits between 2006 and 2010. Revisit rates and costs. Within 3 days of an index ED visit, 8.2% of patients had a revisit; 32% of those revisits occurred at a different institution. Revisit rates varied by diagnosis, with skin infections having the highest rate (23.1% [95% CI, 22.3% to 23.9%]). Revisit rates also varied by state. For skin infections, Florida had higher risk-adjusted revisit rates (24.8% [CI, 23.5% to 26.2%]) than Nebraska (10.6% [CI, 9.2% to 12.1%]). In Florida, the only state with complete cost data, total revisit costs for the 19.8% of patients with a revisit within 30 days were 118% of total index ED visit costs for all patients (including those with and without a revisit). Whether a revisit reflects inadequate access to primary care, a planned revisit, the patient's nonadherence to ED recommendations, or poor-quality care at the initial ED visit remains unknown. Revisits after an index ED encounter are more frequent than previously reported, in part because many occur outside the index institution. Among ED patients in Florida, more resources are spent on revisits than on index ED visits. Agency for Healthcare Research and Quality.

Patient and Community-Level Socio-Demographic Characteristics Associated with Emergency Department Visits for Childhood Injury; A Retrospective Analysis of Data from the Pediatric Emergency Care Applied Research Network (PECARN) Core Data Project 2004–2008

PubMed Central

Macy, Michelle L.; Zonfrillo, Mark R.; Cook, Lawrence J.; Funai, Tomohiko; Goldstick, Jason; Stanley, Rachel M.; Chamberlain, James M.; Cunningham, Rebecca M.; Lipton, Robert; Alpern, Elizabeth R.

2015-01-01

Objective To examine pediatric emergency department (ED) visits over 5 years, trends in injury severity, and associations between injury-related ED visit outcome and patient and community-level socio-demographic characteristics. Study design Retrospective analysis of administrative data provided to the Pediatric Emergency Care Applied Research Network Core Data Project, 2004–2008. Home addresses were geocoded to determine census block group and associated socio-demographic characteristics. Maximum Abbreviated Injury Scale severity and Severity Classification System scores were calculated. Generalized estimating equations were used to test for associations between socio-demographic characteristics and admission or transfer among injury-related ED visits. Results Overall ED visits and injury-related visits increased from 2004 to 2008 at study sites. Of 2,833,676 successfully geocoded visits, 700,821 (24.7%) were injury-related. The proportion of higher severity injury-related visits remained consistent. Nearly 10% of injury-related visits resulted in admission or transfer each year. After adjusting for age, sex, payer, and injury severity, odds of admission or transfer were lower among minority children and children from areas with moderate and high prevalence of poverty. Conclusions Pediatric injury-related ED visits to included sites increased over the study period while injury severity, anticipated resource utilization, and visit outcomes remained stable, with low rates of admission or transfer. Socio-demographic differences in injury-related visits and ED disposition were apparent. ED-based injury surveillance is essential to understand disparities, inform targets for prevention programs, and reduce the overall burden of childhood injuries. PMID:26141551

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

Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features.

PubMed

Kreitzer, Natalie; Lyons, Michael S; Hart, Kim; Lindsell, Cristopher J; Chung, Sora; Yick, Andrew; Bonomo, Jordan

2014-10-01

Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown. This study characterized clinical outcomes in mild TBI patients with acute traumatic ICH seen on initial ED neuroimaging. This retrospective cohort study included patients presenting to the ED with blunt mild TBI with Glasgow Coma Scale (GCS) scores of 14 or 15 and stable vital signs, during the period from January 2001 to January 2010. Patients with any ICH on initial head CT and repeat head CT within 24 hours were eligible. Cases were excluded for initial GCS < 14, injury > 24 hours old, pregnancy, concomitant nonminor injuries, and coagulopathy. A single investigator abstracted data from records using a standardized case report form and data dictionary. Primary endpoints included death, neurosurgical procedures, and for discharged patients, return to the ED within 7 days. Differences in proportions were computed with 95% confidence intervals (CIs). Of 1,011 patients who presented to the ED and had two head CTs within 24 hours, 323 (32%) met inclusion criteria. The median time between CT scans was 6 hours (interquartile range = 5 to 7 hours). A total of 153 (47%) patients had subarachnoid hemorrhage, 132 (41%) patients had subdural hemorrhage, 11 (3%) patients had epidural hemorrhage, 78 (24%) patients had cerebral contusions, and 59 (18%) patients had intraparenchymal hemorrhage. Four of 323 (1.2%, 95% CI = 0.3% to 3.2%) patients died within 2 weeks of injury. Three of the patients who died had been admitted from the ED on their initial visits, and one had been discharged home. There were 206 patients (64%) discharged from the ED, 28 (13.6%) of whom returned to the ED within 1 week. Of the 92 who were hospitalized, three (0.9%, 95% CI = 0.2% to 2.7%) required neurosurgical intervention. Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study. © 2014 by the Society for Academic Emergency Medicine.

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.

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

Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments.

PubMed

Barakat, Monique T; Mithal, Aditi; Huang, Robert J; Mithal, Alka; Sehgal, Amrita; Banerjee, Subhas; Singh, Gurkirpal

2017-01-01

The Affordable Care Act (ACA) has expanded access to health insurance for millions of Americans, but the impact of Medicaid expansion on healthcare delivery and utilization remains uncertain. To determine the early impact of the Medicaid expansion component of ACA on hospital and ED utilization in California, a state that implemented the Medicaid expansion component of ACA and Florida, a state that did not. Analyze all ED encounters and hospitalizations in California and Florida from 2009 to 2014 and evaluate trends by payer and diagnostic category. Data were collected from State Inpatient Databases, State Emergency Department Databases and the California Office of Statewide Health Planning and Development. Hospital and ED encounters. Population-based study of California and Florida state residents. Implementation of Medicaid expansion component of ACA in California in 2014. Changes in ED visits and hospitalizations by payer, percentage of patients hospitalized after an ED encounter, top diagnostic categories for ED and hospital encounters. In California, Medicaid ED visits increased 33% after Medicaid expansion implementation and self-pay visits decreased by 25% compared with a 5.7% increase in the rate of Medicaid patient ED visits and a 5.1% decrease in rate of self-pay patient visits in Florida. In addition, California experienced a 15.4% increase in Medicaid inpatient stays and a 25% decrease in self pay stays. Trends in the percentage of patients admitted to the hospital from the ED were notable; a 5.4% decrease in hospital admissions originating from the ED in California, and a 2.1% decrease in Florida from 2013 to 2014. We observed a significant shift in payer for ED visits and hospitalizations after Medicaid expansion in California without a significant change in top diagnoses or overall rate of these ED visits and hospitalizations. There appears to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization.

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

Trends and Comparisons of Utilization of Emergency Departments Due to Traumatic or Non-Traumatic Causes among the HIV-Positive Population in Taiwan, 2006–2011

PubMed Central

Lin, Ching-Heng; Lin, Ting; Chou, Pesus

2017-01-01

It is important that the utilization of emergency departments (EDs) among people living with the human immunodeficiency virus (HIV) be epidemiologically evaluated in order to assess and improve the HIV care continuum. All participants newly-diagnosed with HIV in Taiwan registered in the National Health Insurance Database from 2000 to 2005 were enrolled in this study and followed-up from 2006 to 2011. In total, 3500 participants newly-diagnosed with HIV in 2000–2005 were selected as a fixed-cohort population and followed-up from 2006 to 2011. Overall, 704, 645, 591, 573, 578, and 568 cases made 1322, 1275, 1050, 1061, 1136, and 992 ED visits in 2006, 2007, 2008, 2009, 2010 and 2011, respectively, with an average number of ED visits ranging from 1.75 to 1.98 per person, accounting for 20.1–22.6% of the whole HIV-positive population. Fewer ED visits were due to traumatic reasons, accounting for 19.6–24.4% of all cases. The incidence of traumatic and non-traumatic ED visits among the HIV-positive participants ranged from 7.2–9.3 and 27.0–33.9 per 100 people, respectively. The average direct medical cost of traumatic and non-traumatic ED visits ranged from $89.3–112.0 and $96.6–120.0, respectively. In conclusion, a lower incidence of ED visits for all reasons and fewer ED visits owing to traumatic causes were observed in the population living with HIV in comparison with the general population; however, the direct medical cost of each ED visit owing to both traumatic and non-traumatic causes was greater among those living with HIV than in the general population. PMID:29019947

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.

Does emergency department use and post-visit physician care cluster geographically and temporally for adolescents who self-harm? A population-based 9-year retrospective cohort study from Alberta, Canada.

PubMed

Rosychuk, Rhonda J; Johnson, David W; Urichuk, Liana; Dong, Kathryn; Newton, Amanda S

2016-07-11

Clustering of adolescent self-harming behaviours in the context of health care utilization has not been studied. We identified geographic areas with higher numbers of adolescents who (1) presented to an emergency department (ED) for self-harm, and (2) were without a physician follow-up visit for mental health within 14 days post-ED visit. We extracted a population-based cohort of adolescents aged 15-17 years (n = 3,927) with ED visits during 2002-2011 in Alberta, Canada. We defined the case as an individual with one or more ED presentations for self-harm in the fiscal year of the analysis. Crude case rates were calculated and clusters were identified using a spatial scan. The rates decreased over time for ED visits for self-harm (differences: girls -199.6/100,000; p < 0.01; boys -58.8/100,000; p < 0.01), and for adolescents without a follow-up visit within 14 days following an ED visit for self-harm (differences: girls -108.3/100,000; p < 0.01; boys -61.9/100,000; p < 0.01). Two space-time clusters were identified: (1) a North zone cluster during 2002-2006 (p < 0.01) and (2) a South zone cluster during 2003-2007 (p < 0.01). These clusters had higher numbers of adolescents who presented to the ED for self-harm (relative risks [RRs]: 1.58 for cluster 1, 3.54 for cluster 2) and were without a 14-day physician follow-up (RRs: 1.78 for cluster 1, 4.17 for cluster 2). In 2010/2011, clusters in the North, Edmonton, and Central zones were identified for adolescents with and without a follow-up visit within 14 days following an ED visit for self-harm (p < 0.01). The rates for ED visits for adolescents who self-harm and rates of adolescents without a 14-day physician follow-up visit following emergency care for self-harm decreased during the study period. The space-time clusters identified the areas and years where visits to the ED by adolescents for self-harm were statistically higher than expected. These clusters can be used to identify locations where adolescents are potentially not receiving follow-up and the mental health support needed after emergency-based care. The 2010/2011 geographic cluster suggests that the northern part of the province still has elevated numbers of adolescents visiting the ED for self-harm. Prospective research is needed to determine outcomes associated with adolescents who receive physician follow-up following ED-based care for self-harm compared to those who do not.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users.

PubMed

Capp, Roberta; Misky, Gregory J; Lindrooth, Richard C; Honigman, Benjamin; Logan, Heather; Hardy, Rose; Nguyen, Dong Q; Wiler, Jennifer L

2017-10-01

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities. Project HOPE—The People-to-People Health Foundation, Inc.

Analysis of Patient Visits and Collections After Opening a Satellite Pediatric Emergency Department.

PubMed

Nichols, Katherine M; Caperell, Kerry; Cross, Keith; Duncan, Scott; Foster, Ben; Liu, Gil; Pritchard, Hank; Southard, Gary; Shinabery, Ben; Sutton, Brad; Kim, In K

2018-04-01

Satellite pediatric emergency departments (PEDs) have emerged as a strategy to increase patient capacity. We sought to determine the impact on patient visits, physician fee collections, and value of emergency department (ED) time at the primary PED after opening a nearby satellite PED. We also illustrate the spatial distribution of patient demographics and overlapping catchment areas for the primary and satellite PEDs using geographical information system. A structured, financial retrospective review was conducted. Aggregate patient demographic data and billing data were collected regarding physician fee charges, collections, and patient visits for both PEDs. All ED visits from January 2009 to December 2013 were analyzed. Geographical information system mapping using ArcGIS mapped ED patient visits. Patient visits at the primary PED were 53,050 in 2009 before the satellite PED opened. The primary PED visits increased after opening the satellite PED to 55,932 in 2013. The satellite PED visits increased to 21,590 in 2013. Collections per visit at the primary PED decreased from $105.13 per visit in 2011 to $86.91 per visit in 2013. Total collections at the satellite PED decreased per visit from $155.41 per visit in 2011 to $128.53 per visit in 2013. After opening a nearby satellite PED, patient visits at the primary PED did not substantially decrease, suggesting that there was a previously unrecognized demand for PED services. The collections per ED visit were greater at the satellite ED, likely due to a higher collection rate.

Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies.

PubMed

Yan, Justin W; Gushulak, Katherine M; Columbus, Melanie P; Hamelin, Alexandra L; Wells, George A; Stiell, Ian G

2018-03-01

Patients with poorly controlled diabetes mellitus may have a sentinel emergency department (ED) visit for a precipitating condition prior to presenting for a hyperglycemic emergency, such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). This study's objective was to describe the epidemiology and outcomes of patients with a sentinel ED visit prior to their hyperglycemic emergency visit. This was a 1-year health records review of patients≥18 years old presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, DKA, or HHS. Trained research personnel collected data on patient characteristics, management, disposition, and determined whether patients came to the ED within the 14 days prior to their hyperglycemia visit. Descriptive statistics were used to summarize the data. Of 833 visits for hyperglycemia, 142 (17.0%; 95% CI: 14.5% to 19.6%) had a sentinel ED presentation within the preceding 14 days. Mean (SD) age was 50.5 (19.0) years and 54.4% were male; 104 (73.2%) were discharged from this initial visit, and 98/104 (94.2%) were discharged either without their glucose checked or with an elevated blood glucose (>11.0 mmol/L). Of the sentinel visits, 93 (65.5%) were for hyperglycemia and 22 (15.5%) for infection. Upon returning to the ED, 61/142 (43.0%) were admitted for severe hyperglycemia, DKA, or HHS. In this unique ED-based study, diabetic patients with a sentinel ED visit often returned and required subsequent admission for hyperglycemia. Clinicians should be vigilant in checking blood glucose and provide clear discharge instructions for follow-up and glucose management to prevent further hyperglycemic emergencies from occurring.

Reasons for Ninety-Day Emergency Visits and Readmissions After Elective Total Joint Arthroplasty: Results From a US Integrated Healthcare System.

PubMed

Kelly, Matthew P; Prentice, Heather A; Wang, Wei; Fasig, Brian H; Sheth, Dhiren S; Paxton, Elizabeth W

2018-07-01

Previous studies evaluating reasons for 30-day readmissions following total joint arthroplasty (TJA) may underestimate hospital-based utilization of healthcare resources during a patient's episode-of-care. We sought to identify common reasons for 90-day emergency department (ED) visits and hospital readmissions following primary elective unilateral TJA. Patients from July 1, 2012 through June 30, 2015 having primary elective TJA and at least one 90-day postoperative ED-only visit and/or readmission for any reason were identified using the Kaiser Permanente Total Joint Replacement Registry. Chart reviews for ED visits/readmissions included 13 surgical and 11 medical reasons. The 2344 total hips and 5520 total knees were analyzed separately. Incidence of at least one ED visit following total hip arthroplasty (THA) was 13.4% and 4.5% for readmissions. The most frequent reasons for ED visits were swelling (15.6%) and pain (12.8%); the most frequent reasons for readmissions were infection (12.5%) and unrelated elective procedures (9.0%). The incidence of at least one ED visit following total knee arthroplasty (TKA) was 13.8%, and the incidence of readmission was 5.5%. The most frequent reasons for ED visits were pain (15.8%) and swelling (15.6%); the most common readmission reasons were gastrointestinal (19.1%) and manipulation under anesthesia (9.4%). Swelling and pain related to the procedure were the most frequent reasons for 90-day ED visits after both THA and TKA. Readmissions were most commonly due to infection or unrelated procedures for THA and gastrointestinal or manipulation under anesthesia for TKA. Modifications to discharge protocols may help prevent or alleviate these issues, avoiding unnecessary hospital returns. Copyright © 2018 Elsevier Inc. All rights reserved.

Effect of ambient temperature on emergency department visits in Shanghai, China: a time series study.

PubMed

Zhang, Yue; Yan, Chenyang; Kan, Haidong; Cao, Junshan; Peng, Li; Xu, Jianming; Wang, Weibing

2014-11-25

Many studies have examined the association between ambient temperature and mortality. However, less evidence is available on the temperature effects on gender- and age-specific emergency department visits, especially in developing countries. In this study, we examined the short-term effects of daily ambient temperature on emergency department visits (ED visits) in Shanghai. Daily ED visits and daily ambient temperatures between January 2006 and December 2011 were analyzed. After controlling for secular and seasonal trends, weather, air pollution and other confounding factors, a Poisson generalized additive model (GAM) was used to examine the associations between ambient temperature and gender- and age-specific ED visits. A moving average lag model was used to evaluate the lag effects of temperature on ED visits. Low temperature was associated with an overall 2.76% (95% confidence interval (CI): 1.73 to 3.80) increase in ED visits per 1°C decrease in temperature at Lag1 day, 2.03% (95% CI: 1.04 to 3.03) and 2.45% (95% CI: 1.40 to 3.52) for males and females. High temperature resulted in an overall 1.78% (95% CI: 1.05 to 2.51) increase in ED visits per 1°C increase in temperature on the same day, 1.81% (95% CI: 1.08 to 2.54) among males and 1.75% (95% CI: 1.03 to 2.49) among females. The cold effect appeared to be more acute among younger people aged <45 years, whereas the effects were consistent on individuals aged ≥65 years. In contrast, the effects of high temperature were relatively consistent over all age groups. These findings suggest a significant association between ambient temperature and ED visits in Shanghai. Both cold and hot temperatures increased the relative risk of ED visits. This knowledge has the potential to advance prevention efforts targeting weather-sensitive conditions.

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.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

PubMed

Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

2017-08-01

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

PubMed

Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

2017-11-01

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

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

PubMed

Rowland, Sandi; Leider, Jonathon P; Davidson, Clare; Brady, Joanne; Knudson, Alana

2016-12-01

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). 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. 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. Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed.

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

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

PubMed

Gurley-Calvez, Tami; Kenney, Genevieve M; Simon, Kosali I; Wissoker, Douglas

2016-08-01

To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. West Virginia Medicaid enrollment and claims data from 2005 to 2010. We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps. Data were obtained from the West Virginia Bureau for Medical Services. We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan. © Health Research and Educational Trust.

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.

Seasonal Variation in Emergency Department Visits Among Pediatric Headache Patients.

PubMed

Pakalnis, A; Heyer, G L

2016-09-01

To ascertain whether seasonal variation occurs in emergency department (ED) visits for headache among children and adolescents. A retrospective review was conducted using the electronic medical records of ED visits for headache at a tertiary children's hospital through calendar years 2010-2014. Using ICD-9 diagnostic codes for headache and migraine, the numbers of headache visits were determined and compared by season and during school months vs summer months. A total of 6572 headache visits occurred. Headache visits increased during the fall season (133 ± 27 visits per month) compared with other seasons (101 ± 19 visits per month), P ≤ .002, but did not differ when comparing school months (113 ± 25 visits per month) and summer months (100 ± 24 visits per month), P = .1. The corresponding increase in ED visits during the fall season coincides with the start of the school year. Academic stressors and the change in daily schedule may lead to more headaches and more ED headache visits among school-aged youth. © 2016 American Headache Society.

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

Trends in the supply of California’s emergency departments and inpatient services, 2005–2014: a retrospective analysis

PubMed Central

Chow, Jessica L; Niedzwiecki, Matthew J; Hsia, Renee Y

2017-01-01

Objectives Given increasing demand for emergency care, there is growing concern over the availability of emergency department (ED) and inpatient resources. Existing studies of ED bed supply are dated and often overlook hospital capacity beyond ED settings. We described recent statewide trends in the capacity of ED and inpatient hospital services from 2005 to 2014. Design Retrospective analysis. Setting Using California hospital data, we examined the absolute and per admission changes in ED beds and inpatient beds in all hospitals from 2005 to 2014. Participants Our sample consisted of all patients inpatient and outpatient) from 501 hospital facilities over 10-year period. Outcome measures We analysed linear trends in the total annual ED visits, ED beds, licensed and staffed inpatient hospital beds and bed types, ED beds per ED visit, and inpatient beds per admission (ED and non-ED). Results Between 2005 and 2014, ED visits increased from 9.8 million to 13.2 million (an increase of 35.0%, p<0.001). ED beds also increased (by 29.8%, p<0.001), with an average annual increase of 195.4 beds. Despite this growth, ED beds per visit decreased by 3.9%, from 6.0 ED beds per 10 000 ED visits in 2005 to 5.8 beds in 2014 (p=0.01). While overall admission numbers declined by 4.9% (p=0.06), inpatient medical/surgical beds per visit grew by 11.3%, from 11.6 medical/surgical beds per 1000 admissions in 2005 to 12.9 beds in 2014 (p<0.001). However, there were reductions in psychiatric and chemical dependency beds per admission, by −15.3% (p<0.001) and −22.4% (p=0.05), respectively. Conclusions These trends suggest that, in its current state, inadequate supply of ED and specific inpatient beds cannot keep pace with growing patient demand for acute care. Analysis of ED and inpatient supply should capture dynamic variations in patient demand. Our novel ‘beds pervisit’ metric offers improvements over traditional supply measures. PMID:28495813

Insurance Expansion and Hospital Emergency Department Access: Evidence From the Affordable Care Act.

PubMed

Garthwaite, Craig; Gross, Tal; Notowidigdo, Matthew; Graves, John A

2017-02-07

Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA). To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits. Quasi-experimental observational study from 2012 to 2014. 126 investor-owned, hospital-based EDs. Uninsured and Medicaid-insured adults aged 18 to 64 years. ACA expansion of Medicaid in January 2014. Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done. There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states. Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types. Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities. Robert Wood Johnson Foundation.

The Impact of a Case of Ebola Virus Disease on Emergency Department Visits in Metropolitan Dallas-Fort Worth, TX, July, 2013-July, 2015: An Interrupted Time Series Analysis.

PubMed

Molinari, Noelle-Angelique M; LeBlanc, Tanya Telfair; Stephens, William

2018-03-20

The first Ebola virus disease (EVD) case in the United States (US) was confirmed September 30, 2014 in a man 45 years old. This event created considerable media attention and there was fear of an EVD outbreak in the US. This study examined whether emergency department (ED) visits changed in metropolitan Dallas-Fort Worth--, Texas (DFW) after this EVD case was confirmed. Using Texas Health Services Region 2/3 syndromic surveillance data and focusing on DFW, interrupted time series analyses were conducted using segmented regression models with autoregressive errors for overall ED visits and rates of several chief complaints, including fever with gastrointestinal distress (FGI). Date of fatal case confirmation was the "event." Results indicated the event was highly significant for ED visits overall (P<0.05) and for the rate of FGI visits (P<0.0001). An immediate increase in total ED visits of 1,023 visits per day (95% CI: 797.0, 1,252.8) was observed, equivalent to 11.8% (95% CI: 9.2%, 14.4%) increase ED visits overall. Visits and the rate of FGI visits in DFW increased significantly immediately after confirmation of the EVD case and remained elevated for several months even adjusting for seasonality both within symptom specific chief complaints as well as overall. These results have implications for ED surge capacity as well as for public health messaging in the wake of a public health emergency.

Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008.

PubMed

Ting, Sarah A; Sullivan, Ashley F; Boudreaux, Edwin D; Miller, Ivan; Camargo, Carlos A

2012-01-01

The objective was to describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period. Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950-E959) during 1993-2008. Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury [1.50 (95% confidence interval, 1.33-1.67) visits per 1000 US population], and the average annual number for these ED visits more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. During the same time frame, ED visits for these injuries per 1000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82) and blacks (1.14 to 2.10). Visits were most common among ages 15-19, and the number of visits coded as urgent/emergent decreased from 0.95 in 1993-1996 to 0.70 in 2005-2008. ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs. Copyright © 2012 Elsevier Inc. All rights reserved.

Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial.

PubMed

Seaberg, David; Elseroad, Stanton; Dumas, Michael; Mendiratta, Sudave; Whittle, Jessica; Hyatte, Cheryl; Keys, Jan

2017-11-01

Emergency department (ED) superutilizers (patients with five or more visits/year) comprise only 5% of the patients seen yet comprise 25% of total ED visits. Although the reasons for this are multifactorial, the cost to the patient and the community is exceedingly high. The cost is not just monetary; care of these patients is inappropriately fragmented and their presence in the ED may contribute to overcrowding affecting the community's emergency readiness. Previous studies using staff trained to help patients navigate their care options have had conflicting results. The objective was to determine whether a trained patient navigator (PN) can reduce ED use and costs in superutilizers over a 1-year period. Superutilizers were enrolled in a prospective randomized controlled clinical trial. Patients were randomized into the treatment arm and met with a PN who reviewed their diagnosis and associated care plan and identified proper primary care services and community resources for follow-up. The remaining control group was provided standard care. Both groups were given a follow-up call and survey by the PN within 7 days of their visit who assessed primary care follow-up and patient satisfaction using a 4-point Likert scale. After 12 months, the patients' return ED visits and ED costs were compared to the year prior and primary care compliance and satisfaction were measured using Student's t-tests with Bonferroni correction or Mann-Whitney U-tests. A total of 282 patients were enrolled (148 in navigation treatment group, 134 controls). Patients were similarly matched in age, race, sex, insurance, and chief complaints. Overall ED visits decreased during the 12-month study period, compared to the 12 months prior to enrollment (2,249 visits prior to 2,050 visits during study period, -8.8%). There was a greater decrease in ED visits from the preenrollment year to postenrollment year in the treatment group (1,148 visits to 996 visits, -13.2%) compared to the control group (1,101 visits to 1,054 visits, -4.3%; p < 0.05). Overall health care costs (ED and hospital) for all 282 patients decreased in the year after compared to the 12 months prior to enrollment ($3.9M to $3.1M) with a greater decrease in the navigation treatment group (-26.6%) compared to the control group (-17.5%). Patient surveys found no difference in patient satisfaction in the pre- and postenrollment periods but there was an increase in primary care physician (PCP) use over the 12-month follow-up period in the treatment group (6.42 visits/patient) compared to the control group (4.07 visits/patient; p < 0.05). Our data showed that the overall number of return ED visits and costs did decrease for both groups, potentially inferring a placebo effect for the use of a PN; however, the decrease in ED visits and costs were greater in the treatment group. One-year follow-up noted an increase in PCP visits in the navigation group. Use of a PN may be cost-effective. © 2017 by the Society for Academic Emergency Medicine.

Emergency visits among end-of-life cancer patients in Taiwan: a nationwide population-based study.

PubMed

Lee, Yi-Hui; Chu, Dachen; Yang, Nan-Ping; Chan, Chien-Lung; Cheng, Shun-Ping; Pai, Jih-Tung; Chang, Nien-Tzu

2015-05-09

An increased number of emergency visits at the end of life may indicate poor-quality cancer care. The study aimed to investigate the prevalence and utilization of emergency visits and to explore the reasons for emergency department (ED) visits among cancer patients at the end of life. A retrospective cohort study was performed by tracking one year of ambulatory medical service records before death. Data were collected from the cancer dataset of Taiwan's National Health Insurance Research Database (NHIRD). A total of 32,772 (19.2%) patients with malignant cancer visited EDs, and 23,883 patients died during the study period. Of these, the prevalence of emergency visits in the mortality group was 81.5%, and their ED utilization was significantly increased monthly to the end of life. The most frequent types of cancer were digestive and peritoneum cancers (34.8%), followed by breast cancer (17.7%) and head and neck cancers (13.3%). Older patients, males, and those diagnosed with metastases, respiratory or digestive cancer were more likely to use ED services at the end of life. Use of an ED service in the nearest community hospital to replace medical centers for dying cancer patients would be more acceptable in emergency situations. Our study provided population-based evidence related to ED utilization. An understanding of the reasons for such visits could be useful in preventing overuse of ED visits to improve the quality of end-of-life care.

A Comparison of Patient Visits to Retail Clinics, Primary Care Physicians, and Emergency Departments

PubMed Central

Wang, Margaret C.; Lave, Judith R.; Adams, John L.; McGlynn, Elizabeth A.

2009-01-01

In this study we compared the demographics and reason for visits in national samples of visits to retail clinics, primary care physicians (PCPs), and emergency departments (EDs). We find that retail clinics appear to be serving a patient population underserved by PCPs. Just 10 clinical issues such as sinusitis and immunizations encompass more than 90% of retail clinic visits. These same 10 clinical issues make up 13% of adult PCP visits, 30% of pediatric PCP visits, and 12% of ED visits. Whether there will be a shift of care from EDs or PCPs to retail clinics in the future is unknown. PMID:18780911

US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014.

PubMed

Shehab, Nadine; Lovegrove, Maribeth C; Geller, Andrew I; Rose, Kathleen O; Weidle, Nina J; Budnitz, Daniel S

2016-11-22

The Patient Protection and Affordable Care Act of 2010 brought attention to adverse drug events in national patient safety efforts. Updated, detailed, nationally representative data describing adverse drug events can help focus these efforts. To describe the characteristics of emergency department (ED) visits for adverse drug events in the United States in 2013-2014 and describe changes in ED visits for adverse drug events since 2005-2006. Active, nationally representative, public health surveillance in 58 EDs located in the United States and participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. Drugs implicated in ED visits. National weighted estimates of ED visits and subsequent hospitalizations for adverse drug events. Based on data from 42 585 cases, an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014 and 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization. An estimated 34.5% (95% CI, 30.3%-38.8%) of ED visits for adverse drug events occurred among adults aged 65 years or older in 2013-2014 compared with an estimated 25.6% (95% CI, 21.1%-30.0%) in 2005-2006; older adults experienced the highest hospitalization rates (43.6%; 95% CI, 36.6%-50.5%). Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9% (95% CI, 44.2%-49.7%) of ED visits for adverse drug events, which included clinically significant adverse events, such as hemorrhage (anticoagulants), moderate to severe allergic reactions (antibiotics), and hypoglycemia with moderate to severe neurological effects (diabetes agents). Since 2005-2006, the proportions of ED visits for adverse drug events from anticoagulants and diabetes agents have increased, whereas the proportion from antibiotics has decreased. Among children aged 5 years or younger, antibiotics were the most common drug class implicated (56.4%; 95% CI, 51.8%-61.0%). Among children and adolescents aged 6 to 19 years, antibiotics also were the most common drug class implicated (31.8%; 95% CI, 28.7%-34.9%) in ED visits for adverse drug events, followed by antipsychotics (4.5%; 95% CI, 3.3%-5.6%). Among older adults (aged ≥65 years), 3 drug classes (anticoagulants, diabetes agents, and opioid analgesics) were implicated in an estimated 59.9% (95% CI, 56.8%-62.9%) of ED visits for adverse drug events; 4 anticoagulants (warfarin, rivaroxaban, dabigatran, and enoxaparin) and 5 diabetes agents (insulin and 4 oral agents) were among the 15 most common drugs implicated. Medications to always avoid in older adults according to Beers criteria were implicated in 1.8% (95% CI, 1.5%-2.1%) of ED visits for adverse drug events. The prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics.

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

Emergency department presentations for atrial fibrillation and flutter in Alberta: a large population-based study.

PubMed

Rosychuk, Rhonda J; Graham, Michelle M; Holroyd, Brian R; Rowe, Brian H

2017-01-10

Atrial fibrillation or flutter (AFF) are not infrequent presenting problems in Emergency Departments (ED); however, little is known of the pattern of these presentations. This study provides a description of AFF presentations and outcomes after ED discharge in Alberta. Provincial administrative databases were used to obtain all primary ED encounters for AFF during 1999 to 2011 for patients aged >35 years. Data extracted included demographics, ED visit timing, and subsequent visits to non-ED settings. Analysis included summaries and standardized rates. During the study period, there were 63,398 ED AFF visits from 32,104 distinct adults. Median ages for females and males were 75 and 67 years, respectively; more men (52%) and patients > 65 presented. Overall, the standardized rates remained similar (2.8 per 1,000 over the study period). Specific populations of human services recipients and First Nations had higher ED visit rates for AFF than other groups. Predictable daily, weekly, and monthly trends were observed. The ED visits were followed by numerous subsequent visits in non-ED settings; however, First Nations and women had lower rates of specialist follow-up. Annually, over 5,000 ED presentations of patients experiencing AFF occur in Alberta and admissions proportions are declining. While presentation rates across the province are stable, follow-up with physicians, consultation with cardiologists and health outcomes vary based on socio-economic, age, sex, and First Nations status. Further research is required to understand the causes and consequences of these inequalities and to standardize care.

Evaluation of the Components of the North Carolina Syndromic Surveillance System Heat Syndrome Case Definition.

PubMed

Harduar Morano, Laurel; Waller, Anna E

To improve heat-related illness surveillance, we evaluated and refined North Carolina's heat syndrome case definition. We analyzed North Carolina emergency department (ED) visits during 2012-2014. We evaluated the current heat syndrome case definition (ie, keywords in chief complaint/triage notes or International Classification of Diseases, Ninth Revision, Clinical Modification [ ICD-9-CM] codes) and additional heat-related inclusion and exclusion keywords. We calculated the positive predictive value and sensitivity of keyword-identified ED visits and manually reviewed ED visits to identify true positives and false positives. The current heat syndrome case definition identified 8928 ED visits; additional inclusion keywords identified another 598 ED visits. Of 4006 keyword-identified ED visits, 3216 (80.3%) were captured by 4 phrases: "heat ex" (n = 1674, 41.8%), "overheat" (n = 646, 16.1%), "too hot" (n = 594, 14.8%), and "heatstroke" (n = 302, 7.5%). Among the 267 ED visits identified by keyword only, a burn diagnosis or the following keywords resulted in a false-positive rate >95%: "burn," "grease," "liquid," "oil," "radiator," "antifreeze," "hot tub," "hot spring," and "sauna." After applying the revised inclusion and exclusion criteria, we identified 9132 heat-related ED visits: 2157 by keyword only, 5493 by ICD-9-CM code only, and 1482 by both (sensitivity = 27.0%, positive predictive value = 40.7%). Cases identified by keywords were strongly correlated with cases identified by ICD-9-CM codes (rho = .94, P < .001). Revising the heat syndrome case definition through the use of additional inclusion and exclusion criteria substantially improved the accuracy of the surveillance system. Other jurisdictions may benefit from refining their heat syndrome case definition.

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.

Hospital-Based Acute Care After Total Hip and Knee Arthroplasty: Implications for Quality Measurement.

PubMed

Trimba, Roman; Laughlin, Richard T; Krishnamurthy, Anil; Ross, Joseph S; Fox, Justin P

2016-03-01

Although hospital readmissions are being adopted as a quality measure after total hip or knee arthroplasty, they may fail accurately capture the patient's postdischarge experience. We studied 272,853 discharges from 517 hospitals to determine hospital emergency department (ED) visit and readmission rates. The hospital-level, 30-day, risk-standardized ED visit (median = 5.6% [2.4%-13.7%]) and hospital readmission (5.0% [2.6%-9.2%]) rates were similar and varied widely. A hospital's risk-standardized ED visit rate did not correlate with its readmission rate (r = -0.03, P = .50). If ED visits were included in a broader "readmission" measure, 246 (47.6%) hospitals would change perceived performance groups. Including ED visits in a broader, hospital-based, acute care measure may be warranted to better describe postdischarge health care utilization. Copyright © 2016 Elsevier Inc. All rights reserved.

Prehospital Naloxone Administration as a Public Health Surveillance Tool: A Retrospective Validation Study.

PubMed

Lindstrom, Heather A; Clemency, Brian M; Snyder, Ryan; Consiglio, Joseph D; May, Paul R; Moscati, Ronald M

2015-08-01

Abuse or unintended overdose (OD) of opiates and heroin may result in prehospital and emergency department (ED) care. Prehospital naloxone use has been suggested as a surrogate marker of community opiate ODs. The study objective was to verify externally whether prehospital naloxone use is a surrogate marker of community opiate ODs by comparing Emergency Medical Services (EMS) naloxone administration records to an independent database of ED visits for opiate and heroin ODs in the same community. A retrospective chart review of prehospital and ED data from July 2009 through June 2013 was conducted. Prehospital naloxone administration data obtained from the electronic medical records (EMRs) of a large private EMS provider serving a metropolitan area were considered a surrogate marker for suspected opiate OD. Comparison data were obtained from the regional trauma/psychiatric ED that receives the majority of the OD patients. The ED maintains a de-identified database of narcotic-related visits for surveillance of narcotic use in the metropolitan area. The ED database was queried for ODs associated with opiates or heroin. Cross-correlation analysis was used to test if prehospital naloxone administration was independent of ED visits for opiate/heroin ODs. Naloxone was administered during 1,812 prehospital patient encounters, and 1,294 ED visits for opiate/heroin ODs were identified. The distribution of patients in the prehospital and ED datasets did not differ by gender, but it did differ by race and age. The frequency of naloxone administration by prehospital providers varied directly with the frequency of ED visits for opiate/heroin ODs. A monthly increase of two ED visits for opiate-related ODs was associated with an increase in one prehospital naloxone administration (cross-correlation coefficient [CCF]=0.44; P=.0021). A monthly increase of 100 ED visits for heroin-related ODs was associated with an increase in 94 prehospital naloxone administrations (CCF=0.46; P=.0012). Frequency of naloxone administration by EMS providers in the prehospital setting varied directly with frequency of opiate/heroin OD-related ED visits. The data correlated both for short-term frequency and longer term trends of use. However, there was a marked difference in demographic data suggesting neither data source alone should be relied upon to determine which populations are at risk within the community.

Spatial variation in hyperthermia emergency department visits among those with employer-based insurance in the United States - a case-crossover analysis.

PubMed

Saha, Shubhayu; Brock, John W; Vaidyanathan, Ambarish; Easterling, David R; Luber, George

2015-03-04

Predictions of intense heat waves across the United States will lead to localized health impacts, most of which are preventable. There is a need to better understand the spatial variation in the morbidity impacts associated with extreme heat across the country to prevent such adverse health outcomes. Hyperthermia-related emergency department (ED) visits were obtained from the Truven Health MarketScan(®) Research dataset for 2000-2010. Three measures of daily ambient heat were constructed using meteorological observations from the National Climatic Data Center (maximum temperature, heat index) and the Spatial Synoptic Classification. Using a time-stratified case crossover approach, odds ratio of hyperthermia-related ED visit were estimated for the three different heat measures. Random effects meta-analysis was used to combine the odds ratios for 94 Metropolitan Statistical Areas (MSA) to examine the spatial variation by eight latitude categories and nine U.S. climate regions. Examination of lags for all three temperature measures showed that the odds ratio of ED visit was statistically significant and highest on the day of the ED visit. For heat waves lasting two or more days, additional statistically significant association was observed when heat index and synoptic classification was used as the temperature measure. These results were insensitive to the inclusion of air pollution measures. On average, the maximum temperature on the day of an ED visit was 93.4°F in 'South' and 81.9°F in the 'Northwest' climatic regions of United States. The meta-analysis showed higher odds ratios of hyperthermia ED visit in the central and the northern parts of the country compared to the south and southwest. The results showed spatial variation in average temperature on days of ED visit and odds ratio for hyperthermia ED visits associated with extreme heat across United States. This suggests that heat response plans need to be customized for different regions and the potential role of hyperthermia ED visits in syndromic surveillance for extreme heat.

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.

Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study.

PubMed

Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S; Gallagher, Pamela J; Davis, Kim; Jauch, Edward C

2018-01-01

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

Reducing High-Users’ Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study

PubMed Central

Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S.; Gallagher, Pamela J.; Davis, Kim; Jauch, Edward C.

2018-01-01

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use–based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users’ mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users’ rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention. PMID:29591539

Prevalence and direct costs of emergency department visits and hospitalizations for selected diseases that can be transmitted by water, United States.

PubMed

Adam, E A; Collier, S A; Fullerton, K E; Gargano, J W; Beach, M J

2017-10-01

National emergency department (ED) visit prevalence and costs for selected diseases that can be transmitted by water were estimated using large healthcare databases (acute otitis externa, campylobacteriosis, cryptosporidiosis, Escherichia coli infection, free-living ameba infection, giardiasis, hepatitis A virus (HAV) infection, Legionnaires' disease, nontuberculous mycobacterial (NTM) infection, Pseudomonas-related pneumonia or septicemia, salmonellosis, shigellosis, and vibriosis or cholera). An estimated 477,000 annual ED visits (95% CI: 459,000-494,000) were documented, with 21% (n = 101,000, 95% CI: 97,000-105,000) resulting in immediate hospital admission. The remaining 376,000 annual treat-and-release ED visits (95% CI: 361,000-390,000) resulted in $194 million in annual direct costs. Most treat-and-release ED visits (97%) and costs ($178 million/year) were associated with acute otitis externa. HAV ($5.5 million), NTM ($2.3 million), and salmonellosis ($2.2 million) were associated with next highest total costs. Cryptosporidiosis ($2,035), campylobacteriosis ($1,783), and NTM ($1,709) had the highest mean costs per treat-and-release ED visit. Overall, the annual hospitalization and treat-and-release ED visit costs associated with the selected diseases totaled $3.8 billion. As most of these diseases are not solely transmitted by water, an attribution process is needed as a next step to determine the proportion of these visits and costs attributable to waterborne transmission.

Adolescent Female Text Messaging Preferences to Prevent Pregnancy After an Emergency Department Visit: A Qualitative Analysis.

PubMed

Chernick, Lauren Stephanie; Schnall, Rebecca; Stockwell, Melissa S; Castaño, Paula M; Higgins, Tracy; Westhoff, Carolyn; Santelli, John; Dayan, Peter S

2016-09-29

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. 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. 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. 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. 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.

Gender differences in discharge dispositions of emergency department visits involving drug misuse and abuse-2004-2011.

PubMed

Manuel, Jennifer I; Lee, Jane

2017-05-30

Drug use-related visits to the emergency department (ED) can undermine discharge planning and lead to recurrent use of acute services. Yet, little is known about where patients go post discharge. We explored trends in discharge dispositions of drug-involved ED visits, with a focus on gender differences. We extracted data from the 2004-2011 Drug Abuse Warning Network, a national probability sample of drug-related visits to hospital EDs in the U.S. We computed weighted multinomial logistic regression models to estimate discharge dispositions over time and to examine associations between gender and the relative risk of discharge dispositions, controlling for patient characteristics. The final pooled sample included approximately 1.2 million ED visits between 2004 and 2011. Men accounted for more than half (57.6%) of all ED visits involving drug misuse and abuse. Compared with women, men had a greater relative risk of being released to the police/jail, being referred to outpatient detox or other treatment, and leaving against medical advice than being discharged home. The relative risk of being referred to outpatient detox/drug treatment than discharged home increased over time for men versus women. Greater understanding of gender-based factors involved in substance-related ED visits and treatment needs may inform discharge planning and preventive interventions.

Relationship between air mass type and emergency department visits for migraine headache across the Triangle region of North Carolina

NASA Astrophysics Data System (ADS)

Elcik, Christopher; Fuhrmann, Christopher M.; Mercer, Andrew E.; Davis, Robert E.

2017-12-01

An estimated 240 million people worldwide suffer from migraines. Because migraines are often debilitating, understanding the mechanisms that trigger them is crucial for effective prevention and treatment. Synoptic air mass types and emergency department (ED) visits for migraine headaches were examined over a 7-year period within a major metropolitan area of North Carolina to identify potential relationships between large-scale meteorological conditions and the incidence of migraine headaches. Barometric pressure changes associated with transitional air masses, or changing weather patterns, were also analyzed for potential relationships. Bootstrapping analysis revealed that tropical air masses (moist and dry) resulted in the greatest number of migraine ED visits over the study period, whereas polar air masses led to fewer. Moist polar air masses in particular were found to correspond with the fewest number of migraine ED visits. On transitional air mass days, the number of migraine ED visits fell between those of tropical air mass days and polar air mass days. Transitional days characterized by pressure increases exhibited a greater number of migraine ED visits than days characterized by pressure decreases. However, no relationship was found between migraine ED visits and the magnitude of barometric pressure changes associated with transitional air masses.

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.

Temperature changes, temperature extremes, and their relationship to emergency department visits and hospitalizations for sickle cell crisis.

PubMed

Smith, Wally R; Coyne, Patrick; Smith, Virginia S; Mercier, Bruce

2003-09-01

Weather changes are among the proposed precursors of painful sickle cell crises. However, epidemiologic data are mixed regarding the relationship between ambient temperature and crisis frequency. To study this relationship among a local sickle cell disease population, emergency department (ED) visits and admissions were evaluated in adults with sickle cell crisis as the primary diagnosis at a major teaching hospital in a temperate climate. Official daily ambient temperatures (average for that day) were obtained from the National Climate Data Center for the days patients visited the ED or were hospitalized, and for 24 or 48 hours prior. Daily ED visit counts and admission counts were correlated with the visit/admission day's ambient temperature, with the ambient temperature 24 hours before admission, and with the magnitude of change in daily ambient temperature over the prior 24 or 48 hours. For all correlations, statistical significance was defined as a p value of <0.01 and clinical significance was defined as a moderate or greater correlation, absolute value of r >/= 0.30. ED visits or admissions correlated statistically, but not clinically, with daily temperatures. On days when temperatures were <32 degrees F or >80 degrees F, these correlations were statistically significant, but clinical significance was variable. ED visits or admissions correlated only statistically with temperatures 24 hours prior, even on days when temperatures were <32 degrees F. When temperatures were >80 degrees F, the correlations were statistically significant, but there was a reverse, clinically significant correlation between admissions and temperatures. Finally, only statistically significant correlations were found between ED visits or admissions and change in temperature over the prior 24 or 48 hours. Weak or inconsistent confirmation of a relationship was found between daily ambient temperatures and ED visits or hospital admissions for sickle cell crises.

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

Changes in insurance status and emergency department visits after the 2008 economic downturn.

PubMed

Watts, Susan H; David Bryan, E; Tarwater, Patrick M

2015-01-01

As the U.S. economy began its downward trend in 2008, many citizens lost their jobs and, ultimately, their employer-sponsored health care insurance. The expectation was that many of the newly uninsured would turn to emergency departments (EDs) for their health care. This study was undertaken to determine, first, if changes in the insurance status of the general population were reflected in the ED insurance payer mix and, second, whether there was evidence of an increased reliance on the ED as a continuing source of health care for any payer group(s). This was a retrospective observational study using public data files from the National Hospital Ambulatory Medical Care Survey for Emergency Departments for years 2006 through 2010 (2008 ± 2 years). Changes in the relative proportions of ED visits funded annually by private insurance, Medicaid, Medicare, and self-pay (uninsured) were analyzed using a logistic model. Poisson regression was used to compare trends in the rates of ED visits for each payer type (i.e., number of ED visits per 100 persons with each insurance type). A linear spline term was used to determine if there was a change in each risk estimate after 2008 compared to the risk estimate before 2008. Before 2008, the odds of an ED visit being funded by private insurance increased by 4% per year (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 0.98 to 1.10; p = 0.15), but after 2008 the odds reversed, decreasing by nearly 10% per year (OR = 0.91, 95% CI = 0.85 to 0.97; p = 0.02). Medicaid-funded visits demonstrated opposite trends with a small decreasing trend of 2% per year before 2008 (OR = 0.98, 95% CI = 0.92 to 1.04; p = 0.52), followed by a significantly increasing trend of 20% per year after 2008 (OR = 1.20, 95% CI = 1.12 to 1.27; p = 0.001). The growth in Medicaid-funded ED visits was attributable to increased numbers of visits by both pediatric (<18 years old) and non-elderly adult (19 to 64 years old) patients. For both Medicaid and private insurance visits, the change in trend in 2008 was statistically significant (p < 0.001 and p = 0.004, respectively). Self-pay visits were fairly steady before 2008 and then increased by about 5% per year after 2008, but this was not statistically significant (OR = 1.05, 95% CI = 0.96 to 1.14; p = 0.46), nor was the change in trend (p = 0.29). The results for Medicare-funded visits were also small and not statistically significant. There was also evidence of increased reliance on the ED by Medicaid-funded patients based on the comparison of ED visit rates. After 2008, the incidence rate ratio (IRR) for Medicaid-funded visits increased by 10% per year (IRR = 1.10, 95% CI = 1.10 to 1.10; p < 0.001) while the IRR for the other three payer groups changed about 1% per year (IRR = 0.99, 95% CI = 0.99 to 0.099; p < 0.001), indicating an increasing utilization of the ED by patients with Medicaid-funded care. After 2008, Medicaid patients were more dependent on ED services than uninsured, Medicare, or privately insured patients. Medicaid patients made up an increasing proportion of ED patients, and the rate of usage of ED services by all ages of Medicaid patients was significantly greater than that of the other three payer groups. © 2014 by the Society for Academic Emergency Medicine.

Emergency Department Visits for Drug-Related Suicide Attempts Involving Antidepressants by Adolescents and Young Adults: 2004 to 2008. The DAWN Report

ERIC Educational Resources Information Center

Substance Abuse and Mental Health Services Administration, 2011

2011-01-01

In 2008, adolescents made 23,124 visits to the emergency department (ED) for drug-related suicide attempts, and young adults made 38,036 such visits; of these visits, 23.0 percent (5,312 visits) among adolescents and 17.6 percent (6,700 visits) among young adults involved antidepressants. Among ED visits for suicide attempts involving…

Medical Services Annual Historical Report - AMEDD Activities. Calendar Year 1979

DTIC Science & Technology

1979-01-01

and comments concerning the future extent and costs of studies to support Project MILES at PM TRADE, Orlando, FL, on 23-24 Oct 79. 4. COL E.S. Beatrice...microscopic criteria. 11. The MILES ED50 device has been evaluated further for evidence of retinal clouding after repeated exposures to the MILES (gallium...visited on 28 Sep 79 to discuss FY 80 research and the budget for Project MILES . 12. LTC McDougall, Canadian Defence Liaison Staff, Washington, DC

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.

Reduction in emergency department visits for children's asthma, ear infections, and respiratory infections after the introduction of state smoke-free legislation.

PubMed

Hawkins, Summer Sherburne; Hristakeva, Sylvia; Gottlieb, Mark; Baum, Christopher F

2016-08-01

Despite the benefits of smoke-free legislation on adult health, little is known about its impact on children's health. We examined the effects of tobacco control policies on the rate of emergency department (ED) visits for childhood asthma (N=128,807), ear infections (N=288,697), and respiratory infections (N=410,686) using outpatient ED visit data in Massachusetts (2001-2010), New Hampshire (2001-2009), and Vermont (2002-2010). We used negative binomial regression models to analyze the effect of state and local smoke-free legislation on ED visits for each health condition, controlling for cigarette taxes and health care reform legislation. We found no changes in the overall rate of ED visits for asthma, ear infections, and upper respiratory infections after the implementation of state or local smoke-free legislation or cigarette tax increases. However, an interaction with children's age revealed that among 10-17-year-olds state smoke-free legislation was associated with a 12% reduction in ED visits for asthma (adjusted incidence rate ratios (aIRR) 0.88; 95% CI 0.83, 0.95), an 8% reduction for ear infections (0.92; 0.88, 0.97), and a 9% reduction for upper respiratory infections (0.91; 0.87, 0.95). We found an overall 8% reduction in ED visits for lower respiratory infections after the implementation of state smoke-free legislation (0.92; 0.87, 0.96). The implementation of health care reform in Massachusetts was also associated with a 6-9% reduction in all children's ED visits for ear and upper respiratory infections. Our results suggest that state smoke-free legislation and health care reform may be effective interventions to improve children's health by reducing ED visits for asthma, ear infections, and respiratory infections. Copyright © 2016 Elsevier Inc. All rights reserved.

Substance abuse and mental health visits among adolescents presenting to US emergency departments.

PubMed

Fahimi, Jahan; Aurrecoechea, Adrian; Anderson, Erik; Herring, Andrew; Alter, Harrison

2015-05-01

The objectives of the study were to identify factors associated with adolescent emergency department (ED) visits for substance abuse, including those complicated by mental health (dual diagnosis), and to analyze their effect on ED length of stay (LOS) and disposition. We performed a secondary analysis of ED visits by adolescents (age, 11-24) using the National Hospital Ambulatory Medical Care Survey (1997-2010) to identify visits for mental health, substance use, and dual diagnosis. Univariate and multivariate statistics were used to analyze demographic and visit-level factors, factors associated with substance use and dual diagnosis visits, as well as the effects of substance use and mental health conditions on ED LOS and disposition. Substance use and mental health accounted for 2.1% and 4.3% of all adolescent visits, respectively, with 20.9% (95% confidence interval [CI], 18.3%-23.5%) of substance abuse visits complicated by mental health. The factors significantly associated with substance use include the following: male sex, urban location, West region, ambulance arrival, night and weekend shift, anxiety disorders, mood disorders, and psychotic disorders. Additional LOS was 89.77 minutes for mental health, 71.33 minutes for substance use, and 139.97 minutes for dual diagnosis visits, as compared with visits where these conditions were not present. Both mental health and substance use were associated with admission/transfer as compared with other dispositions as follows: mental health odds ratio (OR), 5.93 (95% CI, 5.14-6.84); illicit drug use OR, 3.56 (95% CI 2.72-4.64); and dual diagnosis OR, 6.86 (95% CI, 4.67-10.09). Substance abuse and dual diagnosis are common among adolescent ED visits and are strongly associated with increased use of prehospital resources, ED LOS, and need for hospitalization.

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

National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015.

PubMed

Geller, Andrew I; Lovegrove, Maribeth C; Shehab, Nadine; Hicks, Lauri A; Sapiano, Mathew R P; Budnitz, Daniel S

2018-04-20

Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention. Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs. Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015. Antibiotic-treated adults (≥ 20 years) seeking ED care. Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics. Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group. Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

Clinical- and cost-effectiveness of a nurse led self-management intervention to reduce emergency visits by people with epilepsy.

PubMed

Noble, Adam J; McCrone, Paul; Seed, Paul T; Goldstein, Laura H; Ridsdale, Leone

2014-01-01

People with chronic epilepsy (PWE) often make costly, and clinically unnecessary emergency department (ED) visits. Some do it frequently. No studies have examined interventions to reduce them. An intervention delivered by an epilepsy nurse specialist (ENS) might reduce visits. The rationale is it may optimize patients' self-management skills and knowledge of appropriate ED use. We examined such an intervention's clinical- and cost-effectiveness. Eighty-five adults with epilepsy were recruited from three London EDs with similar catchment populations. Forty-one PWE recruited from two EDs received treatment-as-usual (TAU) and formed the comparison group. The remaining 44 PWE were recruited from the ED of a hospital that had implemented a new ENS service for PWE attending ED. These participants formed the intervention group. They were offered 2 one-to-one sessions with an ENS, plus TAU. Participants completed questionnaires on health service use and psychosocial well-being at baseline, 6- and 12-month follow-up. Covariates were identified and adjustments made. Sixty-nine (81%) participants were retained at follow-up. No significant effect of the intervention on ED visits at 12 months or on other outcomes was found. However, due to less time as inpatients, the average service cost for intervention participants over follow-up was less than for TAU participants' (adjusted difference £558, 95% CI, -£2409, £648). Covariates most predictive of subsequent ED visits were patients' baseline feelings of stigmatization due to epilepsy and low confidence in managing epilepsy. The intervention did not lead to a reduction in ED use, but did not cost more, partly because those receiving the intervention had shorter hospital admissions. Our findings on long-term ED predictors clarifies what causes ED use, and suggests that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency-savings generated.

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

The relationship between direct to consumer advertising (DTCA) and asthma-related emergency department use among Medicaid-enrolled children.

PubMed

McRoy, Luceta; Weech-Maldonado, Robert; Kilgore, Meredith

2014-11-01

Asthma is a leading cause of emergency department (ED) visits. There has been much debate on the impact of direct to consumer advertising (DTCA) on healthcare. This study seeks to examine the association between DTCA expenditure and asthma-related ED use. In this study, we combined Medicaid administrative data and a national advertising data on asthma medications. The sample size consisted of 180,584 Medicaid-enrolled children between the ages of 5 and 18 years who had an asthma diagnosis. Twenty percent of the Medicaid-enrolled children in the sample had asthma-related ED visits. We found that DTCA expenditure is associated with a decrease in asthma-related ED visits (OR = 0.75; CI: 0.64-0.89). However, at higher levels of DTCA expenditure, the likelihood of asthma-related ED visits increases (OR = 1.25; CI: 1.05-1.49), indicating a decreased relationship between DTCA and asthma-related ED visits. Our findings suggest that DTCA may be associated with improved health outcomes for Medicaid-enrolled children with asthma.

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

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

Chronic Pain in the Emergency Department: A Pilot Mixed-Methods Cross-Sectional Study Examining Patient Characteristics and Reasons for Presentations.

PubMed

Poulin, Patricia A; Nelli, Jennifer; Tremblay, Steven; Small, Rebecca; Caluyong, Myka B; Freeman, Jeffrey; Romanow, Heather; Stokes, Yehudis; Carpino, Tia; Carson, Amanda; Shergill, Yaadwinder; Stiell, Ian G; Taljaard, Monica; Nathan, Howard; Smyth, Catherine E

2016-01-01

Background . Chronic pain (CP) accounts for 10-16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives . To describe patients with CP attending the ED and identify factors contributing to their visit. Methods . We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results . Fifty-eight patients (66% women; mean age 46.5, SD = 16.9) completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions . Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED.

Should we fear "flu fear" itself? Effects of H1N1 influenza fear on ED use.

PubMed

McDonnell, William M; Nelson, Douglas S; Schunk, Jeff E

2012-02-01

Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear. The aim of this study is to examine the effect of widespread public concern about flu on ED use. We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), (b) a subsequent period of active disease ("Flu Week"), and (c) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data. Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%. At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease. Copyright © 2012 Elsevier Inc. All rights reserved.

Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians.

PubMed

Hunchak, Cheryl; Tannenbaum, David; Roberts, Michael; Shah, Thrushar; Tisma, Predrag; Ovens, Howard; Borgundvaag, Bjug

2015-03-01

Postdischarge emergency department (ED) communication with family physicians is often suboptimal and negatively impacts patient care. We designed and piloted an online notification system that electronically alerts family physicians of patient ED visits and provides access to visitspecific laboratory and diagnostic information. Nine (of 10 invited) high-referring family physicians participated in this single ED pilot. A prepilot chart audit (30 patients from each family physician) determined the baseline rate of paper-based record transmission. A webbased communication portal was designed and piloted by the nine family physicians over 1 year. Participants provided usability feedback via focus groups and written surveys. Review of 270 patient charts in the prepilot phase revealed a 13% baseline rate of handwritten chart and a 44% rate of any information transfer between the ED and family physician offices following discharge. During the pilot, participant family physicians accrued 880 patient visits. Seven and two family physicians accessed online records for 74% and 12% of visits, respectively, an overall 60.7% of visits, corresponding to an overall absolute increase in receipt of patient ED visit information of 17%. The postpilot survey found that 100% of family physicians reported that they were ''often'' or ''always'' aware of patient ED visits, used the portal ''always'' or ''regularly'' to access patients' health records online, and felt that the web portal contributed to improved actual and perceived continuity of patient care. Introduction of a web-based ED visit communication tool improved ED-family physician communication. The impact of this system on improved continuity of care, timeliness of follow-up, and reduced duplication of investigations and referrals requires additional study.

High Utilizers of Emergency Health Services in a Population-Based Cohort of Homeless Adults

PubMed Central

Chambers, Catharine; Chiu, Shirley; Katic, Marko; Kiss, Alex; Redelmeier, Donald A.; Levinson, Wendy

2013-01-01

Objectives. We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. Methods. We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005–2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). Results. Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. Conclusions. Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors. PMID:24148033

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.

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.

Hospital burden of unintentional carbon monoxide poisoning in the United States, 2007.

PubMed

Iqbal, Shahed; Law, Huay-Zong; Clower, Jacquelyn H; Yip, Fuyuen Y; Elixhauser, Anne

2012-06-01

Unintentional, non-fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States, but the overall hospital burden is unknown. This study presents patient characteristics and the most recent comprehensive national estimates of UNFR CO-related emergency department (ED) visits and hospitalizations. Data from the 2007 Nationwide Inpatient and Emergency Department Sample of the Hospitalization Cost and Utilization Project were analyzed. The Council of State and Territorial Epidemiologists' CO poisoning case definition was used to classify confirmed, probable, and suspected cases. In 2007, more than 230,000 ED visits (772 visits/million) and more than 22,000 hospitalizations (75 stays/million) were related to UNFR CO poisoning. Of these, 21,304 ED visits (71 visits/million) and 2302 hospitalizations (8 stays/million) were confirmed cases of UNFR CO poisoning. Among the confirmed cases, the highest ED visit rates were among persons aged 0 to 17 years (76 visits/million) and 18 to 44 years (87 visits/million); the highest hospitalization rate was among persons aged 85 years or older (18 stays/million). Women visited EDs more frequently than men, but men were more likely to be hospitalized. Patients residing in a nonmetropolitan area and in the northeast and midwest regions of the country had higher ED visit and hospitalization rates. Carbon monoxide exposures occurred mostly (>60%) at home. The hospitalization cost for confirmed CO poisonings was more than $26 million. Unintentional, non-fire-related CO poisonings pose significant economic and health burden; continuous monitoring and surveillance of CO poisoning are needed to guide prevention efforts. Public health programs should emphasize CO alarm use at home as the main prevention strategy. Published by Elsevier Inc.

Factors Associated With the Likelihood of Hospitalization Following Emergency Department Visits for Behavioral Health Conditions.

PubMed

Hamilton, Jane E; Desai, Pratikkumar V; Hoot, Nathan R; Gearing, Robin E; Jeong, Shin; Meyer, Thomas D; Soares, Jair C; Begley, Charles E

2016-11-01

Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States. Using Andersen's Behavioral Model of Health Service Use for guidance, the study examined the relationship between predisposing (characteristics of the individual, i.e., age, sex, race/ethnicity), enabling (system or structural factors affecting healthcare access), and need (clinical) factors and the likelihood of hospitalization following ED visits for behavioral health conditions (n = 28,716 ED visits). In the adjusted analysis, a logistic fixed-effects model with blockwise entry was used to estimate the relative importance of predisposing, enabling, and need variables added separately as blocks while controlling for variation in unobserved hospital-specific practices across hospitals and time in years. Significant predisposing factors associated with an increased likelihood of hospitalization following an ED visit included increasing age, while African American race was associated with a lower likelihood of hospitalization. Among enabling factors, arrival by emergency transport and a longer ED LOS were associated with a greater likelihood of hospitalization while being uninsured and the availability of community-based behavioral health services within 5 miles of the ED were associated with lower odds. Among need factors, having a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, dementia, or an impulse control disorder as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit. The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness. © 2016 by the Society for Academic Emergency Medicine.

Disparities in emergency department visits in American children with asthma: 2006-2010.

PubMed

Zhang, Qi; Lamichhane, Rajan; Diggs, Leigh Ann

2017-09-01

This article was to examine the trends in emergency department (ED) visits for asthma among American children in 2006-2010 across sociodemographic factors, parental smoking status, and children's body weight status. We analyzed 5,535 children aged 2-17 years with current asthma in the Asthma Call-Back Survey in 2006-2010. Multivariate log binomial regression was used to examine the disparities of ED visits by demographics, socioeconomic status, parental smoking status, children's body weight status, and the level of asthma control. We controlled for average state-level air pollutants. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were reported. Minority children with current asthma had higher risks of ED visits compared with white children in 2009 and 2010, e.g., the PR (95% CI) for black children in 2009 was 3.64 (1.79, 7.41). Children who had current asthma and more highly educated parents experienced a higher risk of ED visits in 2007 (PRs [95% CI] = 2.15 [1.02, 4.53] and 2.97 [1.29, 6.83] for children with some college or college-graduated parents), but not significant in other years. Children with uncontrolled asthma were significantly more likely to visit the ED in 2008 (PRs [95% CI] = 2.79 [1.44, 5.41] and 6.96 [3.55, 13.64] for not-well-controlled and very poorly controlled children with asthma). Minority children with current asthma or children with uncontrolled asthma were more likely to visit EDs for asthma treatment. However, the disparities in ED visits across sociodemographics, health status, or asthma control vary in scale and significance across time. More research is needed to explain these differences.

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

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

PubMed

Chen, Tianqi; Sarnat, Stefanie E; Grundstein, Andrew J; Winquist, Andrea; Chang, Howard H

2017-05-31

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. We investigated associations between heat waves and ED visits for 17 outcomes in Atlanta over a 20-year period, 1993-2012. 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 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. 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). 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.

Nonurgent Emergency Department Visits by Insured and Uninsured Adults.

PubMed

Searing, Lisabeth M; Cantlin, Kelly A

2016-01-01

To compare nonurgent emergency department (ED) visits by insured and uninsured adults in a Midwest community. Records for this secondary data analysis included 84,877 nonurgent visits to a Midwest ED from September 2004 to January 2012. Insured versus uninsured visits were analyzed using t tests for continuous variables and chi-squared tests for categorical variables. Standardized residuals were compared to determine if changes over time were statistically significant. Variables included demographic characteristics of patients, payment source, patients' access to primary care, acuity rating, time of visit, and the stated reason for the visit. Of all nonurgent visits, 77.9% were made by insured adults. Insured nonurgent visits were more often made by adults who were female, older, White, and had a primary care provider (PCP). Nonurgent visits on weekdays between the hours of 09:00 and 18:00 were more likely to be uninsured visits. Dental issues were the fourth most common issue for uninsured visits. Nonurgent ED visits occur when more appropriate options for prompt care are available in the community. Interventions should target both patients and PCPs. While patients should contact their PCP when in need of prompt care, PCPs should refer patients to facilities other than the ED when medically appropriate. © 2015 Wiley Periodicals, Inc.

Monthly variation of United States pediatric headache emergency department visits.

PubMed

Kedia, Sita; Ginde, Adit A; Grubenhoff, Joseph A; Kempe, Allison; Hershey, Andrew D; Powers, Scott W

2014-05-01

The objective of this article is to determine the monthly variation of emergency department (ED) visits for pediatric headache. We hypothesized youth have increased headache-related ED visits in the months associated with school attendance. Using a United States representative sample of ED visits in the National Hospital Ambulatory Medical Care Survey from 1997 to 2009, we estimated number of visits associated with ICD-9 codes related to headache, migraine, status migrainosus, or tension-type headache in 5- to 18-year-olds. Age-stratified multivariate models are presented for month of visit (July as reference). There was a national estimate of 250,000 ED visits annually related to headache (2.1% of total visits) in 5- to 18-year-olds. In 5- to 11-year-olds, the adjusted rate of headache-related visits was lower in April (OR 0.42, 95% CI 0.20, 0.88). In 12- to 18-year-olds, there were higher rates in January (OR 1.92, 95% CI 1.16, 3.14) and September (OR 1.64, 95% CI 1.06, 2.55). In adolescents we found higher ED utilization in January and September, the same months associated with school return from vacation for a majority of children nationally. No significant reduction in the summer suggests that school itself is not the issue, but rather changes in daily lifestyle and transitions.

Sex Differences in Prevalence of Emergency Department Patient Substance Use.

PubMed

Cannon, Robert D; Beauchamp, Gillian A; Roth, Paige; Stephens, Jennifer; Burmeister, David B; Richardson, David M; Balbi, Alanna M; Park, Tennessee D; Dusza, Stephen W; Greenberg, Marna Rayl

2018-02-01

Substance use and misuse is prevalent in emergency department (ED) populations. While the prevalence of substance use and misuse is reported, sex-specific trends in ED populations have not been documented. We set out to determine the sex-specific prevalence of ED patient substance use during this current epidemic. A retrospective electronic data abstraction tool, developed for quality-improvement purposes, was used to assess ED visits in 3 hospitals in northeastern Pennsylvania. All patients with ED diagnosis codes for substance use F10.000 through F 19.999 (excluding F17 codes for nicotine) were abstracted for network ED visits at all 3 hospitals. Data points included ED clinical enrollment site, primary substance used, sex, date of ED visit, disposition (including left without being seen, left against medical advice, discharged, admitted, and treatment in rehabilitation) for 18 months (January 1, 2016 through July 31, 2017). The categorical parameters of sex, clinical enrollment site, diagnosis, date of ED visit, and disposition status were summarized as a proportion of the subject group. Time series analysis was used to assess trends in substance use and misuse visits by patient sex. A total of 10,511 patients presented to the EDs during the study time period with a final diagnosis of a substance use-related reason and were included in the analysis. The mean age for these patients was 43.6 (SD 16.4) years, and the majority was male (65.6%, n = 6900). The most common substance in the final diagnosis for the ED visit was alcohol (54.3%; 95% CI, 53.3-55.2), followed by opioids (19.2%; 95% CI, 18.4-19.9) and cannabis (14.4%; 95% CI, 13.7-15.0). Females tended to be younger than males (42.4 years vs 44.3 years; P < 0.001), and were more likely to be discharged after the ED visit than males (36.1% vs 32.3%; P < 0.001). When exploring differences in age by sex and substance, males with a final diagnosis including alcohol- and cannabis-related issues were older than females, whereas females diagnosed with opioid-related reasons were older than males (41.3 vs 38.9 years; P < 0.001). There are sex-specific differences in prevalence of patients presenting with substance use in the ED setting. Copyright © 2018 Elsevier HS Journals, Inc. All rights reserved.

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…

Emergency Department Allies: a Web-based multihospital pediatric asthma tracking system.

PubMed

Kelly, Kevin J; Walsh-Kelly, Christine M; Christenson, Peter; Rogalinski, Steven; Gorelick, Marc H; Barthell, Edward N; Grabowski, Laura

2006-04-01

To describe the development of a Web-based multihospital pediatric asthma tracking system and present results from the initial 18-month implementation of patient tracking experience. The Emergency Department (ED) Allies tracking system is a secure, password-protected data repository. Use-case methodology served as the foundation for technical development, testing, and implementation. Seventy-seven data elements addressing sociodemographics, wheezing history, quality of life, triggers, and ED managment were included for each subject visit. The ED Allies partners comprised 1 academic pediatric ED and 5 community EDs. Subjects with a physician diagnosis of asthma who presented to the ED for acute respiratory complaints composed the asthma group; subjects lacking a physician diagnosis of asthma but presenting with wheezing composed the wheezing group. The tracking-system development and implementation process included identification of data elements, system database and use case development, and delineation of screen features, system users, reporting functions, and help screens. For the asthma group, 2005 subjects with physician-diagnosed asthma were enrolled between July 15, 2002 and January 14, 2004. These subjects accounted for 2978 visits; 10.4% had > or = 3 visits. Persistent asthma was noted in 68% of the subjects. During the same time period, 1297 wheezing subjects with a total of 1628 ED visits (wheezing group) were entered into the tracking system. After enrollment, 57% of the subjects with > or = 1 subsequent ED visits received a physician diagnosis of asthma. Our sophisticated tracking system facilitated data collection and identified key intervention opportunities for a diverse ED wheezing population. A significant asthma burden was identified with significant rates of hospitalization, acute care visits and persistent asthma in 68% of subjects. The surveillance component provided important insights into health care issues of both asthmatic subjects and wheezing subjects, many of whom subsequently were diagnosed with asthma.

Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.

PubMed

Rice, Kathryn L; Dewan, Naresh; Bloomfield, Hanna E; Grill, Joseph; Schult, Tamara M; Nelson, David B; Kumari, Sarita; Thomas, Mel; Geist, Lois J; Beaner, Caroline; Caldwell, Michael; Niewoehner, Dennis E

2010-10-01

The effect of disease management for chronic obstructive pulmonary disease (COPD) is not well established. To determine whether a simplified disease management program reduces hospital admissions and emergency department (ED) visits due to COPD. We performed a randomized, adjudicator-blinded, controlled, 1-year trial at five Veterans Affairs medical centers of 743 patients with severe COPD and one or more of the following during the previous year: hospital admission or ED visit for COPD, chronic home oxygen use, or course of systemic corticosteroids for COPD. Control group patients received usual care. Intervention group patients received a single 1- to 1.5-hour education session, an action plan for self-treatment of exacerbations, and monthly follow-up calls from a case manager. We determined the combined number of COPD-related hospitalizations and ED visits per patient. Secondary outcomes included hospitalizations and ED visits for all causes, respiratory medication use, mortality, and change in Saint George's Respiratory Questionnaire. After 1 year, the mean cumulative frequency of COPD-related hospitalizations and ED visits was 0.82 per patient in usual care and 0.48 per patient in disease management (difference, 0.34; 95% confidence interval, 0.15-0.52; P < 0.001). Disease management reduced hospitalizations for cardiac or pulmonary conditions other than COPD by 49%, hospitalizations for all causes by 28%, and ED visits for all causes by 27% (P < 0.05 for all). A relatively simple disease management program reduced hospitalizations and ED visits for COPD. Clinical trial registered with www.clinicaltrials.gov (NCT00126776).

Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review.

PubMed

DiMartino, Lisa D; Weiner, Bryan J; Mayer, Deborah K; Jackson, George L; Biddle, Andrea K

2014-12-01

Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.

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.

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

Impact of operational staging to improve patient throughput in an inner-city emergency department during the novel H1N1 influenza surge: a descriptive study.

PubMed

Waseem, Muhammad; McInerney, Joan E; Perales, Orlando; Leber, Mark

2012-01-01

A level 1 pediatric emergency department (ED) in a public hospital of South Bronx rapidly encountered a significant surge in ED patient census over several days as the novel H1N1 influenza outbreak occurred. Our aim was to identify ill patients with influenza-like illness and evaluate and treat them as expeditiously as possible without failing in our responsibility to treat all patients. We describe the ED response to the outbreak during 2009 H1N1-related visits. The objective of this study was to describe and compare pediatric ED visits during the fall 2009 H1N1 to that in the previous year. The department reorganized patient flow in the ED to maximize the understanding of where to best apportion our resources and to minimize walkout and return visit rates. We developed staging of the flow of patients. This included, but was not limited to, a rapid screening at pretriage stage, early registration before the formal triage, and expanding the service. We compared walkout rates during fall 2009 and fall 2008. Return visits for asthmatic patients within 7 days were also compared. Over a period of 48 days, 8841 patients visited the pediatric ED. The average number of visits during this outbreak was 184 per day (usual visits per day, 80-110). Overall ED visits increased by 93.6% (95% confidence interval [CI], 78.2%-109.6%; P < 0.001). Fifty-two patients tested positive for H1N1. The walkout rate was 2.9% (95% CI, 1.9%-4.0%) in 2009 compared with the walkout rate of 1.5% (95% CI, 1.0%-2.0%) in 2008. There were no statistically significant differences between walkouts (P = 0.06) and 7-day asthma revisits (P = 0.07) in 2008 and 2009 despite the almost doubling of the ED visits. Admission rates from 2009 did not significantly differ from 2008 (11.2% [990/8841] vs 10.2% [464/4560], P = 0.07). Staging of a surge volume allows ED administrators to maintain a strong control of a multipatient event to ensure an effective response and appropriate use of limited resources. The implementation of the reorganized measures during the fall 2009 H1N1-related surge in patient's visits resulted in improved patient flow without significant increase in walkout and 7-day asthma revisit rates. Our strategies accommodated the surge of patients in the ED.

Burden of norovirus gastroenteritis in the ambulatory setting--United States, 2001-2009.

PubMed

Gastañaduy, Paul A; Hall, Aron J; Curns, Aaron T; Parashar, Umesh D; Lopman, Benjamin A

2013-04-01

Gastroenteritis remains an important cause of morbidity in the United States. The burden of norovirus gastroenteritis in ambulatory US patients is not well understood. Cause-specified and cause-unspecified gastroenteritis emergency department (ED) and outpatient visits during July 2001-June 2009 were extracted from MarketScan insurance claim databases. By using cause-specified encounters, time-series regression models were fitted to predict the number of unspecified gastroenteritis visits due to specific pathogens other than norovirus. Model residuals were used to estimate norovirus visits. MarketScan rates were extrapolated to the US population to estimate national ambulatory visits. During 2001-2009, the estimated annual mean rates of norovirus-associated ED and outpatient visits were 14 and 57 cases per 10 000 persons, respectively, across all ages. Rates for ages 0-4, 5-17, 18-64, and ≥65 years were 38, 10, 12, and 15 ED visits per 10 000 persons, respectively, and 233, 85, 35, and 54 outpatient visits per 10 000 persons, respectively. Norovirus was estimated to cause 13% of all gastroenteritis-associated ambulatory visits, with ~50% of such visits occurring during November-February. Nationally, norovirus contributed to approximately 400 000 ED visits and 1.7 million office visits annually, resulting in $284 million in healthcare charges. Norovirus is a substantial cause of gastroenteritis in the ambulatory setting.

Emergency Department Visits by Adolescent and Young Adult Cancer Patients Compared with Pediatric Cancer Patients in the United States.

PubMed

Kaul, Sapna; Russell, Heidi; Livingston, John A; Kirchhoff, Anne C; Jupiter, Daniel

2018-06-20

Limited information exists on emergency department (ED) visits for adolescent and young adult (AYA) patients with cancer. We examined the clinical reasons for ED visits, and outcomes, for AYAs with cancer compared to pediatric cancer patients. The 2013 Nationwide Emergency Department Sample data were used to identify 53,274 AYA (ages 15-39) and 6952 pediatric (ages 0-14) cancer ED visits. We evaluated patient (i.e., demographic and diagnosis) and hospital characteristics, and the ED event outcome (admitted to the same hospital or treated/released). Clinical reasons for visits were identified as procedures, infections, or noninfectious toxicities. Variables were compared between groups using chi-squared tests. Logistic regressions identified characteristics associated with the outcome between and within groups. AYA cancer visits were more likely to be self-paid (15.8% vs. 1.9%, p < 0.001), and be from low-income households and nonmetro counties than pediatric visits. Toxicity was the most prevalent reason for AYA visits (46.0%) and infections for pediatrics (47.3%, p < 0.001). AYA cancer visits were less likely to be admitted (OR = 0.84, 95% CI = 0.71-0.98; p = 0.03) than pediatric cancer. Among AYAs, self-paid visits were less likely to be admitted compared with privately insured visits (OR = 0.58, 95% CI: 0.52-0.66, p < 0.001). Self-pay did not affect the outcome for pediatric visits. In the United States, compared with pediatric cancer patients, AYAs with cancer visit EDs more often for toxicity-related problems, and are more often self-paid and from poorer households. These distinctive features impacting health service use should be incorporated into care plans aimed at delineating effective care for these patients.

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.

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

Timing of Emergency Department Visits for Childhood Asthma after Initial Inhaled Corticosteroid Use

PubMed Central

Zhang, Shun; Holloway, Kelvin; Tyler-Hill, Yasmin

2015-01-01

Abstract Inhaled corticosteroids can prevent acute exacerbations and emergency visits when used as part of a chronic care plan for long-term control of asthma, but low patient adherence and inadequate provider prescribing (clinical inertia) can limit these benefits. State Medicaid programs are a major source of insurance coverage for low-income children, paying for medications and preventive care, as well as bearing the cost of adverse outcomes for common chronic conditions in childhood, such as asthma. This study measured the incidence and timing of emergency department (ED) visits in the first 90 days after an initial inhaled corticosteroid prescription (ICS-Rx) among 43,156 Medicaid-enrolled children with a diagnosis of asthma in 14 southern states in 2007. One in 5 children (19.6%) with asthma had at least 1 ED visit in the first 90 days after initial ICS-Rx; 10% of these visits occurred within the first 48 hours, and 25% occurred within the first week. Continued ICS-Rx use was associated with lower risk of an ED visit. There were no racial differences in the ED visit rates. Initial ICS-Rx for Medicaid-enrolled children is a warning flag for short-term risk of asthma-related ED visits, whereas continued ICS-Rx use is protective for at least 90 days. Primary care follow-up may be needed within the first 2 days after initial ICS-Rx to prevent adverse outcomes. Medicaid programs could use claims data for surveillance of adherence to guideline-concordant therapy and for sentinel events marking windows of a higher risk for ED visits. Population Health Management 2015;18:54–60. PMID:25046059

Early childhood caries-related visits to emergency departments and ambulatory surgery facilities and associated charges in New York state.

PubMed

Nagarkar, Sanket R; Kumar, Jayanth V; Moss, Mark E

2012-01-01

The authors assessed the extent of early childhood caries- (ECC-) related visits to emergency departments (EDs) and ambulatory surgery facilities (ASFs) in children younger than 6 years and associated treatment charges in New York state from 2004 through 2008. The authors obtained data from the New York state's Statewide Planning and Research Cooperative System (Albany) and calculated descriptive statistics and rates according to selected indicators, as well as total and average per-visit treatment charges. From 2004 through 2008, the number of ECC-related visits to EDs and ASFs increased by 349 and 1,039, respectively. Most ECC-related visits were to ASFs. The total annual treatment charges increased from $18.5 million to $31.3 million from 2004 to 2008, and average per-visit charges increased from $4,237 to $5,501 during the same period. ECC-related visits to EDs and ASFs by children younger than 6 years and the associated treatment charges increased substantially from 2004 through 2008 in New York state. Practice Implications. Dental professionals need to determine the reasons parents seek dental care for their children in EDs and ASFs and effective strategies for preventing ECC to avoid the subsequent need for seeking dental care in EDs and ASFs.

Urban air pollution and meteorological factors affect emergency department visits of elderly patients with chronic obstructive pulmonary disease in Taiwan.

PubMed

Ding, Pei-Hsiou; Wang, Gen-Shuh; Guo, Yue-Leon; Chang, Shuenn-Chin; Wan, Gwo-Hwa

2017-05-01

Both air pollution and meteorological factors in metropolitan areas increased emergency department (ED) visits from people with chronic obstructive pulmonary disease (COPD). Few studies investigated the associations between air pollution, meteorological factors, and COPD-related health disorders in Asian countries. This study aimed to investigate the relationship between the environmental factors and COPD-associated ED visits of susceptible elderly population in the largest Taiwanese metropolitan area (Taipei area, including Taipei city and New Taipei city) between 2000 and 2013. Data of air pollutant concentrations (PM 10 , PM 2.5 , O 3 , SO 2 , NO 2 and CO), meteorological factors (daily temperature, relative humidity and air pressure), and daily COPD-associated ED visits were collected from Taiwan Environmental Protection Administration air monitoring stations, Central Weather Bureau stations, and the Taiwan National Health Insurance database in Taipei area. We used a case-crossover study design and conditional logistic regression models with odds ratios (ORs), and 95% confidence intervals (CIs) for evaluating the associations between the environmental factors and COPD-associated ED visits. Analyses showed that PM 2.5 , O 3 , and SO 2 had significantly greater lag effects (the lag was 4 days for PM 2.5 , and 5 days for O 3 and SO 2 ) on COPD-associated ED visits of the elderly population (65-79 years old). In warmer days, a significantly greater effect on elderly COPD-associated ED visits was estimated for PM 2.5 with coexistence of O 3 . Additionally, either O 3 or SO 2 combined with other air pollutants increased the risk of elderly COPD-associated ED visits in the days of high relative humidity and air pressure difference, respectively. This study showed that joint effect of urban air pollution and meteorological factors contributed to the COPD-associated ED visits of the susceptible elderly population in the largest metropolitan area in Taiwan. Government authorities should review existing air pollution policies, and strengthen health education propaganda to ensure the health of the susceptible elderly population. Copyright © 2017 Elsevier Ltd. All rights reserved.

The use of mechanical ventilation in the ED.

PubMed

Easter, Benjamin D; Fischer, Christopher; Fisher, Jonathan

2012-09-01

Although EDs are responsible for the initial care of critically ill patients and the amount of critical care provided in the ED is increasing, there are few data examining mechanical ventilation (MV) in the ED. In addition, characteristics of ED-based ventilation may affect planning for ventilator shortages during pandemic influenza or bioterrorist events. The study examined the epidemiology of MV in US EDs, including demographic, clinical, and hospital characteristics; indications for MV; ED length of stay (LOS); and in-hospital mortality. This study was a retrospective review of the 1993 to 2007 National Hospital Ambulatory Medical Care Survey ED data sets. Ventilated patients were compared with ED patients admitted to the intensive care unit (ICU) and to all other ED visits. There were 3.6 million ED MV visits (95% confidence interval [CI], 3.2-4.0 million) over the study period. Sex, age, race, and payment source were similar for mechanically ventilated and ICU patients (P > .05 for all). Approximately 12.5% of ventilated patients underwent cardiopulmonary resuscitation compared with 1.7% of ICU admissions and 0.2% of all other ED visits (P < .0001). Accordingly, in-hospital mortality was significantly higher for ventilated patients (24%; 95% CI, 13.1%-34.9%) than both comparison groups (9.3% and 2.5%, respectively). Median LOS for ventilated patients was 197 minutes (interquartile range, 112-313 minutes) compared with 224 minutes for ICU admissions and 140 minutes for all other ED visits. Patients undergoing ED MV have particularly high in-hospital mortality rates, but their ED LOS is sufficient for implementation of evidence-based ventilator interventions. Copyright © 2012 Elsevier Inc. All rights reserved.

Is adherence to weight monitoring or weight-based diuretic self-adjustment associated with fewer heart failure-related emergency department visits or hospitalizations?

PubMed

Jones, Christine D; Holmes, George M; Dewalt, Darren A; Erman, Brian; Broucksou, Kimberly; Hawk, Victoria; Cene, Crystal W; Wu, Jia-Rong; Pignone, Michael

2012-07-01

Heart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related emergency department (ED) visits or hospitalizations. We performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training, including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined case time periods as HF-related ED visits or hospitalizations in the 7 preceding days; control time periods were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in case and control time periods, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over 1 year of follow-up. Weight monitoring adherence (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.23-0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19-0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. Adherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity. Copyright © 2012 Elsevier Inc. All rights reserved.

Pattern of non-trauma emergency department resource utilization in older adults: An 8-year experience in Taiwan.

PubMed

Chang, Julia Chia-Yu; Yuan, Zih-Han; Lee, I-Hsin; Hsu, Teh-Fu; How, Chorng-Kuang; Yen, David Hung-Tsang

2018-06-01

To describe the patterns of non-trauma emergency department (ED) resource utilization, cost of visit, acuity level, and admission rate in older adult patients in Taiwan. This is a retrospective observational cohort study conducted at the Taipei Veterans General Hospital with an annual ED population of 80,000 patients. Patients aged ≥20 years with non-trauma ED visits from 2005 to 2012 were included in the study. We analyzed 441,665 ED visits. Older adult patients had higher ED usage, with the ratio of their ED visit and population being 3.56, 8.34, and 7.64 in the age groups 70-79, 80-89, and ≥90 years, respectively. ED cost, acuity level, and risks of intensive care unit (ICU) admission increased with increasing age. Compared with patients aged 20-29 years, patients aged ≥90 years required almost twice as much ED resources per visit [adjusted risk ratio (aRR), 1.98]. aRRs for high acuity in the age groups 70-79, 80-89, and ≥90 years were 1.96, 1.87, and 1.91, respectively. The risk of ICU admission in the age groups 40-49, 50-59, 70-79, and ≥90 years also increased by 3-fold (aRR, 2.99), 4-fold (aRR, 4.09), >6-fold (aRR, 6.66), and almost 10-fold (aRR, 9.84), respectively, compared with that in the age group 20-29 years. Among patients aged ≥90 years, 2.9% with low acuity still required ICU admission, whereas 25.1% with high acuity required ICU admission. Our study shows that older adult patients are associated with more ED visits and higher acuity, higher ED costs, and higher risks of admission to both the ordinary ward and ICU than younger adult patients. Copyright © 2018. Published by Elsevier Taiwan LLC.

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.

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

Factors Associated With Emergency Department Visits: A Multistate Analysis of Adult Fee-for-Service Medicaid Beneficiaries.

PubMed

Agarwal, Parul; Bias, Thomas K; Madhavan, Suresh; Sambamoorthi, Nethra; Frisbee, Stephanie; Sambamoorthi, Usha

2016-04-27

The objective of this study was to examine the association of patient- and county-level factors with the emergency department (ED) visits among adult fee-for-service (FFS) Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. A cross-sectional design using retrospective observational data was implemented. Patient-level data were obtained from 2010 Medicaid Analytic eXtract files. Information on county-level health-care resources was obtained from the Area Health Resource file and County Health Rankings file. In adjusted analyses, the following patient-level factors were associated with higher number of ED visits: African Americans (incidence rate ratios [IRR] = 1.47), Hispanics (IRR = 1.63), polypharmacy (IRR = 1.89), and tobacco use (IRR = 2.23). Patients with complex chronic illness had a higher number of ED visits (IRR = 3.33). The county-level factors associated with ED visits were unemployment rate (IRR = 0.94) and number of urgent care clinics (IRR = 0.96). Patients with complex healthcare needs had a higher number of ED visits as compared to those without complex healthcare needs. The study results provide important baseline context for future policy analysis studies around Medicaid expansion options.

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.

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.

Evaluation of Diagnostic Codes in Morbidity and Mortality Data Sources for Heat-Related Illness Surveillance

PubMed Central

Watkins, Sharon

2017-01-01

Objectives: The primary objective of this study was to identify patients with heat-related illness (HRI) using codes for heat-related injury diagnosis and external cause of injury in 3 administrative data sets: emergency department (ED) visit records, hospital discharge records, and death certificates. Methods: We obtained data on ED visits, hospitalizations, and deaths for Florida residents for May 1 through October 31, 2005-2012. To identify patients with HRI, we used codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to search data on ED visits and hospitalizations and codes from the International Classification of Diseases, Tenth Revision (ICD-10) to search data on deaths. We stratified the results by data source and whether the HRI was work related. Results: We identified 23 981 ED visits, 4816 hospitalizations, and 140 deaths in patients with non–work-related HRI and 2979 ED visits, 415 hospitalizations, and 23 deaths in patients with work-related HRI. The most common diagnosis codes among patients were for severe HRI (heat exhaustion or heatstroke). The proportion of patients with a severe HRI diagnosis increased with data source severity. If ICD-9-CM code E900.1 and ICD-10 code W92 (excessive heat of man-made origin) were used as exclusion criteria for HRI, 5.0% of patients with non–work-related deaths, 3.0% of patients with work-related ED visits, and 1.7% of patients with work-related hospitalizations would have been removed. Conclusions: Using multiple data sources and all diagnosis fields may improve the sensitivity of HRI surveillance. Future studies should evaluate the impact of converting ICD-9-CM to ICD-10-CM codes on HRI surveillance of ED visits and hospitalizations. PMID:28379784

Efficacy of the pentavalent rotavirus vaccine, RotaTeq®, in Finnish infants up to 3 years of age: the Finnish Extension Study.

PubMed

Vesikari, Timo; Karvonen, Aino; Ferrante, Shannon Allen; Ciarlet, Max

2010-11-01

Rotavirus Efficacy and Safety Trial (REST) enrolled nearly 70,000 infants, of whom more than 23,000 were from Finland. REST determined the efficacy of the pentavalent rotavirus vaccine (RV5) against rotavirus-related hospitalisations and emergency department (ED) visits in the first year after vaccination. Finnish infants initially in REST transitioned into the Finnish Extension Study (FES), where they were followed for rotavirus-related hospitalisations and ED visits through their second year of life and beyond. FES identified 150 (31%) additional rotavirus gastroenteritis (RVGE) cases beyond those identified in REST in the Finnish participants. Overall, RV5 reduced RVGE hospitalisations and ED visits, regardless of the rotavirus serotype, by 93.8% (95% confidence interval [CI]: 90.8-95.9%) for up to 3.1 years following the last vaccine dose. Vaccine efficacy against combined hospitalisations and ED visits between ages 4 months to 11 months, 12 months to 23 months, and 24 months to 35 months was 93.9% (95% CI: 89.1-96.9%), 94.4% (95% CI: 90.2-97.0%), and 85.9% (95% CI: 51.6-97.2%), respectively. The reduction of hospitalisations and ED visits due to any acute gastroenteritis, rotavirus or not, was 62.4% (95% CI: 57.6-66.6%) over the entire follow-up period. The results from FES confirm that RV5 induces high and sustained protection against rotavirus-related hospitalisations and ED visits, and has a very substantial impact on all gastroenteritis-related hospitalisations and ED visits into the third year of life in Finnish children.

Interfacility transfers for US ischemic stroke and TIA, 2006-2014.

PubMed

George, Benjamin P; Doyle, Sara J; Albert, George P; Busza, Ania; Holloway, Robert G; Sheth, Kevin N; Kelly, Adam G

2018-05-01

To investigate changes in emergency department (ED) transfers for ischemic stroke (IS) and TIA. We performed a retrospective observational study using the US Nationwide Emergency Department Sample to identify changes in interfacility ED transfers for IS and TIA from the perspective of the transferring ED (2006-2014). We calculated nationwide transfer rates and individual ED transfer rates for IS/TIA by diagnosis and hospital characteristics. Hospital-level fractional logistic regression examined changes in transfer rates over time. The population-estimated number of transfers for IS/TIA increased from 22,576 patient visits in 2006 to 54,485 patient visits in 2014 ( p trend < 0.001). The rate of IS/TIA transfer increased from 3.4 (95% confidence interval [CI] 3.0-3.8) in 2006 to 7.6 (95% CI 7.2-7.9) in 2014 per 100 ED visits. Among individual EDs, mean transfer rates for IS/TIA increased from 8.2 per 100 ED visits (median 2.0, interquartile range [IQR] 0-10.2) to 19.4 per 100 ED visits (median 8.1, IQR 1.1-33.3) (2006-2014) ( p trend < 0.001). Transfers were more common among IS. Transfer rates were greatest among rural (adjusted odds ratio [AOR] 3.05, 95% CI 2.56-3.64) vs urban/teaching and low-volume EDs (AOR 7.49, 95% CI 6.58-8.53, 1st vs 4th quartile). The adjusted odds of transfer for IS/TIA increased threefold (2006-2014). Interfacility ED transfers for IS/TIA more than doubled from 2006 to 2014. Further work should determine the necessity of IS/TIA transfers and seek to optimize the US stroke care system. © 2018 American Academy of Neurology.

Emergency department visits for pediatric trampoline-related injuries: an update.

PubMed

Linakis, James G; Mello, Michael J; Machan, Jason; Amanullah, Siraj; Palmisciano, Lynne M

2007-06-01

To describe the epidemiology of emergency department (ED) visits for trampoline-related injuries among U.S. children from January 1, 2000, to December 31, 2005, using the National Electronic Injury Surveillance System (NEISS) and to compare recent trampoline injury demographics and injury characteristics with those previously published for 1990-1995 using the same data source. A stratified probability sample of U.S. hospitals providing emergency services in NEISS was utilized for 2000-2005. Nonfatal trampoline-related injury visits to the ED were analyzed for patients from 0 to 18 years of age. In 2000-2005, there was a mean of 88,563 ED visits per year for trampoline-related injuries among 0-18-year-olds, 95% of which occurred at home. This represents a significantly increased number of visits compared with 1990-1995, when there was an average of 41,600 visits per year. Primary diagnosis and principal body part affected remained similar between the two study periods. ED visits for trampoline-related injuries in 2000-2005 increased in frequency by 113% over the number of visits for 1990-1995. Trampoline use at home continues to be a significant source of childhood injury morbidity.

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.

Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity.

PubMed

LaMantia, Michael A; Lane, Kathleen A; Tu, Wanzhu; Carnahan, Jennifer L; Messina, Frank; Unroe, Kathleen T

2016-06-01

To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. Retrospective cohort study. Public Health System. A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

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

Psychiatric Case Management in the Emergency Department.

PubMed

Turner, Stephanie B; Stanton, Marietta P

2015-01-01

The care of the mentally ill has reached a real crisis in the United States. There were more than 6.4 million visits to emergency departments (EDs) in 2010, or about 5% of total visits, involved patients whose primary diagnosis was a mental health condition or substance abuse (). That is up 28% from just 4 years earlier, according to the latest figures available from the Agency for Healthcare Research and Quality in Rockville, MD. Using a method called scoping, the purpose of this article is to examine the range, extent, and evidence available regarding case management as an intervention in the ED to manage mental health patients, to determine whether there is sufficient quantity and quality of evidence on this topic to conduct a meta-analysis, and to identify relevant studies that balance comprehensiveness with reasonable limitations. One solution for ensuring that the costs are contained, efficiency is maintained, and quality outcomes are achieved is the placement of a case manager in the ED. According to , because the majority of hospital admissions come through the ED, it makes sense to have case managers located there to act as gatekeepers and ensure that patients who are admitted meet criteria and are placed in the proper bed with the proper status. From the scoping techniques implemented in this study, the authors came to the conclusion that case management has been and can be used to effectively treat mental health patients in the emergency room. A good number of patients with psych mental health issues are frequent visitors and repeat visitors. Case management has not been used very often as a strategy for managing patients through the ED or for follow-up after the visit. Hospitals that have developed a protocol for managing these patients outside the main patient flow have had successful results. Staff training and development on psych mental health issues have been helpful in the ED. While there are not a large number of studies available on this topic, there is sufficient evidence to warrant further examination of this research topic. The findings in this scoping study have broader implications for research, policy, and practice. The framework of this study involved an outcomes-based approach. Clinical outcomes that positively enhance patient care and save the hospital money are necessary in the current health care environment.

A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department.

PubMed

Law, Stephanie; Ghag, Daljit; Grafstein, Eric; Stenstrom, Robert; Harris, Devin

2016-09-01

Patients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy. A chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives. Of the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0-3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1-21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement. VTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective.

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

Air pollution and ED visits for asthma in Australian children: a case-crossover analysis.

PubMed

Jalaludin, Bin; Khalaj, Behnoosh; Sheppeard, Vicky; Morgan, Geoff

2008-08-01

We aimed to determine the effects of ambient air pollutants on emergency department (ED) visits for asthma in children. We obtained routinely collected ED visit data for asthma (ICD9 493) and air pollution (PM(10), PM(2.5), O(3), NO(2), CO and SO(2)) and meteorological data for metropolitan Sydney for 1997-2001. We used the time stratified case-crossover design and conditional logistic regression to model the association between air pollutants and ED visits for four age-groups (1-4, 5-9, 10-14 and 1-14 years). Estimated relative risks for asthma ED visits were calculated for an exposure corresponding to the inter-quartile range in pollutant level. We included same day average temperature, same day relative humidity, daily temperature range, school holidays and public holidays in all models. Associations between ambient air pollutants and ED visits for asthma in children were most consistent for all six air pollutants in the 1-4 years age-group, for particulates and CO in the 5-9 years age-group and for CO in the 10-14 years age-group. The greatest effects were most consistently observed for lag 0 and effects were greater in the warm months for particulates, O(3) and NO(2). In two pollutant models, effect sizes were generally smaller compared to those derived from single pollutant models. We observed the effects of ambient air pollutants on ED attendances for asthma in a city where the ambient concentrations of air pollutants are relatively low.

Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11.

PubMed

Zhu, Jane M; Singhal, Astha; Hsia, Renee Y

2016-09-01

Despite increases in the use of emergency department (EDs) for mental health care, there are limited data on whether psychiatric patients disproportionately contribute to ED crowding. We conducted a retrospective analysis using a national database of ED visits in the period 2002-11 to describe trends in median and ninetieth-percentile length-of-stay for patients with psychiatric versus nonpsychiatric primary diagnoses. Psychiatric patients who visited the ED were transferred to another facility at six times the rate of nonpsychiatric patients. Median lengths-of-stay were similar for psychiatric and nonpsychiatric patients among those who were admitted to the hospital (264 versus 269 minutes) but significantly different for those who were admitted for observation (355 versus 279 minutes), transferred (312 versus 195 minutes), or discharged (189 versus 144 minutes). Overall, differences in ED length-of-stay between psychiatric and nonpsychiatric patients did not narrow over time. These findings suggest deficiencies in ED capacity for psychiatric care, which may necessitate improvements in both throughput and alternative models of care. Project HOPE—The People-to-People Health Foundation, Inc.

California emergency department visit rates for medical conditions increased while visit rates for injuries fell, 2005-11.

PubMed

Hsia, Renee Y; Nath, Julia B; Baker, Laurence C

2015-04-01

The emergency department (ED) is the source of most hospital admissions; provides care for patients with no other point of access to the health care system; receives advanced care referrals from primary care physicians; and provides surveillance data on injuries, infectious diseases, violence, and adverse drug events. Understanding the changes in the profile of disease in the ED can inform emergency services administration and planning and can provide insight into the public's health. We analyzed the trends in the diagnoses seen in California EDs from 2005 to 2011, finding that while the ED visit rate for injuries decreased by 0.7 percent, the rate of ED visits for noninjury diagnoses rose 13.4 percent. We also found a rise in symptom-related diagnoses, such as abdominal pain, along with nervous system disorders, gastrointestinal disease, and mental illness. These trends point out the increasing importance of EDs in providing care for complex medical cases, as well as the changing nature of illness in the population needing immediate medical attention. Project HOPE—The People-to-People Health Foundation, Inc.

Air pollution and emergency department visits for depression in Edmonton, Canada.

PubMed

Szyszkowicz, Mieczysław

2007-01-01

Depression is a common cause of morbidity. Sufferers are very sensitive to many external factors. Emergency department (ED) visits for this condition can be associated with the concentration of ambient air pollutants. The study objective was to examine and assess the associations between ED visits for depression and ambient air pollution. The present study analyzed 15,556 ED visits for depression (ICD-9: 311) at Edmonton hospitals between 1992 and 2002. The data were clustered based on the triplet {year, month, day of the week}. The generalized linear mixed models (GLMM) technique was used to regress the logarithm of the clustered counts for ED visits for depression on the levels of air pollutants (CO, NO2, SO2, O3, PM10 and PM2.5) and the meteorological variables. The number of ED visits for depression was analyzed separately for all patients, and males and females. An analysis by season was also conducted: for the whole year (I-XII), warm season (IV-IX), and cold season (X-III). After adjusting for temperature and relative humidity, the following increments in daily depression-related ED visits could be noted: 6.9% (95% CI: 1.3, 12.9) for carbon monoxide (CO) for all patients in warm season; 7.4% (95% CI: 0.5, 14.8) for nitrogen dioxide (NO2) for female patients in warm season; 4.5% (95% CI: 0.1, 9.1) for sulphur dioxide (SO2) for female patients in warm season; 6.9% (95% CI: 0.6, 13.6) for ground level ozone (O3, 1-day lagged) for female patients in warm season; 7.2% (95% CI: 2.7, 12.0) for particulate matter (PM10) for females in cold season; and 7.2% (95% CI: 2.0, 12.8) for particulate matter (PM2.5) for females in cold season. The findings provide support for the hypothesis that ED visits for depression are associated with exposure to ambient air pollution.

Predictors of Emergency Department Visits and Inpatient Admissions Among Homeless and Unstably Housed Adolescents and Young Adults.

PubMed

Mackelprang, Jessica L; Qiu, Qian; Rivara, Frederick P

2015-12-01

Individuals under age 25 years are estimated to comprise one third of the homeless population nationally. Understanding the reasons for utilization of hospitals by homeless youth is important for optimizing disposition planning. Objectives of the present study were to: (1) report prevalence of emergency department (ED) and inpatient admissions among homeless and unstably housed youth; (2) describe demographic characteristics of those youth who seek hospital care; (3) describe their patterns of injury, illness, psychiatric, and substance use conditions; and (4) identify demographic and diagnostic predictors of ED visit or hospital readmission. Retrospective cohort study of 15-25-year-olds (N=402) who were admitted to the ED or inpatient floors of 2 urban teaching hospitals in King County, WA between July 1, 2009 and June 30, 2012 and whose address was "homeless" or "none" or a homeless shelter or service agency (ie, homeless or unstably housed), during any recorded encounter between July 1, 2009 and June 30, 2012. A total of 1151 ED visits and 227 inpatient admissions were documented. Fifty percent of patients had an ED visit or hospital readmission within 1 year, with 43.1% receiving care within 30 days of discharge. Cox regression showed that female individuals with an injury diagnosis (hazard ratio=1.74, 95% confidence interval=1.06, 2.85) and male individuals with an acute medical condition (hazard ratio=1.59, 95% confidence interval=1.09, 2.32) at index visit were more likely to have an ED visit or hospital readmission during the following year, as were patients who provided a private address at their index visit. Homeless young people who seek hospital care demonstrate a high rate of ED visits and hospital readmissions, with unique predictors of utilization associated with sex and housing status. Additional research is necessary to determine how best to transition these young people from hospital-based to community-based care.

The impact on emergency department visits for respiratory illness during the southern california wildfires.

PubMed

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

2013-03-01

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. 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. 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. 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.

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

Adverse drug event-related emergency department visits associated with complex chronic conditions.

PubMed

Feinstein, James A; Feudtner, Chris; Kempe, Allison

2014-06-01

Outpatient adverse drug events (ADEs) can result in serious outcomes requiring emergency department (ED) visits and hospitalizations. The incidence and severity of ADEs in children with complex chronic conditions (CCCs), who often take multiple medications, is unknown. We sought to describe the characteristics of ADE-related ED visits, including association with CCC status; determine the implicated medications; and determine if CCC status increased the risk of ADE-related admission. Retrospective cohort study of ED visits by patients aged 0 to 18 years using a national sample. ADEs were identified by external cause of injury codes; cases with overdose, wrongful administration, self-harm, or diagnosis of malignancy were excluded. Multivariable logistic regression was used to test outcomes of having an ADE-related ED visit and of subsequent admission. All statistics accounted for the complex survey design. Of 144 million ED visits, 0.5% were associated with ADEs. Adjusting for age, gender, insurance type, day of week, and location of hospital, ADEs were associated with the presence of a CCC (odds ratio 4.76; 95% confidence interval: 4.45-5.10). The implicated medications differed significantly by CCC status. Adjusting for the same variables, ADEs were associated with subsequent inpatient admission (odds ratio 2.18; 95% confidence interval: 2.04-2.32) for all children; an interaction between ADE and CCC status was not significant. ED visits associated with ADEs were more likely to occur for children with CCCs, and the implicated drugs differed, but ADE-related admissions were not differentially affected by CCC status. Copyright © 2014 by the American Academy of Pediatrics.

Randomized trial of pragmatic education for low-risk COPD patients: impact on hospitalizations and emergency department visits.

PubMed

Siddique, Haamid H; Olson, Raymond H; Parenti, Connie M; Rector, Thomas S; Caldwell, Michael; Dewan, Naresh A; Rice, Kathryn L

2012-01-01

Most interventions aimed at reducing hospitalizations and emergency department (ED) visits in patients with chronic obstructive pulmonary disease (COPD) have employed resource-intense programs in high-risk individuals. Although COPD is a progressive disease, little is known about the effectiveness of proactive interventions aimed at preventing hospitalizations and ED visits in the much larger population of low-risk (no known COPD-related hospitalizations or ED visits in the prior year) patients, some of whom will eventually become high-risk. We tested the effect of a simple educational and self-efficacy intervention (n = 2243) versus usual care (n = 2182) on COPD/breathing-related ED visits and hospitalizations in a randomized study of low-risk patients at three Veterans Affairs (VA) medical centers in the upper Midwest. Administrative data was used to track VA admissions and ED visits. A patient survey was used to determine health-related events outside the VA. Rates of COPD-related VA hospitalizations in the education and usual care group were not significantly different (3.4 versus 3.6 admissions per 100 person-years, respectively; 95% CI of difference -1.3 to 1.0, P = 0.77). The much higher patient-reported rates of non-VA hospitalizations for breathing-related problems were lower in the education group (14.0 versus 19.0 per 100 person-years; 95% CI -8.6 to -1.4, P = 0.006). Rates of COPD-related VA ED visits were not significantly different (6.8 versus 5.3; 95% CI -0.1 to 3.0, P = 0.07), nor were non-VA ED visits (32.4 versus 36.5; 95% CI -9.3 to 1.1, P = 0.12). All-cause VA admission and ED rates did not differ. Mortality rates (6.9 versus 8.3 per 100 person-years, respectively; 95% CI -3.0 to 0.4, P = 0.13) did not differ. An educational intervention that is practical for large numbers of low-risk patients with COPD may reduce the rate of breathing-related hospitalizations. Further research that more closely tracks hospitalizations to non-VA facilities is needed to confirm this finding.

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

Annual Cost of U.S. Hospital Visits for Pediatric Abusive Head Trauma.

PubMed

Peterson, Cora; Xu, Likang; Florence, Curtis; Parks, Sharyn E

2015-08-01

We estimated the frequency and direct medical cost from the provider perspective of U.S. hospital visits for pediatric abusive head trauma (AHT). We identified treat-and-release hospital emergency department (ED) visits and admissions for AHT among patients aged 0-4 years in the Nationwide Emergency Department Sample and Nationwide Inpatient Sample (NIS), 2006-2011. We applied cost-to-charge ratios and estimated professional fee ratios from Truven Health MarketScan(®) to estimate per-visit and total population costs of AHT ED visits and admissions. Regression models assessed cost differences associated with selected patient and hospital characteristics. AHT was diagnosed during 6,827 (95% confidence interval [CI] [6,072, 7,582]) ED visits and 12,533 (95% CI [10,395, 14,671]) admissions (28% originating in the same hospital's ED) nationwide over the study period. The average medical cost per ED visit and admission were US$2,612 (error bound: 1,644-3,581) and US$31,901 (error bound: 29,266-34,536), respectively (2012 USD). The average total annual nationwide medical cost of AHT hospital visits was US$69.6 million (error bound: 56.9-82.3 million) over the study period. Factors associated with higher per-visit costs included patient age <1 year, males, coexisting chronic conditions, discharge to another facility, death, higher household income, public insurance payer, hospital trauma level, and teaching hospitals in urban locations. Study findings emphasize the importance of focused interventions to reduce this type of high-cost child abuse. © The Author(s) 2015.

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

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.

Unscheduled-return-visits after an emergency department (ED) attendance and clinical link between both visits in patients aged 75 years and over: a prospective observational study.

PubMed

Pereira, Laurent; Choquet, Christophe; Perozziello, Anne; Wargon, Mathias; Juillien, Gaelle; Colosi, Luisa; Hellmann, Romain; Ranaivoson, Michel; Casalino, Enrique

2015-01-01

Predictors of unscheduled return visits (URV), best time-frame to evaluate URV rate and clinical relationship between both visits have not yet been determined for the elderly following an ED visit. We conducted a prospective-observational study including 11,521 patients aged ≥75-years and discharged from ED (5,368 patients (53.5%)) or hospitalized after ED visit (6,153 patients). Logistic Regression and time-to-failure analyses including Cox proportional model were performed. Mean time to URV was 17 days; 72-hour, 30-day and 90-day URV rates were 1.8%, 6.1% and 10% respectively. Multivariate analysis indicates that care-pathway and final disposition decisions were significantly associated with a 30-day URV. Thus, we evaluated predictors of 30-day URV rates among non-admitted and hospitalized patient groups. By using the Cox model we found that, for non-admitted patients, triage acuity and diagnostic category and, for hospitalized patients, that visit time (day, night) and diagnostic categories were significant predictors (p<0.001). For URV, we found that 25% were due to closely related-clinical conditions. Time lapses between both visits constituted the strongest predictor of closely related-clinical conditions. Our study shows that a decision of non-admission in emergency departments is linked with an accrued risk of URV, and that some diagnostic categories are also related for non-admitted and hospitalized subjects alike. Our study also demonstrates that the best time frame to evaluate the URV rate after an ED visit is 30 days, because this is the time period during which most URVs and cases with close clinical relationships between two visits are concentrated. Our results suggest that URV can be used as an indicator or quality.

Traumatic brain injury in the Netherlands, trends in emergency department visits, hospitalization and mortality between 1998 and 2012.

PubMed

Van den Brand, Crispijn L; Karger, Lennard B; Nijman, Susanne T M; Hunink, Myriam G M; Patka, Peter; Jellema, Korné

2017-03-06

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. The effects of epidemiological changes such as ageing of the population and increased traffic safety on the incidence of TBI are unknown. The objective of this study was to evaluate trends in TBI-related emergency department (ED) visits, hospitalization and mortality in the Netherlands between 1998 and 2012. This was a retrospective observational, longitudinal study. The main outcome measures were TBI-related ED visits, hospitalization and mortality. Between 1998 and 2012, there were 500 000 TBI-related ED visits in the Netherlands. In the same period, there were 222 000 TBI-related admissions and 17 000 TBI-related deaths. During this period, there was a 75% increase in ED visits for TBI and a 95% increase for TBI-related hospitalization; overall mortality because of TBI did not change significantly. Despite the overall increase in TBI-related ED visits, this increase was not evenly distributed among age groups or trauma mechanisms. In patients younger than 65 years, a declining trend in ED visits for TBI caused by road traffic accidents was observed. Among patients 65 years or older, ED visits for TBI caused by a fall increased markedly. TBI-related mortality shifted from mainly young (67%) and middle-aged individuals (<65 years) to mainly elderly (63%) individuals (≥65 years) between 1998 and 2012. The conclusions of this study did not change when adjusting for changes in age, sex and overall population growth. The incidence of TBI-related ED visits and hospitalization increased markedly between 1998 and 2012 in the Netherlands. TBI-related mortality occurred at an older age. These observations are probably the result of a change in aetiology of TBI, specifically a decrease in traffic accidents and an increase in falls in the ageing population. This hypothesis is supported by our data. However, ageing of the population is not the only cause of the changes observed; the observed changes remained significant when correcting for age and sex. The higher incidence of TBI with a relatively stable mortality rate highlights the importance of clinical decision rules to identify patients with a high risk of poor outcome after TBI.

Characteristics of sports and recreation-related emergency department visits among school-age children and youth in North Carolina, 2010-2014.

PubMed

Harmon, Katherine J; Proescholdbell, Scott K; Register-Mihalik, Johna; Richardson, David B; Waller, Anna E; Marshall, Stephen W

2018-05-15

Sports and recreational activities are an important cause of injury among children and youth, with sports-related traumatic brain injuries (TBIs) being of particular concern given the developing brain. This paper reports the characteristics of sport and recreation-related (SR) emergency department (ED) visits among school-age children and youth in a statewide population. This study included all injury-related visits made to all North Carolina 24/7 acute-care civilian hospital-affiliated EDs by school-age youth, 5-18 years of age, during 2010-2014 (N = 918,662). Population estimates were based on US decennial census data. Poisson regression methods were used to estimate incidence rates and rate ratios. During the five-year period, there were 767,075 unintentional injury-related ED visits among school-age youth, of which 213,518 (27.8%) were identified as SR injuries. The average annual absolute number and incidence rate (IR) of SR ED visits among school-age youth was 42,704 and 2374.5 ED visits per 100,000 person-years (95% confidence interval [CI], 2364.4-2384.6), respectively. In comparison to other unintentional injuries among school-age youth, SR ED visits were more likely to be diagnosed with an injury to the upper extremity (Injury Proportion Ratio [IPR] = 1.28; 95% CI, 1.27-1.29), the lower extremity (IPR = 1.14; 95% CI, 1.13-1.15), and a TBI or other head/neck/facial injury (IPR = 1.12; 95% CI, 1.11-1.13). Among ED visits made by school-age youth, the leading cause of SR injury was sports/athletics played as a group or team. The leading cause of team sports/athletics injury was American tackle football among boys and soccer among girls. The proportion of ED visits diagnosed with a TBI varied by age and sex, with 15-18 year-olds and boys having the highest population-based rates. Sports and recreational activities are an important component of a healthy lifestyle, but they are also a major source of injury morbidity among school-age youth. Physical activity interventions should take into account sex and age differences in SR injury risk.

Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study.

PubMed

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

2016-06-08

To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition. A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan. Adult ED visits (aged ≥18 years) during 2009-2013, with or without receiving CT, were enrolled as the study participants. 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. 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). 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. 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/

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.

Cost-Sharing for Emergency Care and Unfavorable Clinical Events: Findings from the Safety and Financial Ramifications of ED Copayments Study

PubMed Central

Hsu, John; Price, Mary; Brand, Richard; Ray, G Thomas; Fireman, Bruce; Newhouse, Joseph P; Selby, Joseph V

2006-01-01

Objective To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting Kaiser Permanente–Northern California (KPNC), a prepaid integrated delivery system. Study Design In a quasi-experimental longitudinal study with concurrent controls, we estimated rates of ED visits, hospitalizations, ICU admissions, and deaths associated with higher ED copayments relative to no copayment, using Poisson random effects and proportional hazard models, controlling for patient characteristics. The study period began in January 1999; more than half of the population experienced an employer-chosen increase in their ED copayment in January 2000. Data Collection/Extraction Methods Using KPNC automated databases, the 2000 U.S. Census, and California state death certificates, we collected data on ED visits and unfavorable clinical events over a 36-month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare insured health system members. Principal Findings Among commercially insured subjects, ED visits decreased 12 percent with the $20–35 copayment (95 percent confidence interval [CI]: 11–13 percent), and 23 percent with the $50–100 copayment (95 percent CI: 23–24 percent) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not increase with copayments. Hospitalizations decreased 4 percent (95 percent CI: 2–6 percent) and 10 percent (95 percent CI: 7–13 percent) with ED copayments of $20–35 and $50–100, respectively, compared with no copayment. Among Medicare subjects, ED visits decreased by 4 percent (95 percent CI: 3–6 percent) with the $20–50 copayments compared with no copayment; unfavorable clinical events did not increase with copayments, e.g., hospitalizations were unchanged (95 percent CI: −3 percent to +2 percent) with $20–50 ED copayments compared with no copayment. Conclusions Relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events. PMID:16987303

Safety of an ED High-Dose Opioid Protocol for Sickle Cell Disease Pain.

PubMed

Tanabe, Paula; Martinovich, Zoran; Buckley, Barbara; Schmelzer, Annie; Paice, Judith A

2015-05-01

A nurse-initiated high dose, opioid protocol for vaso-occlusive crisis (VOC) was implemented. Total intravenous morphine sulfate equivalents (IVMSE) in mgs] and safety was evaluated. A medical record review was conducted for all ED visits in adult patients with VOC post protocol implementation. Opioids doses and routes administered during the ED stay, and six hours into the hospital admission were abstracted and total IVMSE administered calculated. Oxygen saturation (SPO2), respiratory rate (RR), administration of naloxone or vasoactive medications, evidence of respiratory arrest, or any other types of resuscitation effort were abstracted. A RR of <10 or SPO2 <92% were coded as abnormal. Descriptive statistics report the total dose. Logistic regression was used to predict abnormal events. Predictors were age, gender, ED dose (10 mg increments) administered, and time from 1st dose to discharge from ED. 72 patients, 603 visits, 276 admitted. The total (ED & hospital dose) mean (95% CI) mg IVMSE administered for all visits was 93 mg (CI 86, 100), ED visit 63 mg (CI 59, 67) and hospital 66 mg (CI 59, 72). The mean (SD) time from administration of 1st analgesic dose to discharge from the ED was 203 (143) minutes, (range = 30-1396 minutes). During two visits, patients experienced a RR <10; while 61 visits were associated with a SPO2 <92%. No medications were administered, or resuscitative measures required. Controlling for demographics and evaluated at the average total ED dose, the longer patients were in the ED, patients were 1.359 times more likely to experience an abnormal vital sign. Controlling for demographics and evaluated at the average total time in the ED, for every 10 mg increase in IVMSE, patients were 1.057 times more likely to experience an abnormal vital sign. The effect of ED dose on the odds of experiencing an abnormal vital sign decreased by a multiplicative factor of 0.0970 for every 1 hour increase in time until discharge. The larger the dose administered in less time, the more likely patients experienced an abnormal vital sign. High opioid doses were safely administered to patients with sickle cell disease. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Emergency Department Visits for Homelessness or Inadequate Housing in New York City before and after Hurricane Sandy.

PubMed

Doran, Kelly M; McCormack, Ryan P; Johns, Eileen L; Carr, Brendan G; Smith, Silas W; Goldfrank, Lewis R; Lee, David C

2016-04-01

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.

Returns to Emergency Department, Observation, or Inpatient Care Within 30 Days After Hospitalization in 4 States, 2009 and 2010 Versus 2013 and 2014.

PubMed

Nuckols, Teryl K; Fingar, Kathryn R; Barrett, Marguerite L; Martsolf, Grant; Steiner, Claudia A; Stocks, Carol; Owens, Pamela L

2018-05-01

Nationally, readmissions have declined for acute myocardial infarction (AMI) and heart failure (HF) and risen slightly for pneumonia, but less is known about returns to the hospital for observation stays and emergency department (ED) visits. To describe trends in rates of 30-day, all-cause, unplanned returns to the hospital, including returns for observation stays and ED visits. By using Healthcare Cost and Utilization Project data, we compared 210,007 index hospitalizations in 2009 and 2010 with 212,833 matched hospitalizations in 2013 and 2014. Two hundred and one hospitals in Georgia, Nebraska, South Carolina, and Tennessee. Adults with private insurance, Medicaid, or no insurance and seniors with Medicare who were hospitalized for AMI, HF, and pneumonia. Thirty-day hospital return rates for inpatient, observation, and ED visits. Return rates remained stable among adults with private insurance (15.1% vs 15.3%; P = 0.45) and declined modestly among seniors with Medicare (25.3% vs 25.0%; P = 0.04). Increases in observation and ED visits coincided with declines in readmissions (8.9% vs 8.2% for private insurance and 18.3% vs 16.9% for Medicare, both P ≤ 0.001). Return rates rose among patients with Medicaid (31.0% vs 32.1%; P = 0.04) and the uninsured (18.8% vs 20.1%; P = 0.004). Readmissions remained stable (18.7% for Medicaid and 9.5% for uninsured patients, both P > 0.75) while observation and ED visits increased. Total returns to the hospital are stable or rising, likely because of growth in observation and ED visits. Hospitalists' efforts to improve the quality and value of hospital care should consider observation and ED care. © 2017 Society of Hospital Medicine

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

Postpartum psychiatric emergency visits: a nested case-control study.

PubMed

Barker, Lucy Church; Kurdyak, Paul; Fung, Kinwah; Matheson, Flora I; Vigod, Simone

2016-12-01

Mental health conditions are one of the most common reasons for postpartum emergency department (ED) visits. Characteristics of women using the ED and their mental health service use before presentation are unknown. We characterized all women in Ontario, Canada (2006-2012), who delivered a live born infant and had a psychiatric ED visit within 1 year postpartum (n = 8728). We compared those whose ED visit was the first physician mental health contact since delivery to those who had accessed mental health services on specific indicators of marginalization hypothesized to be associated with lower likelihood of mental health contact prior to the ED visit. For 60.4 % of women, this was the first physician mental health contact since delivery. The majority were presenting with a mood or anxiety disorder, and only 13.6 % required hospital admission. These women were more likely to have material deprivation and residential instability than women with contact (Q5 vs. Q1 aORs 1.30, 95 % CI 1.12-1.50; 1.17, 95 % CI 1.01-1.36), to live in rural vs. urban areas (aOR 1.58, 95 % CI 1.38-1.80), and to be low vs. high income quintile (aOR 1.18, 95 % CI 1.01-1.38). The frequent use of ED services as the first point of contact for mental health concerns suggests that interventions to improve timely and equitable access to effective outpatient postpartum mental health care are needed. Marginalized women are at particularly high risk of not having accessed outpatient services prior to an ED visit, and therefore, future research and interventions will specifically need to consider the needs of this group.

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

Benzodiazepine Prescribing in Older Adults in U.S. Ambulatory Clinics and Emergency Departments (2001-10).

PubMed

Marra, Erin M; Mazer-Amirshahi, Maryann; Brooks, Gillian; van den Anker, John; May, Larissa; Pines, Jesse M

2015-10-01

To assess trends in benzodiazepine use from 2001 to 2010 in older adults in U.S. ambulatory clinics and emergency departments (EDs). Retrospective analysis. 2001 to 2010 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Individuals aged 65 and older for whom the reason for visit might prompt a physician to use a benzodiazepine (e.g., anxiety, detoxification, back sprain). The NAMCS and NHAMCS were used to evaluate U.S. ambulatory clinic and ED visits. Encounters involving individuals aged 65 and older for whom a benzodiazepine might be prescribed were analyzed. Trends in benzodiazepine use in these visits were explored, and predictors of use were assessed using survey-weighted chi-square tests and logistic regression. From 2001 to 2010, benzodiazepines were used in 16.6 million of 133.3 million ambulatory clinic visits and 1.9 million of 18.1 million ED visits with the selected reasons for the visits. There was no change in benzodiazepine use in either setting over the study period, although benzodiazepine use for those aged 85 and older increased from 8.9% to 19.3% in ambulatory clinics and 10.1% to 17.2% in EDs. Individuals visiting clinics with anxiety were five times as likely to receive benzodiazepines (odds ratio (OR) = 4.8), and those in EDs were twice as likely (OR = 2.3). Despite safety concerns, benzodiazepine use in older adults in U.S. ambulatory clinics and EDs did not change from 2001 to 2010. In the oldest individuals, who are at higher risk of adverse events, a greater increase was seen than in those aged 65 to 84. Additional measures may be needed to promote alternatives to benzodiazepines. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Effect of Socioeconomic Status and Underlying Disease on the Association between Ambient Temperature and Ischemic Stroke.

PubMed

Cho, Seong Kyung; Sohn, Jungwoo; Cho, Jaelim; Noh, Juhwan; Ha, Kyoung Hwa; Choi, Yoon Jung; Pae, Sangjoon; Kim, Changsoo; Shin, Dong Chun

2018-07-01

Inconsistent findings have been reported regarding the effect of ambient temperature on ischemic stroke. Furthermore, little is known about how underlying disease and low socioeconomic status influence the association. We, therefore, investigated the relationship between ambient temperature and emergency department (ED) visits for ischemic stroke, and aimed to identify susceptible populations. Using medical claims data, we identified ED visits for ischemic stroke during 2005-2009 in Seoul, Korea. We conducted piecewise linear regression analyses to find optimum ambient temperature thresholds in summer and winter, and estimated the relative risks (RR) and 95% confidence intervals (CI) per a 1°C increase in temperature above/below the thresholds, adjusting for relative humidity, holidays, day of the week, and air pollutant levels. There were 63564 ED visits for ischemic stroke. In summer, the risk of ED visits for ischemic stroke was not significant, with the threshold at 26.8°C. However, the RRs were 1.055 (95% CI, 1.006-1.106) above 25.0°C in medical aid beneficiaries and 1.044 (1.007-1.082) above 25.8°C in patients with diabetes. In winter, the risk of ED visits for ischemic stroke significantly increased as the temperature decreased above the threshold at 7.2°C. This inverse association was significant also in patients with hypertension and diabetes mellitus above threshold temperatures. Ambient temperature increases above a threshold were positively associated with ED visits for ischemic stroke in patients with diabetes and medical aid beneficiaries in summer. In winter, temperature, to a point, and ischemic stroke visits were inversely associated. © Copyright: Yonsei University College of Medicine 2018.

Impact of mass media on public behavior and physicians: an ecological study of the H1N1 influenza pandemic.

PubMed

Codish, Shlomi; Novack, Lena; Dreiher, Jacob; Barski, Leonid; Jotkowitz, Alan; Zeller, Lior; Novack, Victor

2014-06-01

The mass media plays an important role in public health behavior. The objective of the present study was to investigate the effect of mass media coverage of the H1N1 pandemic on the number of emergency department (ED) visits and hospital admission rates. An ecological study of ED visits to 8 general Israeli hospitals due to influenza-like illness during the period June-October 2009 was performed. Data on the number of visits per day for children and adults and daily hospitalization rates were analyzed. Associations with the estimated value of H1N1-related publications and weekly reports from nationwide sentinel clinics were assessed. The analysis was performed in 2012-2013. There were 55,070 ED visits due to influenza-like illness during the study period. The overall number of media reports was 1,812 (14.3% radio broadcasts, 9.8% television broadcasts, 27.5% newspaper articles, and 48.5% major website reports). The overall estimated value of advertising of publications was $16,399,000, excluding the Internet. While H1N1 incidence recorded by Israeli sentinel clinics showed no association with mass media publications, peaks of media reports were followed by an increase in the number of ED visits, usually with a delay of 3 days (P = .005). This association was noted in children (P < .001) but not in adults (P > .1), with a corresponding decrease in hospital admission rates. Publications' framing had no association with ED visits. During the 2009 H1N1 influenza outbreak in Israel, an increase in mass media coverage was associated with an increase in pediatric ED visits.

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

PubMed

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

2016-03-01

Elder abuse is under-recognized by emergency department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma. 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. 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. Sixty-six ED visits were judged to have high probability of being related to elder abuse and 244 were 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. 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. Forty-two percent of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring more than 1 day prior to presentation, and the most common suspicious injury pattern being maxillofacial injuries. Victims of physical elder abuse commonly have injuries on the 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. Copyright © 2016 Elsevier Inc. All rights reserved.

Influenza-Related Hospitalization and ED Visits in Children Less Than 5 Years: 2000–2011

PubMed Central

Jules, Astride; Grijalva, Carlos G.; Zhu, Yuwei; Talbot, H. Keipp; Williams, John V.; Poehling, Katherine A.; Chaves, Sandra S.; Edwards, Kathryn M.; Schaffner, William; Shay, David K.

2015-01-01

BACKGROUND AND OBJECTIVES: In the United States, recommendations for annual influenza vaccination gradually expanded from 2004 to 2008, to include all children aged ≥6 months. The effects of these policies on vaccine uptake and influenza-associated health care encounters are unclear. The objectives of the study were to examine the annual incidence of influenza-related health care encounters and vaccine uptake among children age 6 to 59 months from 2000–2001 through 2010–2011 in Davidson County, TN. METHODS: We estimated the proportion of laboratory-confirmed influenza-related hospitalizations and emergency department (ED) visits by enrolling and testing children with acute respiratory illness or fever. We estimated influenza-related health care encounters by multiplying these proportions by the number of acute respiratory illness/fever hospitalizations and ED visits for county residents. We assessed temporal trends in vaccination coverage, and influenza-associated hospitalizations and ED visit rates. RESULTS: The proportion of fully vaccinated children increased from 6% in 2000–2001 to 38% in 2010–2011 (P < .05). Influenza-related hospitalizations ranged from 1.9 to 16.0 per 10 000 children (median 4.5) per year. Influenza-related ED visits ranged from 89 to 620 per 10 000 children (median 143) per year. Significant decreases in hospitalizations (P < .05) and increases in ED visits (P < .05) over time were not clearly related to vaccination trends. Influenza-related encounters were greater when influenza A(H3N2) circulated than during other years with median rates of 8.2 vs 3.2 hospitalizations and 307 vs 143 ED visits per 10 000 children, respectively. CONCLUSIONS: Influenza vaccination increased over time; however, the proportion of fully vaccinated children remained <50%. Influenza was associated with a substantial illness burden particularly when influenza A(H3N2) predominated. PMID:25489015

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

PubMed

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

2017-12-01

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. 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. 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 Visit t =7111.161+(a t +0.37462 a t -1). 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. © 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.

Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older adults.

PubMed

Salanitro, Amanda H; Hovater, Martha; Hearld, Kristine R; Roth, David L; Sawyer, Patricia; Locher, Julie L; Bodner, Eric; Brown, Cynthia J; Allman, Richard M; Ritchie, Christine S

2012-09-01

To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults. Prospective, observational study with a baseline in-home assessment of symptom burden. Central Alabama. Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence. Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined. During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity. Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Symptom Burden Predicts Hospitalization Independent of Comorbidity in Community-Dwelling Older Adults

PubMed Central

Salanitro, Amanda H.; Hovater, Martha; Hearld, Kristine Ria; Roth, David L.; Sawyer, Patricia; Locher, Julie L.; Bodner, Eric; Brown, Cynthia J.; Allman, Richard M.; Ritchie, Christine S.

2012-01-01

OBJECTIVES To determine if cumulative symptom burden predicted hospitalizations or emergency department (ED) visits in a cohort of older adults. DESIGN Prospective, observational study with a baseline in-home assessment of symptom burden. SETTING Central Alabama. PARTICIPANTS 980 community-dwelling adults age 65 years or older recruited from a random sample of Medicare beneficiaries, stratified by sex, race, and urban/rural residence. MEASUREMENTS Symptom burden score (range 0–10). One point was added to the score for each symptom reported: shortness of breath, tiredness/fatigue, problems with balance/dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables: Hospitalizations and ED visits assessed every 6 months during the 8.5 year follow-up period. Using Cox proportional hazard models, we determined time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit. RESULTS During the 8.5 year follow up period, 545 (55.6%) participants were hospitalized or had an ED visit. The participants’ mean age was 75.3 years ± 6.7. Compared to those with lower scores, participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR)=1.09, 95% confidence interval=1.05–1.14) and hospitalization or ED visit (HR=1.10, 95% CI=1.06–1.14). Participants living in rural areas had significantly lower risk of hospitalization (HR=0.83, 95% CI= 0.69–0.99) and hospitalization or ED visit (HR=0.80, 95% CI=0.70–0.95) compared to individuals in urban areas, independent of symptom burden and comorbidity. CONCLUSION Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Health care providers treating older adults should consider symptom burden as an additional risk factor for subsequent hospital utilization. PMID:22985139

The accuracy of International Classification of Diseases coding for dental problems not associated with trauma in a hospital emergency department.

PubMed

Figueiredo, Rafael L F; Singhal, Sonica; Dempster, Laura; Hwang, Stephen W; Quinonez, Carlos

2015-01-01

Emergency department (ED) visits for nontraumatic dental conditions (NTDCs) may be a sign of unmet need for dental care. The objective of this study was to determine the accuracy of the International Classification of Diseases codes (ICD-10-CA) for ED visits for NTDC. ED visits in 2008-2099 at one hospital in Toronto were identified if the discharge diagnosis in the administrative database system was an ICD-10-CA code for a NTDC (K00-K14). A random sample of 100 visits was selected, and the medical records for these visits were reviewed by a dentist. The description of the clinical signs and symptoms were evaluated, and a diagnosis was assigned. This diagnosis was compared with the diagnosis assigned by the physician and the code assigned to the visit. The 100 ED visits reviewed were associated with 16 different ICD-10-CA codes for NTDC. Only 2 percent of these visits were clearly caused by trauma. The code K0887 (toothache) was the most frequent diagnostic code (31 percent). We found 43.3 percent disagreement on the discharge diagnosis reported by the physician, and 58.0 percent disagreement on the code in the administrative database assigned by the abstractor, compared with what it was suggested by the dentist reviewing the chart. There are substantial discrepancies between the ICD-10-CA diagnosis assigned in administrative databases and the diagnosis assigned by a dentist reviewing the chart retrospectively. However, ICD-10-CA codes can be used to accurately identify ED visits for NTDC. © 2015 American Association of Public Health Dentistry.

Specialized survivor clinic attendance is associated with decreased rates of emergency department visits in adult survivors of childhood cancer.

PubMed

Sutradhar, Rinku; Agha, Mohammad; Pole, Jason D; Greenberg, Mark; Guttmann, Astrid; Hodgson, David; Nathan, Paul C

2015-12-15

Survivors of childhood cancer are at considerable risk of experiencing treatment-related adverse health outcomes. To provide survivors with specialized care focused on these risks during adulthood, the government of Ontario funded a provincial network of specialized survivor clinics in 1999. The aim of this study was to determine whether prior attendance at survivor clinics by adult survivors of childhood cancer was associated with rates of emergency department (ED) visits. This was a population-based, retrospective cohort study using multiple linked administrative health databases. The cohort consisted of all adult survivors of childhood cancer diagnosed between January 1, 1986 and December 31, 2005 in Ontario, Canada. A recurrent event regression model was used to evaluate the association between prior attendance at survivor clinics and the rate of ED visits; adjustments were made for individual, demographic, treatment, and provider characteristics. The study consisted of 3912 adult survivors of childhood cancer. Individuals who had at least 1 prior visit to a survivor clinic had a 19% decreased rate of ED visits in comparison with individuals who had not visited a survivor clinic (adjusted relative rate, 0.81; 95% confidence interval, 0.78-0.85). Each additional prior visit to a survivor clinic was associated with a 5% decrease in the rate of ED visits (adjusted relative rate, 0.95; 95% confidence interval, 0.93-0.96). These results were independent of whether or not survivors received care from a primary care physician. Attendance at a specialized survivor clinic was significantly associated with decreased ED visits among adult survivors of childhood cancer. © 2015 American Cancer Society.

Strategies to reduce nonurgent emergency department use: experience of a Northern Virginia Employer Group.

PubMed

DeVries, Andrea; Li, Chia-Hsuan; Oza, Manish

2013-03-01

This administrative claims analysis evaluated the impact of a health plan-sponsored Emergency Room Utilization Management Initiative (ERUMI), which combined increased patient copays for ED visits with educational outreach to reduce inappropriate ED use and encourage use of retail health clinics (RHCs) and other alternative treatment sites among a commercially insured population. Emergency department (ED) utilization rates for select acute but nonurgent conditions that could be treated appropriately in an RHC were compared for members of an employer group with (intervention group) and without (comparators) ERUMI. Utilization was compared for baseline period (January-June 2009) and ERUMI implementation period (January-June 2010). A total of 56,896 members (14,224 intervention, 42,672 matched comparators) were included. ED utilization for conditions that could be treated appropriately by RHCs decreased by 10.39 visits/1000 members in the intervention group versus 6.29 visits in comparators. RHC visits rose for both the groups, with a greater increase in the intervention group (22.61 visits/1000 members, P<0.001) versus comparison (1.64/1000, P=0.064). After ERUMI implementation, intervention group members were nearly 5 times more likely than comparators to choose RHCs over ED for nonurgent care. The health plan-sponsored ERUMI program, consisting of both financial and educational components, decreased nonurgent ED utilization while increasing the use of alternative treatment sites.

Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix.

PubMed

Pines, Jesse M; Zocchi, Mark; Moghtaderi, Ali; Black, Bernard; Farmer, Steven A; Hufstetler, Greg; Klauer, Kevin; Pilgrim, Randy

2016-08-01

In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1 percent, decreased uninsured visits by 31.4 percent, and decreased privately insured visits by 6.7 percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3 percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume. Project HOPE—The People-to-People Health Foundation, Inc.

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

Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management.

PubMed

Tanabe, Paula; Artz, Nicole; Mark Courtney, D; Martinovich, Zoran; Weiss, Kevin B; Zvirbulis, Elena; Hafner, John W

2010-04-01

The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

Bronchiolitis in US emergency departments 1992 to 2000: epidemiology and practice variation.

PubMed

Mansbach, Jonathan M; Emond, Jennifer A; Camargo, Carlos A

2005-04-01

To describe the epidemiology of US emergency department (ED) visits for bronchiolitis, including the characteristics of children presenting to the ED and the variability in bronchiolitis care in the ED. Data were obtained from the 1992 to 2000 National Hospital Ambulatory Medical Care Survey. Cases had International Classification of Diseases, Ninth Revision, Clinical Modification code 466 and were younger than 2 years. National estimates were obtained using assigned patient visit weights; 95% confidence intervals were calculated using the relative standard error of the estimate; analysis used chi2 and logistic regression. From 1992 to 2000, bronchiolitis accounted for approximately 1,868,000 ED visits for children younger than 2 years. Among this same age group, the overall rate was 26 (95% confidence interval 22-31) per 1000 US population and 31 (95% confidence interval 26-36) per 1000 ED visits. These rates were stable over the 9-year period. Comparing children with bronchiolitis to those presenting with other problems, children with bronchiolitis were more likely boys (61% vs. 53%; P = 0.01) and Hispanic (27% vs. 20%; P = 0.008). Therapeutic interventions varied and 19% were admitted to the hospital. The multivariate predictor for receiving systemic steroids was urgent/emergent status at triage (odds ratio 4.0, 1.9-8.4). Multivariate predictors for admission were Hispanic ethnicity (odds ratio 2.3, 1.1-5.0) and urgent/emergent status at triage (odds ratio 3.7, 2.0-6.9). ED visit rates for bronchiolitis among children younger than 2 years were stable between 1992 and 2000. The observed ED practice variation demonstrates that children are receiving medications for which there is little supporting evidence. Boys and Hispanics are at-risk groups for presentation to the ED, and Hispanics are more likely to be hospitalized.

Epidemiologic analysis of an urban, public emergency department's frequent users.

PubMed

Mandelberg, J H; Kuhn, R E; Kohn, M A

2000-06-01

To determine how the demographic, clinical, and utilization characteristics of emergency department (ED) frequent users differ from those of other ED patients. A cross-sectional and retrospective cohort study was performed using a database of all 348,858 visits to the San Francisco General Hospital ED during a five-year period (July 1, 1993, to June 30, 1998). A "frequent user" visited the ED five or more times in a 12-month period. Frequent users constituted 3.9% of ED patients but accounted for 20.5% of ED visits. The relative risk (RR) of frequent use was high among patients who were homeless (RR = 4.5), African American (RR = 1.8), and Medi-Cal sponsored (RR = 2.1). Frequent users were more likely to be seen for alcohol withdrawal (RR = 4.4), alcohol dependence (RR = 3.4), and alcohol intoxication (RR = 2.4). Frequent users were also more likely to visit for exacerbations of chronic conditions, including sickle cell anemia (RR = 8.0), renal failure (RR = 3.6), and chronic obstructive pulmonary disease (RR = 3.3). They were less likely to visit for all forms of trauma (RR = 0.43). Survival analysis showed that only 38% of frequent users for one year remained frequent users the next year. However, 56% of frequent users for two consecutive years remained frequent users in the third year. Frequent use of the ED reflects the urban social problems of homelessness, poverty, alcohol abuse, and chronic illness. Frequent use of the ED shows a high rate of decline from one year to the next. This rate of decline slows after the first year and suggests the existence of a smaller group of chronic frequent users.

The role of charity care and primary care physician assignment on ED use in homeless patients.

PubMed

Wang, Hao; Nejtek, Vicki A; Zieger, Dawn; Robinson, Richard D; Schrader, Chet D; Phariss, Chase; Ku, Jocelyn; Zenarosa, Nestor R

2015-08-01

Homeless patients are a vulnerable population with a higher incidence of using the emergency department (ED) for noncrisis care. Multiple charity programs target their outreach toward improving the health of homeless patients, but few data are available on the effectiveness of reducing ED recidivism. The aim of this study is to determine whether inappropriate ED use for nonemergency care may be reduced by providing charity insurance and assigning homeless patients to a primary care physician (PCP) in an outpatient clinic setting. A retrospective medical records review of homeless patients presenting to the ED and receiving treatment between July 2013 and June 2014 was completed. Appropriate vs inappropriate use of the ED was determined using the New York University ED Algorithm. The association between patients with charity care coverage, PCP assignment status, and appropriate vs inappropriate ED use was analyzed and compared. Following New York University ED Algorithm standards, 76% of all ED visits were deemed inappropriate with approximately 77% of homeless patients receiving charity care and 74% of patients with no insurance seeking noncrisis health care in the ED (P=.112). About 50% of inappropriate ED visits and 43.84% of appropriate ED visits occurred in patients with a PCP assignment (P=.019). Both charity care homeless patients and those without insurance coverage tend to use the ED for noncrisis care resulting in high rates of inappropriate ED use. Simply providing charity care and/or PCP assignment does not seem to sufficiently reduce inappropriate ED use in homeless patients. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

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

Incidence, Risk Factors, and Costs for Hospital Returns After Total Joint Arthroplasties.

PubMed

Sibia, Udai S; Mandelblatt, Abigail E; Callanan, Maura A; MacDonald, James H; King, Paul J

2017-02-01

Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA. We retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode. Of the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654. Unplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs. Copyright © 2016 Elsevier Inc. All rights reserved.

Drug abuse-related accidents leading to emergency department visits at two medical centers.

PubMed

Chen, Isaac Chun-Jen; Hung, Dong-Zong; Hsu, Chi-Ho; Wu, Ming-Ling; Deng, Jou-Fang; Chang, Chin-Yu; Shih, Hsin-Chin; Liu, Chen-Chi; Wang, Chien-Ying; Wen, Yi-Szu; Wu, Jackson Jer-Kan; Huang, Mu-Shun; Yang, Chen-Chang

2012-05-01

Drug abuse is becoming more prevalent in Taiwan, as evidenced by increasing reports of drug trafficking and drug abuse-related criminal activity, and the wide use of more contemporary illicit drugs. Consequently, drug abuse-related accidents are also expected to occur with greater frequency. However, no study has yet specifically evaluated the prevalence, pattern, and outcomes of drug abuse-related accidents among patients visiting emergency departments (EDs) in Taiwan. We conducted an ambidirectional study with patients who visited the EDs of Taipei Veterans General Hospital (TVGH) and China Medical University Hospital (CMUH) due to drug abuse-related accidents from January 2007 through September 2009. Information on the patients' baseline characteristics and clinical outcomes was collected and analyzed. During the study period, a total of 166 patients visited the EDs of one of the two study hospitals due to drug abuse-related accidents. This yielded a prevalence of drug abuse of 0.1% among all patients visiting the ED due to accident and/or trauma. Fifty-six out of the 166 patients visited the ED at TVGH, most patients being between 21 and 40 years old. Opioids (41.1%) were the drugs most commonly abused by the patients, followed by benzodiazepines (32.1%). More than two-thirds of the patients (n=38, 67.9%) required hospitalization, and three patients died (5.4%). In contrast, 110 patients with drug abuse-related accidents visited the ED at CMUH during the study period. Most of these subjects had abused benzodiazepines (69.1%), were between 21 and 40 years old, and were female. Fewer than one-fifth of the patients (n=19, 17.3%) required hospitalization, with no deaths reported. There were significant between-hospital differences in terms of patient gender, drugs of choice, injury mechanisms, method and time of the ED visit, triage levels, and need for hospitalization. Although the prevalence of drug abuse-related accidents was low, and only three patient deaths were reported in this study, many patients presented to the EDs with severe effects and later required hospitalization. Better and timely management of such patients will help to minimize the adverse health impacts associated with drug abuse. Governmental agencies and all healthcare professionals should also work together to fight against the surging trend of drug abuse in Taiwan. Copyright © 2012. Published by Elsevier B.V.

Randomized trial of pragmatic education for low-risk COPD patients: impact on hospitalizations and emergency department visits

PubMed Central

Siddique, Haamid H; Olson, Raymond H; Parenti, Connie M; Rector, Thomas S; Caldwell, Michael; Dewan, Naresh A; Rice, Kathryn L

2012-01-01

Background: Most interventions aimed at reducing hospitalizations and emergency department (ED) visits in patients with chronic obstructive pulmonary disease (COPD) have employed resource-intense programs in high-risk individuals. Although COPD is a progressive disease, little is known about the effectiveness of proactive interventions aimed at preventing hospitalizations and ED visits in the much larger population of low-risk (no known COPD-related hospitalizations or ED visits in the prior year) patients, some of whom will eventually become high-risk. Methods: We tested the effect of a simple educational and self-efficacy intervention (n = 2243) versus usual care (n = 2182) on COPD/breathing-related ED visits and hospitalizations in a randomized study of low-risk patients at three Veterans Affairs (VA) medical centers in the upper Midwest. Administrative data was used to track VA admissions and ED visits. A patient survey was used to determine health-related events outside the VA. Results: Rates of COPD-related VA hospitalizations in the education and usual care group were not significantly different (3.4 versus 3.6 admissions per 100 person-years, respectively; 95% CI of difference −1.3 to 1.0, P = 0.77). The much higher patient-reported rates of non-VA hospitalizations for breathing-related problems were lower in the education group (14.0 versus 19.0 per 100 person-years; 95% CI −8.6 to −1.4, P = 0.006). Rates of COPD-related VA ED visits were not significantly different (6.8 versus 5.3; 95% CI −0.1 to 3.0, P = 0.07), nor were non-VA ED visits (32.4 versus 36.5; 95% CI −9.3 to 1.1, P = 0.12). All-cause VA admission and ED rates did not differ. Mortality rates (6.9 versus 8.3 per 100 person-years, respectively; 95% CI −3.0 to 0.4, P = 0.13) did not differ. Conclusion: An educational intervention that is practical for large numbers of low-risk patients with COPD may reduce the rate of breathing-related hospitalizations. Further research that more closely tracks hospitalizations to non-VA facilities is needed to confirm this finding. PMID:23118535

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.

Emergency department visits with facial fractures among children and adolescents: an analysis of profile and predictors of causes of injuries.

PubMed

Allareddy, Veerasathpurush; Itty, Abraham; Maiorini, Elyse; Lee, Min Kyeong; Rampa, Sankeerth; Allareddy, Veerajalandhar; Nalliah, Romesh P

2014-09-01

The objectives of this study were to provide nationally representative estimates of hospital-based emergency department (ED) visits for facial fractures in children and adolescents, examine the burden associated with such visits, identify common types of facial fracture, and examine the role of patient-related demographic factors on the causes of facial fractures. The Nationwide Emergency Department Sample for 2008 to 2010 was used. All ED visits with a diagnosis of facial fractures in those no older than 21 years were selected. Demographic characteristics, types of facial fracture, causes of injuries, and hospital charges were examined. During the study period, 336,124 ED visits were for facial fractures in those no older than 21 years. Late adolescents (18 to 21 yr old) and middle adolescents (15 to 17 yr old) comprised 45.6% and 26.6% of all ED visits, respectively. Male patients comprised 74.7% of ED visits. The most common facial fractures were those of the nasal bones and mandible. Younger children were more likely to have falls, pedal cycle accidents, pedestrian accidents, and transport accidents, whereas older groups were more likely to have firearm injuries, motor vehicle traffic accidents, and assaults (P < .05). Female patients were more likely to have falls, motor vehicle traffic accidents, and transport accidents, whereas male patients were more likely to have firearm injuries, pedal cycle accidents, and assaults (P < .05). Those residing at low annual income household levels were at a high risk for having firearm injuries, motor vehicle traffic accidents, and transport accidents (P < .05). Late adolescents, middle adolescents, and male patients comprise a significant proportion of these ED visits. Age, gender, and household income levels are significantly associated with the causes of facial fracture injuries. Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

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.

Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments.

PubMed

Mehrotra, Ateev; Gidengil, Courtney A; Setodji, Claude M; Burns, Rachel M; Linder, Jeffrey A

2015-04-01

To compare antibiotic prescribing among retail clinics, primary care practices, and emergency departments (EDs) for acute respiratory infections (ARIs): antibiotics-may-be-appropriate ARIs (eg, sinusitis) and antibiotics-never-appropriate ARIs (eg, acute bronchitis). We analyzed retail clinic data from the electronic health records of the 3 largest retail clinic chains in the United States, and data on visits to primary care practices and EDs from the nationally representative National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Using multivariate models, we estimated an adjusted antibiotic prescribing rate for each site of care, controlling for differences in patient characteristics and diagnosis. From 2007 to 2009 in the United States, there were 3 million, 167 million, and 29 million ARI visits at retail clinics, primary care practices, and EDs, respectively. For all ARI visits, the adjusted antibiotic prescribing rate at retail clinics (58%) was similar to the rate at primary care practices (62%; P=.09) and EDs (59%; P=.48). For antibiotics-may-be-appropriate ARI visits, the adjusted antibiotic prescribing rate (95%) at retail clinics was higher than at primary care practices (85%; P<.01) and EDs (83%; P<.01). For antibiotics-never-appropriate ARI visits, the adjusted antibiotic prescribing rate (34%) at retail clinics was lower than at primary care practices (51%; P<.01) and EDs (48%; P<.01). Compared with primary care practices and EDs, there was no difference at retail clinics in overall ARI antibiotic prescribing. At retail clinics, antibiotic prescribing was more diagnosis-appropriate.

Depression but Not Symptom Severity is Associated With Work and School Absenteeism in Refractory Chronic Constipation.

PubMed

Staller, Kyle; Barshop, Kenneth; Kuo, Braden; Ananthakrishnan, Ashwin N

We sought to determine the patient characteristics associated with increased absenteeism and Emergency Department (ED) utilization among patients with constipation. Chronic constipation is associated with significant direct and indirect economic costs. There has been limited study of the predictors of direct and indirect costs in a population with refractory constipation. We conducted a cross-sectional cohort study of patients with chronic constipation who presented to a tertiary care center for anorectal manometry. We used standardized instruments to assess disease severity, quality of life, somatization, and psychiatric comorbidities. We used multivariable logistic regression to determine the predictors of work and school absenteeism as well as ED visits for constipation. There were 148 consecutive patients enrolled (87% female, mean age 43) of whom 32 (21.6%) had high absenteeism and 36 (24.3%) visited the ED for constipation in the past year. Patients with high absenteeism and ED visits were more likely to be depressed (56.3% vs. 18.5%, P<0.0001 for high absenteeism; 47.2% vs. 19.6%, P<0.01 for ED visits). After multivariable adjustment and sensitivity analyses, only depression (OR, 4.41; P<0.01) was associated with increased absenteeism while there was a trend toward an association between depression and ED visits (OR, 2.57; P=0.067). Symptom severity was not associated with high absenteeism or ED utilization. Among patients with chronic constipation, depression is a stronger predictor of absenteeism than symptom severity. Depression may drive a portion of the indirect costs of chronic constipation.

International perspectives on emergency department crowding.

PubMed

Pines, Jesse M; Hilton, Joshua A; Weber, Ellen J; Alkemade, Annechien J; Al Shabanah, Hasan; Anderson, Philip D; Bernhard, Michael; Bertini, Alessio; Gries, André; Ferrandiz, Santiago; Kumar, Vijaya Arun; Harjola, Veli-Pekka; Hogan, Barbara; Madsen, Bo; Mason, Suzanne; Ohlén, Gunnar; Rainer, Timothy; Rathlev, Niels; Revue, Eric; Richardson, Drew; Sattarian, Mehdi; Schull, Michael J

2011-12-01

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes. © 2011 by the Society for Academic Emergency Medicine.

City housing atmospheric pollutant impact on emergency visit for asthma: A classification and regression tree approach.

PubMed

Mazenq, Julie; Dubus, Jean-Christophe; Gaudart, Jean; Charpin, Denis; Viudes, Gilles; Noel, Guilhem

2017-11-01

Particulate matter, nitrogen dioxide (NO 2 ) and ozone are recognized as the three pollutants that most significantly affect human health. Asthma is a multifactorial disease. However, the place of residence has rarely been investigated. We compared the impact of air pollution, measured near patients' homes, on emergency department (ED) visits for asthma or trauma (controls) within the Provence-Alpes-Côte-d'Azur region. Variables were selected using classification and regression trees on asthmatic and control population, 3-99 years, visiting ED from January 1 to December 31, 2013. Then in a nested case control study, randomization was based on the day of ED visit and on defined age groups. Pollution, meteorological, pollens and viral data measured that day were linked to the patient's ZIP code. A total of 794,884 visits were reported including 6250 for asthma and 278,192 for trauma. Factors associated with an excess risk of emergency visit for asthma included short-term exposure to NO 2 , female gender, high viral load and a combination of low temperature and high humidity. Short-term exposures to high NO 2 concentrations, as assessed close to the homes of the patients, were significantly associated with asthma-related ED visits in children and adults. 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…

Screening for violence risk factors identifies young adults at risk for return emergency department visit for injury.

PubMed

Hankin, Abigail; Wei, Stanley; Foreman, Juron; Houry, Debra

2014-08-01

Homicide is the second leading cause of death among youth aged 15-24. Prior cross-sectional studies, in non-healthcare settings, have reported exposure to community violence, peer behavior, and delinquency as risk factors for violent injury. However, longitudinal cohort studies have not been performed to evaluate the temporal or predictive relationship between these risk factors and emergency department (ED) visits for injuries among at-risk youth. The objective was to assess whether self-reported exposure to violence risk factors in young adults can be used to predict future ED visits for injuries over a 1-year period. This prospective cohort study was performed in the ED of a Southeastern US Level I trauma center. Eligible participants were patients aged 18-24, presenting for any chief complaint. We excluded patients if they were critically ill, incarcerated, or could not read English. Initial recruitment occurred over a 6-month period, by a research assistant in the ED for 3-5 days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from 8AM-8PM. At the time of initial contact in the ED, patients were asked to complete a written questionnaire, consisting of previously validated instruments measuring the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. At 12 months following the initial ED visit, the participants' medical records were reviewed to identify any subsequent ED visits for injury-related complaints. We analyzed data with chi-square and logistic regression analyses. Three hundred thirty-two patients were approached, of whom 300 patients consented. Participants' average age was 21.1 years, with 60.1% female, 86.0% African American. After controlling for participant gender, ethnicity, or injury complaint at time of first visit, return visits for injuries were significantly associated with: hostile/aggressive feelings (Odds ratio (OR) 3.5, 95% Confidence interval (CI): 1.3, 9.8), self-reported perceived likelihood of violence (OR 10.1, 95% CI: 2.5, 40.6), and peer group violence (OR 6.7, 95% CI: 2.0, 22.3). A brief survey of risk factors for violence is predictive of increased probability of a return visit to the ED for injury. These findings identify a potentially important tool for primary prevention of violent injuries among at-risk youth seen in the ED for trauma-related and non-traumatic complaints.

Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program.

PubMed

Huded, Jill M; Dresden, Scott M; Gravenor, Stephanie J; Rowe, Theresa; Lindquist, Lee A

2015-12-01

Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model. Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%). The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.

Is Low Health Literacy Associated with Increased Emergency Department Utilization and Recidivism?

PubMed Central

Griffey, Richard T.; Kennedy, Sarah K.; McGownan, Lucy; Goodman, Melody; Kaphingst, Kimberly A.

2015-01-01

Objectives To determine whether patients with low health literacy have higher ED utilization and higher ED recidivism than patients with adequate health literacy. Methods The study was conducted at an urban academic ED with over 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (STOFHLA), and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period, and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis, and retaining those significant at an alpha of 0.05 in the final model. Results Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. Conclusions In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days. PMID:25308133

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 effect of North Carolina hospital payor mix on dental-related pediatric emergency room utilization.

PubMed

Hom, Jacqueline M; Burgette, Lane F; Lee, Jessica Y

2013-01-01

We examined the effect of hospital payor mix on the proportion of pediatric emergency department (ED) visits that were dental related. We used the North Carolina (NC) Emergency Room Discharge Database from 2007 to 2009 to estimate the relationship between the percent of pediatric ED patients that were covered by Medicaid and the percent of pediatric ED visits that were dental related. Hospital-level fixed effects controlled for unobserved hospital-level characteristics. Discharge claims from 110 ED facilities in NC were analyzed over the 3-year study period. Claims were limited to individuals under 18 years old with dental disease-related International Classification of Diseases, Ninth Edition, Clinical Modification diagnostic codes, 520.00-530.00. Using 327 hospital-years of data, 62 percent of ED visits for pediatric dental reasons were covered by Medicaid, a proportion over two times greater than for pediatric reasons overall, 26 percent. Hospitals with a greater proportion of Medicaid payors had a greater proportion of pediatric dental ED visits (P < 0.01). Hospitals serving a large population of children on Medicaid should be prepared to provide emergency dental services. Public health administrators should prioritize oral health resources at hospital communities with a high proportion of Medicaid payors. © 2013 American Association of Public Health Dentistry.

Association between Rainfall and Pediatric Emergency Department Visits for Acute Gastrointestinal Illness

PubMed Central

Drayna, Patrick; McLellan, Sandra L.; Simpson, Pippa; Li, Shun-Hwa; Gorelick, Marc H.

2010-01-01

Background Microbial water contamination after periods of heavy rainfall is well described, but its link to acute gastrointestinal illness (AGI) in children is not well known. Objectives We hypothesize an association between rainfall and pediatric emergency department (ED) visits for AGI that may represent an unrecognized, endemic burden of pediatric disease in a major U.S. metropolitan area served by municipal drinking water systems. Methods We conducted a retrospective time series analysis of visits to the Children’s Hospital of Wisconsin ED in Wauwatosa, Wisconsin. Daily visit totals of discharge International Classification of Diseases, 9th Revision codes of gastroenteritis or diarrhea were collected along with daily rainfall totals during the study period from 2002 to 2007. We used an autoregressive moving average model, adjusting for confounding variables such as sewage release events and season, to look for an association between daily visits and rainfall after a lag of 1–7 days. Results A total of 17,357 AGI visits were identified (mean daily total, 7.9; range, 0–56). Any rainfall 4 days prior was significantly associated with an 11% increase in AGI visits. Expected seasonal effects were also seen, with increased AGI visits in winter months. Conclusions We observed a significant association between rainfall and pediatric ED visits for AGI, suggesting a waterborne component of disease transmission in this population. The observed increase in ED visits for AGI occurred in the absence of any disease outbreaks reported to public health officials in our region, suggesting that rainfall-associated illness may be underestimated. Further study is warranted to better address this association. PMID:20515725

The impact of rotavirus vaccination on emergency department visits and hospital admissions for acute diarrhea in children under 5 years.

PubMed

Paulo, Rodrigo Locatelli Pedro; Rodrigues, André Broggin Dutra; Machado, Beatriz Marcondes; Gilio, Alfredo Elias

2016-09-01

Acute diarrheal disease is the second cause of death in children under 5 years. In Brazil, from 2003 to 2009, acute diarrhea was responsible for nearly 100,000 hospital admissions per year and 4% of the deaths in children under 5 years. Rotavirus is the leading cause of severe acute diarrhea worldwide. In 2006, the rotavirus monovalent vaccine (RV1) was added to the Brazilian National Immunization Program. To analyze the impact of the RV1 on emergency department (ED) visits and hospital admissions for acute diarrhea. A retrospective ecologic study at the University Hospital, University of São Paulo. The study analyzed the pre-vaccine (2003-2005) and the post-vaccine (2007-2009) periods. We screened the main diagnosis of all ED attendances and hospital admissions of children under 5 years in an electronic registry system database and calculated the rates of ED visits and hospital admissions. The reduction rate was analyzed according to the following formula: reduction (%) = (1 - odds ratio) x 100. The rates of ED visits for acute diarrhea was 85.8 and 80.9 per 1,000 total ED visits in the pre and post vaccination periods, respectively, resulting in 6% reduction (95CI 4 to 9%, p<0.001). The rates of hospital admissions for acute diarrhea was 40.8 per 1,000 in the pre-vaccine period and dropped to 24.9 per 1,000 hospitalizations, resulting in 40% reduction (95CI 22 to 54%, p<0.001). The introduction of the RV1 vaccine resulted in 6% reduction in the ED visits and 40% reduction in hospital admissions for acute diarrhea.

Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.

PubMed

Tanabe, Paula; Hafner, John W; Martinovich, Zoran; Artz, Nicole

2012-04-01

The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED. © 2012 by the Society for Academic Emergency Medicine.

Nonurgent use of a pediatric emergency department: a preliminary qualitative study.

PubMed

Chin, Nancy P; Goepp, Julius G; Malia, Timothy; Harris, LeWanza; Poordabbagh, Armin

2006-01-01

To understand patterns of decision making among families presenting to a pediatric emergency department (ED) for nonacute care and to understand pediatric ED staff responses. Cross-sectional qualitative study using in-depth interviews, direct observations, and nonidentifying demographic data. Eleven percent of visits made during the study period were identified as nonacute. All were made by families from low-income areas. Three main themes emerged: (1) most families had been referred by their primary care providers; (2) the complexity of living in low-income areas makes the ED a choice of convenience for these stressed families; and (3) mistrust of primary health services was not identified by our respondents as a motivator for ED utilization, in contrast with other published data. Two themes emerged from ED staff: (1) actual nonurgent visit rates were lower than staff estimates; and (2) these visits produced frustration among staff members, although their degrees of insight and understanding of factors motivating these visits were variable. In this setting, nonacute visits occurred with lower than perceived frequency and caused disproportionate frustration among staff and families. These visits appear to be driven more by consequences of system design and structure than by family members' decision making. Mistrust of primary care services was not a strong family decision-making factor; the study's setting may have limited its ability to capture such data. Recommended system changes to lower barriers to primary care include expanded office hours, subsidized staffing for offices in medically underserved areas, and lowering barriers to sick care.

Alternate site surge capacity in times of public health disaster maintains trauma center and emergency department integrity: Hurricane Katrina.

PubMed

Eastman, Alexander L; Rinnert, Kathy J; Nemeth, Ira R; Fowler, Raymond L; Minei, Joseph P

2007-08-01

Hospital surge capacity has been advocated to accommodate large increases in demand for healthcare; however, existing urban trauma centers and emergency departments (TC/EDs) face barriers to providing timely care even at baseline patient volumes. The purpose of this study is to describe how alternate-site medical surge capacity absorbed large patient volumes while minimizing impact on routine TC/ED operations immediately after Hurricane Katrina. From September 1 to 16, 2005, an alternate site for medical care was established. Using an off-site space, the Dallas Convention Center Medical Unit (DCCMU) was established to meet the increased demand for care. Data were collected and compared with TC/ED patient volumes to assess impact on existing facilities. During the study period, 23,231 persons displaced by Hurricane Katrina were registered to receive evacuee services in the City of Dallas, Texas. From those displaced, 10,367 visits for emergent or urgent healthcare were seen at the DCCMU. The mean number of daily visits (mean +/- SD) to the DCCMU was 619 +/- 301 visits with a peak on day 3 (n = 1,125). No patients died, 3.2% (n = 257) were observed in the DCCMU, and only 2.9% (n = 236) required transport to a TC/ED. During the same period, the mean number of TC/ED visits at the region's primary provider of indigent care (Hospital 1) was 346 +/- 36 visits. Using historical data from Hospital 1 during the same period of time (341 +/- 41), there was no significant difference in the mean number of TC/ED visits from the previous year (p = 0.26). Alternate-site medical surge capacity provides for safe and effective delivery of care to a large influx of patients seeking urgent and emergent care. This protects the integrity of existing public hospital TC/ED infrastructure and ongoing operations.

Injuries associated with the use of riding mowers in the United States, 2002-2007.

PubMed

Hammig, Bart; Childers, Elizabeth; Jones, Ches

2009-10-01

To examine injuries among patients treated in an emergency department (ED) related to the use of a riding lawn mower. Data were obtained from the National Electronic Injury Surveillance System for the years 2002-2007. National estimates of ED visits for injuries associated with the use of a riding lawn mower were analyzed. Narrative text entries were categorized to provide a detailed record of the circumstances precipitating the injury. Average annual rates were calculated and logistic regression analyses were employed to determine risk estimates for patient disposition and demographic characteristics related to ED visits for injuries associated with riding mowers. From 2002 through 2007, there were an estimated 66,341 ED visits for injuries related to the use of riding lawnmowers in the U.S., with an average annual rate of 6.0 ED visits per 100,000 males, and 1.6 ED visits per 100,000 females. Older adults had higher rates of ED visits for injuries (7.2/100,000) than younger age groups. The most common injuries involved contusions (24%); sprains/strains (22%) and fractures (17%). The majority of patients (90%) were treated and released the same day. Results of logistic regression analyses revealed that older adults were more likely to be hospitalized when compared to younger age groups; and incidents involving rollovers [OR=5.45 (95% CI=3.22-9.23)] and being run over [6.01 (95% CI 3.23-11.17)] were more likely to result in hospitalization when compared to all other circumstances of injury. Riding mowers present injury patterns and circumstances that are different than those reported for push mowers. Circumstances related to injuries and age groups affected were varied, making prevention of riding mower injuries challenging. APPLICATION/IMPACT: Findings support the need to increase awareness and/or change the design of riding mowers with respect to risk of rollover injuries.

Risk of Fall-Related Injury due to Adverse Weather Events, Philadelphia, Pennsylvania, 2006-2011.

PubMed

Gevitz, Kathryn; Madera, Robbie; Newbern, Claire; Lojo, José; Johnson, Caroline C

Following a surge in fall-related visits to local hospital emergency departments (EDs) after a severe ice storm, the Philadelphia Department of Public Health examined the association between inclement winter weather events and fall-related ED visits during a 5-year period. Using a standardized set of keywords, we identified fall-related injuries in ED chief complaint logs submitted as part of Philadelphia Department of Public Health's syndromic surveillance from December 2006 through March 2011. We compared days when falls exceeded the winter fall threshold (ie, "high-fall days") with control days within the same winter season. We then conducted matched case-control analysis to identify weather and patient characteristics related to increased fall-related ED visits. Fifteen high-fall days occurred during winter months in the 5-year period. In multivariable analysis, 18- to 64-year-olds were twice as likely to receive ED care for fall-related injuries on high-fall days than on control days. The crude odds of ED visits occurring from 7:00 am to 10:59 am were 70% higher on high-fall days vs control days. Snow was a predictor of a high-fall day: the adjusted odds of snow before a high-fall day as compared with snow before a control day was 13.4. The association between the number of fall-related ED visits and weather-related fall injuries, age, and timing suggests that many events occurred en route to work in the morning. Promoting work closures or delaying openings after severe winter weather would allow time for better snow or ice removal, and including "fall risk" in winter weather advisories might effectively warn morning commuters. Both strategies could help reduce the number of weather-related fall injuries.

Incidence of emergency department visits and complications after abortion.

PubMed

Upadhyay, Ushma D; Desai, Sheila; Zlidar, Vera; Weitz, Tracy A; Grossman, Daniel; Anderson, Patricia; Taylor, Diana

2015-01-01

To conduct a retrospective observational cohort study to estimate the abortion complication rate, including those diagnosed or treated at emergency departments (EDs). Using 2009-2010 abortion data among women covered by the fee-for-service California Medicaid program and all subsequent health care for 6 weeks after having an abortion, we analyzed reasons for ED visits and estimated the abortion-related complication rate and the adjusted relative risk. Complications were defined as receiving an abortion-related diagnosis or treatment at any source of care within 6 weeks after an abortion. Major complications were defined as requiring hospital admission, surgery, or blood transfusion. A total of 54,911 abortions among 50,273 fee-for-service Medi-Cal beneficiaries were identified. Among all abortions, 1 of 16 (6.4%, n=3,531) was followed by an ED visit within 6 weeks but only 1 of 115 (0.87%, n=478) resulted in an ED visit for an abortion-related complication. Approximately 1 of 5,491 (0.03%, n=15) involved ambulance transfers to EDs on the day of the abortion. The major complication rate was 0.23% (n=126, 1/436): 0.31% (n=35) for medication abortion, 0.16% (n=57) for first-trimester aspiration abortion, and 0.41% (n=34) for second-trimester or later procedures. The total abortion-related complication rate including all sources of care including EDs and the original abortion facility was 2.1% (n=1,156): 5.2% (n=588) for medication abortion, 1.3% (n=438) for first-trimester aspiration abortion, and 1.5% (n=130) for second-trimester or later procedures. Abortion complication rates are comparable to previously published rates even when ED visits are included and there is no loss to follow-up. II.

Profile and costs of secondary conditions resulting in emergency department presentations and readmission to hospital following traumatic spinal cord injury.

PubMed

Gabbe, Belinda J; Nunn, Andrew

2016-08-01

People with traumatic spinal cord injury (SCI) face complex challenges in their care, recovery and life. Secondary conditions can develop to involve many body systems and can impact health, function, quality of life, and community participation. These secondary conditions can be costly, and many are preventable. The aim of this study was to describe the type and direct costs of secondary conditions requiring readmission to hospital, or visit to an emergency department (ED), within the first two years following traumatic spinal cord injury (SCI). A retrospective cohort study using population-level linked data from hospital ED and admission datasets was undertaken in Victoria, Australia. The incidence and direct treatment costs of readmission to hospital and ED visit within 2-years post-injury for secondary conditions related to SCI were measured for the 356 persons with traumatic SCI with a date of injury from 2008 to 2011. Of the 356 cases, 141 (40%) experienced 366 (median 2, range 1-11) readmissions to hospital for secondary conditions. 95 (27%) visited an ED at least once, within two years of injury for a secondary condition. The cost of hospital readmissions was AUD$5,553,004 and AUD$87,790 for ED visits. The mean±SD cost was AUD$15,172±$20,957 per readmission and AUD$670±$198 per ED visit. Urological conditions (e.g. urinary tract infection) were most common, followed by pressure areas/ulcers for readmissions, and fractures in the ED. Hospitalisation for complications within two years of traumatic SCI was common and costly in Victoria, Australia. Improved bladder and pressure area management could result in substantial morbidity and cost savings following SCI. Copyright © 2016 Elsevier Ltd. All rights reserved.

Expanding Hospital Human Immunodeficiency Virus Testing in the Bronx, New York and Washington, District of Columbia: Results From the HPTN 065 Study.

PubMed

Branson, Bernard M; Chavez, Pollyanna R; Hanscom, Brett; Greene, Elizabeth; McKinstry, Laura; Buchacz, Kate; Beauchamp, Geetha; Gamble, Theresa; Zingman, Barry S; Telzak, Edward; Naab, Tammey; Fitzpatrick, Lisa; El-Sadr, Wafaa M

2018-05-02

Human immunodeficiency virus (HIV) testing is critical for both HIV treatment and prevention. Expanding testing in hospital settings can identify undiagnosed HIV infections. To evaluate the feasibility of universally offering HIV testing during emergency department (ED) visits and inpatient admissions, 9 hospitals in the Bronx, New York and 7 in Washington, District of Columbia (DC) undertook efforts to offer HIV testing routinely. Outcomes included the percentage of encounters with an HIV test, the change from year 1 to year 3, and the percentages of tests that were HIV-positive and new diagnoses. From 1 February 2011 to 31 January 2014, HIV tests were conducted during 6.5% of 1621016 ED visits and 13.0% of 361745 inpatient admissions in Bronx hospitals and 13.8% of 729172 ED visits and 22.0% of 150655 inpatient admissions in DC. From year 1 to year 3, testing was stable in the Bronx (ED visits: 6.6% to 6.9%; inpatient admissions: 13.0% to 13.6%), but increased in DC (ED visits: 11.9% to 15.8%; inpatient admissions: 19.0% to 23.9%). In the Bronx, 0.4% (408) of ED HIV tests were positive and 0.3% (277) were new diagnoses; 1.8% (828) of inpatient tests were positive and 0.5% (244) were new diagnoses. In DC, 0.6% (618) of ED tests were positive and 0.4% (404) were new diagnoses; 4.9% (1349) of inpatient tests were positive and 0.7% (189) were new diagnoses. Hospitals consistently identified previously undiagnosed HIV infections, but universal offer of HIV testing proved elusive.

Evaluation of a programme for ‘Rapid Assessment of Febrile Travelers’ (RAFT): a clinic-based quality improvement initiative

PubMed Central

Jazuli, Farah; Lynd, Terence; Mah, Jordan; Klowak, Michael; Jechel, Dale; Klowak, Stefanie; Ovens, Howard; Sabbah, Sam; Boggild, Andrea K

2016-01-01

Background Fever in the returned traveller is a potential medical emergency warranting prompt attention to exclude life-threatening illnesses. However, prolonged evaluation in the emergency department (ED) may not be required for all patients. As a quality improvement initiative, we implemented an algorithm for rapid assessment of febrile travelers (RAFT) in an ambulatory setting. Methods Criteria for RAFT referral include: presentation to the ED, reported fever and travel to the tropics or subtropics within the past year. Exclusion criteria include Plasmodium falciparum malaria, and fulfilment of admission criteria such as unstable vital signs or significant laboratory derangements. We performed a time series analysis preimplementation and postimplementation, with primary outcome of wait time to tropical medicine consultation. Secondary outcomes included number of ED visits averted for repeat malaria testing, and algorithm adherence. Results From February 2014 to December 2015, 154 patients were seen in the RAFT clinic: 68 men and 86 women. Median age was 36 years (range 16–78 years). Mean time to RAFT clinic assessment was 1.2±0.07 days (range 0–4 days) postimplementation, compared to 5.4±1.8 days (range 0–26 days) prior to implementation (p<0.0001). The RAFT clinic averted 132 repeat malaria screens in the ED over the study period (average 6 per month). Common diagnoses were: traveller's diarrhoea (n=27, 17.5%), dengue (n=12, 8%), viral upper respiratory tract infection (n=11, 7%), chikungunya (n=10, 6.5%), laboratory-confirmed influenza (n=8, 5%) and lobar pneumonia (n=8, 5%). Conclusions In addition to provision of more timely care to ambulatory febrile returned travellers, we reduced ED bed-usage by providing an alternate setting for follow-up malaria screening, and treatment of infectious diseases manageable in an outpatient setting, but requiring specific therapy. PMID:27473947

A retrospective descriptive study of the characteristics of deliberate self-poisoning patients with single or repeat presentations to an Australian emergency medicine network in a one year period.

PubMed

Martin, Catherine A; Chapman, Rose; Rahman, Asheq; Graudins, Andis

2014-08-23

A proportion of deliberate self-poisoning (DSP) patients present repeatedly to the emergency department (ED). Understanding the characteristics of frequent DSP patients and their presentation is a first step to implementing interventions that are designed to prevent repeated self-poisoning. All DSP presentations to three networked Australian ED's were retrospectively identified from the ED electronic medical record and hospital scanned medical records for 2011. Demographics, types of drugs ingested, emergency department length of stay and disposition for the repeat DSP presenters were extracted and compared to those who presented once with DSP in a one year period. Logistic regression was used to analyse repeat versus single DSP data. The study determined 755 single presenters and 93 repeat DSP presenters. The repeat presenters contributed to 321 DSP presentations. They were more likely to be unemployed (61.0% versus 39.9%, p = 0.008) and have a psychiatric illness compared to single presenters (36.6% versus 15.5%, p < 0.001). Repeat presenters were less likely to receive a toxicology consultation (11.5% versus 27.3%, p < 0.001) and were more likely to abscond from the ED (7.5% versus 3.4%, p = 0.004). Repeat presenters were more likely to ingest paracetamol and antipsychotics than single presenters. The defined daily dose for the most common antipsychotic ingested, quetiapine, was less in the repeat presenter group (median 1.9 [IQR: 1.3-3.5]) compared with the single presenter group (4 [1.4-9.5]), (OR 0.85, 95% CI 0.74-0.99). Patients who present repeatedly to the ED with DSP have pre-existing disadvantages, with increased likelihood of being unemployed and having a mental illness. These patients are also more likely to have health service inequities given the greater likelihood to abscond from the ED and lower likelihood of receiving toxicology consultation for their DSP. Early recognition of repeat DSP patients in the ED may facilitate the development of individualised care plans with the aim to reduce repeat episodes of self-poisoning and subsequent risk of successful suicide.

Decreased health care utilization and health care costs in the inpatient and emergency department setting following initiation of ketogenic diet in pediatric patients: The experience in Ontario, Canada.

PubMed

Whiting, Sharon; Donner, Elizabeth; RamachandranNair, Rajesh; Grabowski, Jennifer; Jetté, Nathalie; Duque, Daniel Rodriguez

2017-03-01

To assess the change in inpatient and emergency department utilization and health care costs in children on the ketogenic diet for treatment of epilepsy. Data on children with epilepsy initiated on the ketogenic diet (KD) Jan 1, 2000 and Dec 31, 2010 at Ontario pediatric hospitals were linked to province wide inpatient, emergency department (ED) data at the Institute for Clinical Evaluative Sciences. ED and inpatient visits and costs for this cohort were compared for a maximum of 2 years (730days) prior to diet initiation and for a maximum of 2 years (730days) following diet initiation. KD patient were compared to matched group of children with epilepsy who did not receive the ketogenic diet (no KD). Children on the KD experienced a mean decrease in ED visits of 2.5 visits per person per year [95% CI (1.5-3.4)], and a mean decrease of 0.8 inpatient visits per person per year [95% CI (0.3-1.3)], following diet initiation. They had a mean decrease in ED costs of $630 [95% CI (249-1012)] per person per year and a median decrease in inpatient costs of $1059 [IQR: 7890; p<0.001] per child per year. Compared with the no KD children, children on the diet experienced a mean reduction of 2.1 ED visits per child per year [95% CI (1.0-3.2)] and a mean decrease of 0.6 [95% CI (0.1-1.1)] inpatient visits per child per year. Patients on the KD experienced a reduction of $442 [95% CI (34.4-850)] per child per year more in ED costs than the matched group. The ketogenic diet group had greater median decrease in inpatient costs per child per year than the matched group [p<0.001]. Patients initiated on ketogenic diet, experienced decreased ED and inpatient visits as well as costs following diet initiation in Ontario, Canada. Copyright © 2017 Elsevier B.V. All rights reserved.

Emergency department characteristics and capabilities in Bogotá, Colombia.

PubMed

Bustos, Yury; Castro, Jenny; Wen, Leana S; Sullivan, Ashley F; Chen, Dinah K; Camargo, Carlos A

2015-12-01

Emergency departments (EDs) are a critical, yet heterogeneous, part of international emergency care. The National ED Inventories (NEDI) survey has been used in multiple countries as a standardized method to benchmark ED characteristics. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in the densely populated capital city of Bogotá, Colombia. Bogotá EDs accessible to the general public 24/7 were surveyed using the 23-item NEDI survey used in several other countries ( www.emnet-nedi.org ). ED staff were asked about ED characteristics with reference to calendar year 2011. Seventy EDs participated (82 % response). Most EDs (87 %) were located in hospitals, and 83 % were independent hospital departments. The median annual ED visit volume was approximately 50,000 visits. Approximately 90 % (95 % confidence interval (CI) 80-96 %) had a contiguous layout, with medical and surgical care provided in one area. Almost all EDs saw both adults and children (91 %), while 6 % saw only adults and 3 % saw only children. Availability of technological and consultant resources in EDs was variable. Nearly every ED had cardiac monitoring (99 %, 95 % CI 92-100 %), but less than half had a dedicated CT scanner (39 %, 95 % CI 28-52 %). While most EDs were able to treat trauma 24/7 (81 %, 95 % CI 69-89 %), few could manage oncological (22 %, 95 % CI 13-34 %) or dental (3 %, 95 % CI 0-11 %) emergencies 24/7. The typical ED length-of-stay was between 1 and 6 h in 59 % of EDs (95 % CI, 46-70 %), while most others reported that patients remained for >6 h (39 %). Almost half of respondents (46 %, 95 % CI 34-59 %) reported their ED was over capacity. Bogotá EDs have high annual visit volumes and long length-of-stay, and half are over capacity. To meet the emergency care needs of people in Bogotá and other large cities, Colombia should consider improving urban ED capacity and training more emergency medicine specialists capable of efficiently staffing its large and crowded EDs.

Inpatient admissions from the ED for adults with injuries: the role of clinical and nonclinical factors.

PubMed

Spector, William D; Limcangco, Rhona; Mutter, Ryan L; Pines, Jesse M; Owens, Pamela

2015-06-01

Inpatient hospital costs represent nearly a third of heath care spending. The proportion of inpatients visits that originate in the emergency department (ED) has been growing, approaching half of all inpatient admissions. Injury is the most common reason for adult ED visits, representing nearly one-quarter of all ED visits. The objective was to explore the association of clinical and nonclinical factors with the decision to admit ED patients with injury. This is a retrospective cohort study of injury-related ED encounters by adults in select states in 2009. We limited the study to ED visits of persons with moderately severe injuries. We used logistic regression to calculate the marginal effects, estimating 4 equations to account for different risk patterns for older and younger adults, and types of injuries. Regression models controlled for comorbidities, injury characteristics, demographic characteristics, and state fixed effects. Injury location, type, and mechanism and comorbidities had large effects on hospitalization rates as expected. We found higher inpatient admission rates by level of trauma center designation and hospital size, but findings differed by age and type of injury. For younger adults, patients with private insurance and patients who traveled more than 30 miles were more likely to be admitted. There is great variation in inpatient admission decisions for moderately injured patients in the ED. Decisions appear to be dominated by clinical factors such as injury characteristics and comorbidities; however, nonclinical factors, such as type of insurance, hospital size, and trauma center designation, also play an important role. Published by Elsevier Inc.

Living on the edge of asthma: A grounded theory exploration.

PubMed

Shaw, Michele R; Oneal, Gail

2014-10-01

Most asthma-related emergency department (ED) visits and hospitalizations for asthma are preventable. Our purpose was to develop a grounded theory to guide interventions to reduce unnecessary hospitalizations and ED visits. Grounded theory inquiry guided interviews of 20 participants, including 13 parents and 7 children. Living on the edge of asthma was the emergent theory. Categories included: balancing, losing control, seeking control, and transforming. The theory provides the means for nurses to understand the dynamic process that families undergo in trying to prevent and then deal with and learn from an acute asthma attack requiring hospitalization or an ED visit. © 2014, Wiley Periodicals, Inc.

Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003–2010

PubMed Central

Shankar, Kalpana N.; Liu, Shan W.; Ganz, David A.

2017-01-01

Introduction One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. Methods We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. Results Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9–68.8]) to 68.8 (95% CI [57.8–79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75–84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). Conclusion ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting. PMID:28874929

Mount Sinai leverages smartphone technology, aiming to boost care, coordination of ED patients while also trimming costs.

PubMed

2015-05-01

Mount Sinai Hospital in New York, NY, is using smartphone technology to enhance follow-up calls to senior patients who have visited the ED, and to help provide acute-level care to select patients in their own homes. Investigators are hoping to show that these approaches can improve care and coordination while trimming costs, and they expect that patients will approve of these new approaches as well. While senior patients are still in the ED, nurse coordinators will work with them to load a HIPAA-compliant application to their smartphones so they can conduct face-to-face follow-up calls that meet HIPAA standards. Nurses say the face-to-face communications enhance their ability to assess how patients are doing following their ED visit. The hospital is also testing a program that enables some ED patients who meet inpatient criteria to receive this care in the home setting through the use of a mobile acute care team (MACT). In the case of emergencies, the MACT team relies on community paramedics who will visit the patients' homes and provide care under the direction of MACT physicians who are linked in to these visits via smartphone technology.

Effects of Education and Health Literacy on Postoperative Hospital Visits in Bariatric Surgery.

PubMed

Mahoney, Stephen T; Tawfik-Sexton, Dahlia; Strassle, Paula D; Farrell, Timothy M; Duke, Meredith C

2018-04-02

Hospital readmissions following bariatric surgery are high and it is necessary to identify modifiable risk factors to minimize this postoperative cost. We hypothesize that lower levels of education and health literacy are associated with increased risks of nonadherence, thus leading to increased emergency department (ED) visits and preventable readmissions postoperatively. Bariatric surgery patients presenting between October 2015 and December 2016 were administered a preoperative questionnaire that measured education level and the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) health literacy test. The rates of postoperative ED visits and readmissions were across education levels (≤12th grade versus >12th grade) and health literacy scores (≤8th grade versus high school level). A composite "hospital visit" outcome was also assessed. Ninety-five patients were enrolled; 23 had ≤12th grade level education and 7 scored ≤8th grade on the REALM-SF. Patients with ≤12th grade education were significantly more likely to have a hospital visit after surgery, compared with patients with >12th grade education (incidence rate ratio [IRR] 3.06, P = .008). No significant difference in ED visits, readmission, or hospital visits was seen when stratified by REALM-SF health literacy score. Lower level of education was associated with more than threefold increased risk of postoperative ED visits and readmission in our center's bariatric surgery patients. A patient's education level is a low-cost means to identify patients who are at risk for postoperative hospital visits, and who may benefit from enhanced educational efforts or more intensive postoperative follow-up.

Notes from the field: severe illness associated with reported use of synthetic marijuana - Colorado, August-September 2013.

PubMed

2013-12-13

On August 30, 2013, the Colorado Department of Public Health and Environment (CDPHE) was notified by several hospitals of an increase in the number of patients visiting their emergency departments (EDs) with altered mental status after using synthetic marijuana. Synthetic marijuana is dried plant material sprayed with various synthetic cannabinoids and smoked as an alternative to smoking marijuana. In response to the increase in ED visits associated with the use of synthetic marijuana, CDPHE asked all Colorado EDs to report through EMResource (a web-based reporting system) any patients examined on or after August 21 with altered mental status after use of a synthetic marijuana product. Serum and urine specimens from patients also were requested. On September 8, CDPHE, with the assistance of CDC, began an epidemiologic investigation to characterize the outbreak, determine the active substance and source of the synthetic marijuana product, and prevent further morbidity and mortality. Investigators reviewed ED visit reports submitted through EMResource and medical charts. A probable case was defined as any illness resulting in a visit to a Colorado ED during August 21-September 18, 2013, by a patient with suspected synthetic marijuana use in the 24 hours preceding illness onset. Of 263 patient visits reported to CDPHE through EMResource (214) and other means, such as e-mail and fax (49), a total of 221 (84%) represented probable cases (Figure).

Effect of a nurse-led psychoeducational intervention on healthcare service utilization among adults with advanced cancer

PubMed Central

Martinez, Kathryn A.; Friese, Christopher; Kershaw, Trace; Given, Charles W.; Fendrick, A. Mark; Northouse, Laurel

2015-01-01

Purpose/Objectives To examine differences in healthcare service utilization among patients with advanced cancer participating in a nurse-led psychoeducational intervention. Design Secondary analysis of trial data. Setting Four Michigan cancer centers. Sample 484 patients with advanced cancer. Methods Patients were randomized to three groups: brief intervention, extensive intervention, or control. Medical chart review took place at baseline, three months, and six months to measure patients’ healthcare service utilization, defined as emergency department (ED) visits or inpatient hospitalizations. Multivariable logistic regression was used to examine the odds, by study arm, of visiting the ED and being hospitalized, controlling for patient sociodemographic and health status factors, as well as baseline health-related quality of life (QOL). Main Research Variables Study arm (brief, extensive, or control), ED visitation (one or more times versus none), inpatient hospitalizations (one or more times versus none), and covariates. Findings No significant differences in ED visits or inpatient hospitalizations were observed among study arms. ED visits were more frequent for patients with lung or colorectal cancer, more comorbidities, and lower baseline QOL. Baseline QOL was associated with inpatient hospitalizations in the adjusted analysis. Conclusions The psychoeducational intervention, either in brief or extensive format, is unlikely to increase healthcare service utilization. Implications for Nursing Efficacious nurse-led psychoeducational interventions to improve QOL do not place undue burdens on the healthcare system and may improve care. PMID:26148327

Using the Hendrich II Inpatient Fall Risk Screen to Predict Outpatient Falls After Emergency Department Visits.

PubMed

Patterson, Brian W; Repplinger, Michael D; Pulia, Michael S; Batt, Robert J; Svenson, James E; Trinh, Alex; Mendonça, Eneida A; Smith, Maureen A; Hamedani, Azita G; Shah, Manish N

2018-04-01

To evaluate the utility of routinely collected Hendrich II fall scores in predicting returns to the emergency department (ED) for falls within 6 months. Retrospective electronic record review. Academic medical center ED. Individuals aged 65 and older seen in the ED from January 1, 2013, through September 30, 2015. We evaluated the utility of routinely collected Hendrich II fall risk scores in predicting ED visits for a fall within 6 months of an all-cause index ED visit. For in-network patient visits resulting in discharge with a completed Hendrich II score (N = 4,366), the return rate for a fall within 6 months was 8.3%. When applying the score alone to predict revisit for falls among the study population the resultant receiver operating characteristic (ROC) plot had an area under the curve (AUC) of 0.64. In a univariate model, the odds of returning to the ED for a fall in 6 months were 1.23 times as high for every 1-point increase in Hendrich II score (odds ratio (OR)=1.23 (95% confidence interval (CI)=1.19-1.28). When included in a model with other potential confounders or predictors of falls, the Hendrich II score is a significant predictor of a return ED visit for fall (adjusted OR=1.15, 95% CI=1.10-1.20, AUC=0.75). Routinely collected Hendrich II scores were correlated with outpatient falls, but it is likely that they would have little utility as a stand-alone fall risk screen. When combined with easily extractable covariates, the screen performs much better. These results highlight the potential for secondary use of electronic health record data for risk stratification of individuals in the ED. Using data already routinely collected, individuals at high risk of falls after discharge could be identified for referral without requiring additional screening resources. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids.

PubMed

Ryoo, Hyeon-Ju; Choo, Esther K

2016-05-01

Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide. We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient "seeking detox," or patient explicitly requesting for detox referral. Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02-1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15-1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17-1.43]). This significant association prevailed after controlling for "seeking detox." Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are "seeking detox." Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.

Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids

PubMed Central

Ryoo, Hyeon-Ju; Choo, Esther K.

2016-01-01

Introduction Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide. Methods We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient “seeking detox,” or patient explicitly requesting for detox referral. Results Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02–1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15–1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17–1.43]). This significant association prevailed after controlling for “seeking detox.” Conclusion Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are “seeking detox.” Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes. PMID:27330662

Cardiovascular and Cerebrovascular Emergency Department Visits Associated With Wildfire Smoke Exposure in California in 2015.

PubMed

Wettstein, Zachary S; Hoshiko, Sumi; Fahimi, Jahan; Harrison, Robert J; Cascio, Wayne E; Rappold, Ana G

2018-04-11

Wildfire smoke is known to exacerbate respiratory conditions; however, evidence for cardiovascular and cerebrovascular events has been inconsistent, despite biological plausibility. A population-based epidemiologic analysis was conducted for daily cardiovascular and cerebrovascular emergency department (ED) visits and wildfire smoke exposure in 2015 among adults in 8 California air basins. A quasi-Poisson regression model was used for zip code-level counts of ED visits, adjusting for heat index, day of week, seasonality, and population. Satellite-imaged smoke plumes were classified as light, medium, or dense based on model-estimated concentrations of fine particulate matter. Relative risk was determined for smoky days for lag days 0 to 4. Rates of ED visits by age- and sex-stratified groups were also examined. Rates of all-cause cardiovascular ED visits were elevated across all lags, with the greatest increase on dense smoke days and among those aged ≥65 years at lag 0 (relative risk 1.15, 95% confidence interval [1.09, 1.22]). All-cause cerebrovascular visits were associated with smoke, especially among those 65 years and older, (1.22 [1.00, 1.49], dense smoke, lag 1). Respiratory conditions were also increased, as anticipated (1.18 [1.08, 1.28], adults >65 years, dense smoke, lag 1). No association was found for the control condition, acute appendicitis. Elevated risks for individual diagnoses included myocardial infarction, ischemic heart disease, heart failure, dysrhythmia, pulmonary embolism, ischemic stroke, and transient ischemic attack. Analysis of an extensive wildfire season found smoke exposure to be associated with cardiovascular and cerebrovascular ED visits for all adults, particularly for those over aged 65 years. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

[Football, television and emergency services].

PubMed

Miró, O; Sánchez, M; Borrás, A; Millá, J

2000-04-15

To know the influence of televised football on the use of emergency department (ED). We assessed the number, demographic characteristics and acuity of patients attended during the broadcast of football matches played by FC Barcelona during Champions' League (n = 12), and they were compared with days without televised football (n = 12). Televised football was associated with a decrease in visits to ED (-18%; p = 0.002). Such a decrease was observed for all ED units, but only for traumatology unit reached statistical significance (-28%; p = 0.006). Decay of ED visits were mainly due to a decrease of low-acuity consults (-30%; p = 0.04). There is a significant decrease on ED use associated with televised football.

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

Susceptibility to Heat-Related Fluid and Electrolyte Imbalance Emergency Department Visits in Atlanta, Georgia, USA.

PubMed

Heidari, Leila; Winquist, Andrea; Klein, Mitchel; O'Lenick, Cassandra; Grundstein, Andrew; Ebelt Sarnat, Stefanie

2016-10-02

Identification of populations susceptible to heat effects is critical for targeted prevention and more accurate risk assessment. Fluid and electrolyte imbalance (FEI) may provide an objective indicator of heat morbidity. Data on daily ambient temperature and FEI emergency department (ED) visits were collected in Atlanta, Georgia, USA during 1993-2012. Associations of warm-season same-day temperatures and FEI ED visits were estimated using Poisson generalized linear models. Analyses explored associations between FEI ED visits and various temperature metrics (maximum, minimum, average, and diurnal change in ambient temperature, apparent temperature, and heat index) modeled using linear, quadratic, and cubic terms to allow for non-linear associations. Effect modification by potential determinants of heat susceptibility (sex; race; comorbid congestive heart failure, kidney disease, and diabetes; and neighborhood poverty and education levels) was assessed via stratification. Higher warm-season ambient temperature was significantly associated with FEI ED visits, regardless of temperature metric used. Stratified analyses suggested heat-related risks for all populations, but particularly for males. This work highlights the utility of FEI as an indicator of heat morbidity, the health threat posed by warm-season temperatures, and the importance of considering susceptible populations in heat-health research.

Susceptibility to Heat-Related Fluid and Electrolyte Imbalance Emergency Department Visits in Atlanta, Georgia, USA

PubMed Central

Heidari, Leila; Winquist, Andrea; Klein, Mitchel; O’Lenick, Cassandra; Grundstein, Andrew; Ebelt Sarnat, Stefanie

2016-01-01

Identification of populations susceptible to heat effects is critical for targeted prevention and more accurate risk assessment. Fluid and electrolyte imbalance (FEI) may provide an objective indicator of heat morbidity. Data on daily ambient temperature and FEI emergency department (ED) visits were collected in Atlanta, Georgia, USA during 1993–2012. Associations of warm-season same-day temperatures and FEI ED visits were estimated using Poisson generalized linear models. Analyses explored associations between FEI ED visits and various temperature metrics (maximum, minimum, average, and diurnal change in ambient temperature, apparent temperature, and heat index) modeled using linear, quadratic, and cubic terms to allow for non-linear associations. Effect modification by potential determinants of heat susceptibility (sex; race; comorbid congestive heart failure, kidney disease, and diabetes; and neighborhood poverty and education levels) was assessed via stratification. Higher warm-season ambient temperature was significantly associated with FEI ED visits, regardless of temperature metric used. Stratified analyses suggested heat-related risks for all populations, but particularly for males. This work highlights the utility of FEI as an indicator of heat morbidity, the health threat posed by warm-season temperatures, and the importance of considering susceptible populations in heat-health research. PMID:27706089

Emergency department visits for work-related injuries.

PubMed

Tadros, Allison; Sharon, Melinda; Chill, Nicholas; Dragan, Shane; Rowell, Jeremy; Hoffman, Shelley

2018-04-25

Work-related injuries are commonly seen in the emergency department (ED). This study sought to analyze characteristics of ED patient visits that were billed under workers' compensation. This was a retrospective chart review of visits during 2015 that were billed under workers' compensation at an academic ED. The following variables were collected: age, gender, mechanism of injury/exposure, diagnoses, imaging performed, specialty consultation, operative requirement, follow-up specialty, and ED disposition. In 2015, 377 patients presented to the ED for work-related injuries. The most common mechanism of injury was fall. Frequent diagnoses included lower extremity injuries and hand/finger injuries. The most common consulting service was orthopedics. Only five patients were referred to occupational medicine for follow up. Knowledge of the types of occupational injuries and subsequent care required may help guide both workers and employers how to best triage patients within the healthcare system. Alternative settings such as occupational medicine or primary care services may be appropriate for some patients. Copyright © 2018 Elsevier Inc. All rights reserved.

Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization.

PubMed

Gordon, Aliza S; Adamson, Wallace C; DeVries, Andrea R

2017-02-17

Expansion of virtual health care-real-time video consultation with a physician via the Internet-will continue as use of mobile devices and patient demand for immediate, convenient access to care grow. The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions. A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy. A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs. Virtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care. ©Aliza S Gordon, Wallace C Adamson, Andrea R DeVries. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 17.02.2017.

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

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).

Repeated nightmares

MedlinePlus

Nightmares - repeated; Dream anxiety disorder ... Arnulf I, Nightmares and dream disturbances. In: Kryger M, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine . 6th ed. Philadelphia, PA: Elsevier; ...

[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.

Association Between Maternal Comorbidities and Emergency Department Use Among a National Sample of Commercially Insured Pregnant Women.

PubMed

Cunningham, Shayna D; Magriples, Urania; Thomas, Jordan L; Kozhimannil, Katy B; Herrera, Carolina; Barrette, Eric; Shebl, Fatma M; Ickovics, Jeannette R

2017-08-01

Evidence suggests that, despite routine engagement with the health system, pregnant women commonly seek emergency care. The objectives of this study were to examine the association between maternal comorbidities and emergency department (ED) use among a national sample of commercially insured pregnant women. We conducted a retrospective cohort study using multipayer medical claims data maintained by the Health Care Cost Institute for women ages 18 to 44 years with a live singleton birth in 2011 (N = 157,786). The association between common maternal comorbidities (e.g., hypertension, gestational diabetes) and ED use during pregnancy was examined using multilevel models, while controlling for age, region, and residential zip code. Twenty percent (n = 31,413) of pregnant women had one or more ED visit (mean ± SD = 1.52 ± 1.15). Among those who used the ED, 29% had two or more visits, and 11% had three or more visits. Emergency care seekers were significantly more likely to have one or more comorbid condition compared to those with no emergency care: 30% versus 21%, respectively (p < 0.001). Pregnant women with asthma had 2.5 times the likelihood of having had any ED visit (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI] = 2.32-2.62). There was a significant increase in the probability (approximately 50%) of ED use among pregnant women with diabetes (AOR = 1.47, 95% CI = 1.33-1.63) or hypertension (AOR = 1.49, 95% CI = 1.43-1.55) or who were obese (AOR = 1.55, 95% CI = 1.47-1.64). Increased odds associated with gestational diabetes were more modest, resulting in a 13% increased odds of using the ED (AOR = 1.13, 95% CI = 1.07-1.18). Less than 0.6% of pregnant women (n = 177) received emergency care that resulted in a hospital admission. The admission rate was 0.4% (189 admissions/47,608 ED visits). Among pregnant women, comorbidity burden was associated with more ED utilization. Efforts to reduce acute unscheduled care and improve care coordination during pregnancy should target interventions to patient comorbidity. © 2017 by the Society for Academic Emergency Medicine.

Baseline Characteristics and Outcomes of Older Adults Seeking Care in Ambulatory Urgent Care Clinics.

PubMed

Reyes, Bernardo J; Lopez, Javier M; Galindo, Diana J; Briceno, Maria; Ouslander, Joseph G

2017-12-01

To determine the most common clinical conditions associated with older adults visiting Urgent care centers (UCCs) and the potential need for further resource use. Cross-sectional retrospective study. Nonprofit academic medical center with campuses and multiple satellite offices in Ohio and Florida. Individuals aged 55 and older who visited UCCs between August 2014 and March 2015 (N = 9,445; average age 63.1 ± 10.1, 64% female). Of those, 2,445 had at least one encounter within the same healthcare system within 30 days after the index visit and were included in our final analysis. 30-day ED visits and hospitalizations. Of the 2,445 patients, 578 (23.6%) visited the emergency department (ED) or were hospitalized, 974 (39.8%) returned to the UCC, and 895 (63.4%) visited their primary care physician's office. A significantly higher proportion (38.4%, n = 68/177) of individuals aged 85 and older visited the ED or were hospitalized within 30 days (P < .010) than of those younger than 65 (20.0%, n = 273/1,367). Diabetes mellitus (odds ratio (OR) = 1.73, 95% confidence interval (CI) = 1.40-2.15, P < .001), coronary artery disease or cerebrovascular disease (OR = 2.45 CI 1.95-3.09, P < .001), chronic obstructive pulmonary disorder or asthma (OR = 1.57, 95% CI = 1.23-2.01, P < .001), polypharmacy (OR = 1.45, 95% CI = 1.18-1.78, P = .004), and cognitive impairment (OR = 2.74, 95% CI = 1.74-4.31, P < .010) were associated with higher rates of ED visits or hospitalizations within 30 days of the UCC visit. Older adults (especially those aged ≥85) and those with conditions such as polypharmacy and dementia are at higher risk of being hospitalized or visit the ED after seeking care at UCCs than younger adults and those without these conditions. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon.

PubMed

Saleh, Shadi; Mourad, Yara; Dimassi, Hani; Hitti, Eveline

2016-03-18

As health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon. The study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable. Findings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions' contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0-18 after controlling for all other variables. Understanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.

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

Pesticide Spraying for West Nile Virus Control and Emergency Department Asthma Visits in New York City, 2000

PubMed Central

Karpati, Adam M.; Perrin, Mary C.; Matte, Tom; Leighton, Jessica; Schwartz, Joel; Barr, R. Graham

2004-01-01

Pyrethroid pesticides were applied via ground spraying to residential neighborhoods in New York City during July–September 2000 to control mosquito vectors of West Nile virus (WNV). Case reports link pyrethroid exposure to asthma exacerbations, but population-level effects on asthma from large-scale mosquito control programs have not been assessed. We conducted this analysis to determine whether widespread urban pyrethroid pesticide use was associated with increased rates of emergency department (ED) visits for asthma. We recorded the dates and locations of pyrethroid spraying during the 2000 WNV season in New York City and tabulated all ED visits for asthma to public hospitals from October 1999 through November 2000 by date and ZIP code of patients’ residences. The association between pesticide application and asthma-related emergency visits was evaluated across date and ZIP code, adjusting for season, day of week, and daily temperature, precipitation, particulate, and ozone levels. There were 62,827 ED visits for asthma during the 14-month study period, across 162 ZIP codes. The number of asthma visits was similar in the 3-day periods before and after spraying (510 vs. 501, p = 0.78). In multivariate analyses, daily rates of asthma visits were not associated with pesticide spraying (rate ratio = 0.92; 95% confidence interval, 0.80–1.07). Secondary analyses among children and for chronic obstructive pulmonary disease yielded similar null results. This analysis shows that spraying pyrethroids for WNV control in New York City was not followed by population-level increases in public hospital ED visit rates for asthma. PMID:15289164

Health resource utilization varies by comorbidities in children with epilepsy.

PubMed

Puka, Klajdi; Smith, Mary Lou; Moineddin, Rahim; Snead, O Carter; Widjaja, Elysa

2016-04-01

Comorbidities in adults with epilepsy have been shown to significantly increase health resource utilization (HRU). The current study aimed to determine whether a similar association exists among children with epilepsy in a universal health insurance system. Health administrative databases in Ontario, Canada were used to evaluate the frequency of neurologist visits, emergency department (ED) visits, and hospitalizations. We evaluated the association between HRU and comorbidities, including depression, anxiety, learning disability, attention deficit hyperactivity disorder (ADHD), and autistic spectrum disorder (ASD), adjusting for age, sex, residence, and socio-economic status. The frequency of neurology visits was increased by comorbid depression, ASD, and learning disability (adjusted relative risk [aRR]=1.29-2.07; p<.01). The frequency of ED visits was increased by all comorbidities (aRR=1.26-2.83; p<.0001). The frequency of hospitalizations was increased by comorbid depression, anxiety, ASD, and learning disability (aRR=1.77-7.20; p<.0001). Learning disability had the largest impact on HRU. For each additional comorbidity, the frequency of neurology visits, ED visits, and hospitalizations increased by 1.64 to 3.16 times (p<.0001). Among children with epilepsy, mental health and developmental comorbidities were associated with increased HRU, and different comorbidities influenced different types of HRU. In addition, we highlight the importance of identifying and managing these comorbidities, as they increased the risks of costly HRU such as ED visits and hospitalizations. Copyright © 2016 Elsevier Inc. All rights reserved.

Nurse-Initiated Telephone Follow Up after Ureteroscopic Stone Surgery.

PubMed

Tackitt, Helen M; Eaton, Samuel H; Lentz, Aaron C

2016-01-01

This article presents findings of a quality improvement (QI) project using the DMAIC (define, measure, analyze, improve, and control) model designed to decrease the rate of emergency department (ED) visits and nurse advice line calls after ureteroscopic stone surgery. Results indicated that nurse-initiated follow- up phone calls can decrease ED visits.

Care plan program reduces the number of visits for challenging psychiatric patients in the ED.

PubMed

Abello, Arthur; Brieger, Ben; Dear, Kim; King, Ben; Ziebell, Chris; Ahmed, Atheer; Milling, Truman J

2012-09-01

A small number of patients representing a significant demand on emergency department (ED) services present regularly for a variety of reasons, including psychiatric or behavioral complaints and lack of access to other services. A care plan program was created as a database of ED high users and patients of concern, as identified by ED staff and approved by program administrators to improve care and mitigate ED strain. A list of medical record numbers was assembled by searching the care plan program database for adult patients initially enrolled between the dates of November 1, 2006, and October 21, 2007. Inclusion criteria were the occurrence of a psychiatric International Classification Diseases, Ninth Revision, code in their medical record and a care plan level implying a serious psychiatric disorder causing harmful behavior. Additional data about these patients were acquired using an indigent care tracking database and electronic medical records. Variables collected from these sources were analyzed for changes before and after program enrollment. Of 501 patients in the database in the period studied, 48 patients fulfilled the criteria for the cohort. There was a significant reduction in the number of visits to the ED from the year before program enrollment to the year after enrollment (8.9, before; 5.9, after; P < .05). There was also an increase in psychiatric hospital visits (2%, before; 25%, after; P < .05). An alert program that identifies challenging ED patients with psychiatric conditions and creates a care plan appears to reduce visits and lead to more appropriate use of other resources. Copyright © 2012 Elsevier Inc. All rights reserved.

Occult Klebsiella pneumoniae bacteremia at emergency department: A single center experience.

PubMed

Chang, Eileen Kevyn; Kao, Kai-Liang; Tsai, Mao-Song; Yang, Chia-Jui; Huang, Yu-Tsung; Liu, Chia-Ying; Liao, Chun-Hsing

2015-12-01

Patients with undetected bacteremia when discharged from a hospital are considered to have occult bacteremia. Klebsiella pneumoniae bacteremia (KPB) is endemic to Taiwan. Our purpose was to study the impact of occult KPB. We retrospectively reviewed the records of patients who were discharged from our emergency department (ED) and subsequently diagnosed with KPB (occult bacteremia), from January 2008 to March 2014. All patients are followed for at least 3 months after the index ED visit. The study group was compared to KPB patients who were directly hospitalized (DH) from ED in 2008. Thirty-day mortality was the primary endpoint. A total of 913 patients were admitted to our ED with KPB, and 88 of these patients (9.6%) had occult KPB. Among them, 43 had second ED visit and 41 were admitted. The overall 30-day mortality was 2.3%. Relative to patients with occult KPB, DH patients had more respiratory tract infections (p < 0.001) but fewer other intra-abdominal infections (p = 0.015). Liver abscess was the major diagnosis for the second ED visit (37.2%). DH patients had significantly greater 30-day mortality than that of overall patients with KPB (19.2% vs.2.3%, p < 0.001). Most patients with occult KPB had favorable outcomes, but about half of them required a second ED visit. Clinicians should aggressively follow patients with occult KPB and should seek to identify the focus of infection in this endemic area. Copyright © 2015. Published by Elsevier B.V.

A comparison of ED and direct admission care of cancer patients with febrile neutropenia.

PubMed

Owolabi, Diwura K; Rowland, Richard; King, Lauren; Miller, Rick; Hegde, Gajanan G; Shang, Jennifer; Lister, John; Venkat, Arvind

2015-07-01

We compared the quality of care in admitted febrile neutropenic cancer patients presenting through the emergency department (ED) vs those directly admitted (DA) from the clinic or infusion center. We hypothesized that the quality of care would be comparable between these 2 pathways. We conducted a retrospective, observational cohort study of all adult cancer patients hospitalized with subjective or objective fever (≥100.4°F) and documented neutropenia (absolute neutrophil count ≤1000/mm(3)) from January 1, 2011 to June 30, 2013, at 2 hospitals. Two investigators retrieved data including patient age, sex, race, tumor type, blood culture growth, temperature (actual or reported), pathway to admission (ED or DA), time to antibiotic administration, length of stay, and the Multinational Association for Supportive Care in Cancer (MASCC) risk score. The primary outcome measures were time to antibiotic administration, appropriateness of antibiotic(s) administered based on published guidelines, length of stay, and MASCC score-based risk assessment. We used the t test for the difference between 2 means with unequal population variances to compare these outcome measures between ED and DA patients. One hundred twenty-seven visits met inclusion criteria (42 [33%] ED visits, 85 [67%] DA visits). Mean time to antibiotic administration, mean length of stay, appropriateness of antibiotics, and MASCC score-based risk assessment were comparable between ED and DA visits (P>.05 for all comparisons). The quality of care for febrile neutropenia in patients presenting through the ED was comparable to those directly admitted to the hospital in this 2-center study. Copyright © 2015 Elsevier Inc. All rights reserved.

Timing of opioid administration as a quality indicator for pain crises in sickle cell disease.

PubMed

Mathias, Melissa D; McCavit, Timothy L

2015-03-01

Time to opioid administration (TTO) has been suggested as a quality of care measure for sickle cell disease patients with vaso-occlusive crisis (VOC). We sought to determine whether TTO was associated with outcomes of emergency department (ED) visits for VOC. We conducted a single-center retrospective cohort study of ED visits for VOC. The primary outcome was hospital admission, with secondary outcomes of change between the first 2 pain scores, area under the curve (AUC) for pain scores at 4 hours (pain score AUC), total ED length of stay, and total intravenous opioids. In both univariate and multivariate analyses, mixed regression (logistic for admission, linear for secondary outcome variables) was used to evaluate association of TTO with outcome. In 177 subjects, 414 ED visits for VOC were identified. Inpatient admission occurred in 53% of visits. The median TTO for admitted patients was 86 minutes vs 87 minutes for those not admitted. TTO was not associated with inpatient admission in either univariate or multivariate analyses. In multivariate analyses with secondary outcomes, decreased TTO was associated with greater improvement between the first 2 pain scores, decreased pain score AUC, decreased total ED length of stay, and increased total opioids. Although TTO was not associated with admission, it was independently associated with 4 important secondary outcomes: change in initial pain scores, pain score AUC, total ED length of stay, and total intravenous opioids. The association of a process measure, TTO, with these outcomes encourages the institution of TTO reduction efforts in the ED. Copyright © 2015 by the American Academy of Pediatrics.

A Spatial Poisson Hurdle Model for Exploring Geographic Variation in Emergency Department Visits

PubMed Central

Neelon, Brian; Ghosh, Pulak; Loebs, Patrick F.

2012-01-01

Summary We develop a spatial Poisson hurdle model to explore geographic variation in emergency department (ED) visits while accounting for zero inflation. The model consists of two components: a Bernoulli component that models the probability of any ED use (i.e., at least one ED visit per year), and a truncated Poisson component that models the number of ED visits given use. Together, these components address both the abundance of zeros and the right-skewed nature of the nonzero counts. The model has a hierarchical structure that incorporates patient- and area-level covariates, as well as spatially correlated random effects for each areal unit. Because regions with high rates of ED use are likely to have high expected counts among users, we model the spatial random effects via a bivariate conditionally autoregressive (CAR) prior, which introduces dependence between the components and provides spatial smoothing and sharing of information across neighboring regions. Using a simulation study, we show that modeling the between-component correlation reduces bias in parameter estimates. We adopt a Bayesian estimation approach, and the model can be fit using standard Bayesian software. We apply the model to a study of patient and neighborhood factors influencing emergency department use in Durham County, North Carolina. PMID:23543242

Rates and causes of 30-day readmission and emergency room utilization following head and neck surgery.

PubMed

Wu, Vincent; Hall, Stephen F

2018-05-18

Unplanned returns to hospital are common, costly, and potentially avoidable. We aimed to investigate and characterize reasons for all-cause readmissions to hospital as in-patients (IPs) and visits to the Emergency Department (ED) within 30-days following patient discharge post head and neck surgery (HNS). Retrospective case series with chart review. All patients within the Department of Otolaryngology - Head and Neck Surgery who underwent HNS for benign and malignant disease from January 1, 2010 to May 31, 2015 were identified. The electronic medical records of readmitted patients were reviewed for reasons of readmission, demographic data, and comorbidities. Following 1281 surgical cases, there were 41 (3.20%) IP readmissions and 109 (8.43%) ED visits within 30-days after discharge for HNS. For IP readmissions, most common causes included infection (26.8%), respiratory symptoms (17.1%), and pain (17.1%). Most common reasons for ED visits were for pain (31.5%), bleeding (17.6%), and infection (14.8%). Readmitted IPs had significantly higher health burden at pre-operative baseline as compared to patients who visited the ED when assessed with the American Society of Anesthesiology scores (p = 0.002) and the Cumulative Illness Rating Scale (p = 0.004). Rate of 30-day IP readmission and ED utilization was 3.20 and 8.43%, respectively. Pain and infection were common causes for returns to hospital. Discharge planning may be improved to target common causes for post-surgical hospital visits in order to decrease readmission rates.

Real-Time Support of Pediatric Diabetes Self-Care by a Transport Team

PubMed Central

Franklin, Brandi E.; Crisler, S. Crile; Shappley, Rebekah; Armour, Meri M.; McCommon, Dana T.; Ferry, Robert J.

2014-01-01

OBJECTIVE The study seeks to improve access for underserved patients via novel integration of Pedi-Flite (a critical care transport team) and to validate whether this safely enhances diabetes care and effectively expands the endocrine workforce. RESEARCH DESIGN AND METHODS The study retrospectively analyzed pager service use in a cohort of established diabetic patients (n = 979) after inception of Pedi-Flite support. Outcomes included incidence and severity of recurrent diabetic ketoacidosis (DKA) and cost savings generated from reduced referrals to the emergency department (ED) and on-call endocrinologist. We generated descriptive statistics to characterize the study population and ED visits for DKA and constructed logistic regression models to examine associations of pager use and likelihood of ED visitation and nonelective inpatient admission from an ED for DKA. RESULTS Pager users comprised 30% of the patient population. They were younger but had more established diabetes than nonusers. While pager users were 2.75 times more likely than nonusers to visit the ED for DKA (P < 0.0001), their visits were less likely to lead to inpatient admissions (odds ratio 0.58; P < 0.02). More than half (n = 587) of all calls to the pager were resolved without need for further referral. Estimates suggest that 439 ED visits and 115 admissions were avoided at a potential cost savings exceeding 760,000 USD. CONCLUSIONS Integration of a transport service provides a novel, cost-effective approach to reduce disparities in diabetes care. Advantages include scalability, applicability to other disease areas and settings, and low added costs. These findings enrich an emerging evidence base for telephonic care-management models supported by allied health personnel. PMID:23959568

Real-time support of pediatric diabetes self-care by a transport team.

PubMed

Franklin, Brandi E; Crisler, S Crile; Shappley, Rebekah; Armour, Meri M; McCommon, Dana T; Ferry, Robert J

2014-01-01

OBJECTIVE The study seeks to improve access for underserved patients via novel integration of Pedi-Flite (a critical care transport team) and to validate whether this safely enhances diabetes care and effectively expands the endocrine workforce. RESEARCH DESIGN AND METHODS The study retrospectively analyzed pager service use in a cohort of established diabetic patients (n = 979) after inception of Pedi-Flite support. Outcomes included incidence and severity of recurrent diabetic ketoacidosis (DKA) and cost savings generated from reduced referrals to the emergency department (ED) and on-call endocrinologist. We generated descriptive statistics to characterize the study population and ED visits for DKA and constructed logistic regression models to examine associations of pager use and likelihood of ED visitation and nonelective inpatient admission from an ED for DKA. RESULTS Pager users comprised 30% of the patient population. They were younger but had more established diabetes than nonusers. While pager users were 2.75 times more likely than nonusers to visit the ED for DKA (P < 0.0001), their visits were less likely to lead to inpatient admissions (odds ratio 0.58; P < 0.02). More than half (n = 587) of all calls to the pager were resolved without need for further referral. Estimates suggest that 439 ED visits and 115 admissions were avoided at a potential cost savings exceeding 760,000 USD. CONCLUSIONS Integration of a transport service provides a novel, cost-effective approach to reduce disparities in diabetes care. Advantages include scalability, applicability to other disease areas and settings, and low added costs. These findings enrich an emerging evidence base for telephonic care-management models supported by allied health personnel.

Sex and age differences in ED patients with mental and behavioral disorders due to psychoactive substance use.

PubMed

Le Querrec, Fanny; Bounes, Vincent; Mestre, Maryse Lapeyre; Azema, Olivier; Longeaux, Nicolas; Gallart, Jean-Christophe

2015-11-01

The objectives of this study are to describe an emergency department (ED) adult population with the chief complaint of mental and behavioral disorders due to psychoactive substance use and to investigate sex- and age-related differences. We analyzed data (2009-2011) from the Regional Observatory of Emergency Medicine ORU-MiP (700000 patients per year) for all patients with a primary diagnosis of mental and behavioral disorders due to psychoactive substance use. Day data were weighted by the number of days in the year and expressed for 100000 inhabitants of the area. Pearson χ(2) test and Fisher tests were used. The Brown-Mood test was used to compare medians. Of the 1411597 ED visits analyzed, 20838 consults (1.3%) were for primary diagnosis of mental and behavioral disorders due to psychoactive substance use. The median age (interquartile range) was 41 (28-51) years; 69.5% were men. More women consulted the ED for sedative or hypnotic use (4.9% vs 1.5%, P < 10(-4)) than men, and more men consulted for alcohol consumption (93.5% vs 90%, P < 10(-4)) and cannabinoids (1.4% vs 1.0%, P < 10(-3)) than women. Young consumer visits dramatically increased during weekends (average of 88 visits a day per 100000 inhabitants vs 34 on Mondays to Thursdays). Another difference was found between young adults and middle-aged adults, with a peak in visits at 2 am and 9 pm respectively. Mental and behavioral disorders due to psychoactive substance use account for 1.3% of ED visits. Older people should be screened for chronic alcohol consumption. Our findings underscore the opportunity provided by the ED for screening and brief intervention in drug- and alcohol-related problems. Copyright © 2015 Elsevier Inc. All rights reserved.

Adolescent presentations to an adult hospital emergency department.

PubMed

Noori, Omar; Batra, Shweta; Shetty, Amith; Steinbeck, Katharine

2017-10-01

Age-related policies allow adolescents to access paediatric and adult EDs. Anecdotally, paediatric and adult EDs report challenges when caring for older and younger adolescents, respectively. Our aim was to describe the characteristics of an adolescent population attending an adult ED, co-located with a tertiary paediatric ED. The Westmead Hospital ED database was accessed for 14.5-17.9 years old presentations between January 2010 and December 2012. Patient diagnosis coding (SNOMED) was converted to ICD-10. De-identified data were transferred into Microsoft Excel with analysis performed using spss V22. There were 5718 presentations made to the Westmead Hospital, Sydney, Australia ED by 4450 patients, representing 3.3% (95% CI 3.2-3.4) of total visits from all patients 14.5 years and above. The mean age of the sample was 16.6 years (male 51.8%). Presentations triaged as level 4 or 5 represented 61.0% (95% CI 58.7-61.3) of visits. The proportion of patients who did not wait to receive care was 13.8% (95% CI 12.9-14.7), which was significantly higher than adult rates (P < 0.01). There were 279 unscheduled return visits (visits made <72 h of discharge) representing 4.9% (95% CI 4.4-5.8) of all presentations. Injury was the most common diagnosis (30.2%, 95% CI 28.8-31.6). Chronic physical illness and alcohol-related visits comprised 2.1% (95% CI 1.7-2.5) and 0.8% (95% CI 0.6-1.0) of adolescent presentations, respectively. Contrary to reported staff perceptions, adolescent chronic physical illness presentations were not a major burden. Alcohol was likely under-recorded as a contributing factor to presentations. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Treating psychiatric emergencies in incarcerated minors in the emergency department: what is the cost and what is their disposition?

PubMed

Wood, David Brian; Donofrio, Joy Joelle; Santillanes, Genevieve; Lam, Chun Nok; Claudius, Ilene

2014-06-01

Although mental health disorders are common among incarcerated minors, psychiatric urgencies and emergencies often cannot be treated in juvenile detention facilities, necessitating emergency department (ED) transfers. The cost of this ED care has not been well studied. This study aimed to provide information on disposition and cost related to ED visits by juvenile hall patients transported for urgent psychiatric evaluation. A retrospective cross-sectional descriptive study of patients presenting to 1 ED from juvenile detention centers for consideration of psychiatric holds was conducted. Eligible patients were identified by a search of the International Classification of Diseases, Ninth Revision, discharge diagnosis codes and chart review. We collected information on patient demographics and disposition and calculated costs of ED visits, screening laboratories performed, inpatient stays on a medical ward, sitter and parole officer salaries, and ambulance transfers. One hundred eight patients accounting for 196 visits were transported from juvenile hall for urgent psychiatric evaluation. Of the 196 visits, 131 (67%) resulted in an involuntary psychiatric hold. More than half of the patients on hold (75 patients) were admitted to a medical ward for boarding because of lack of psychiatric inpatient beds. Included charges for the 196 visits during the 18-month period totaled US $1,357,884, with most of the costs due to boarding on the medical ward. We describe the magnitude and cost associated with addressing psychiatric emergencies in a juvenile correctional system relying on transport of patients to an ED for acute psychiatric evaluation and treatment. Further research is needed to determine if costs could be decreased by increasing psychiatric resources in juvenile detention centers.

Accuracy of automatic syndromic classification of coded emergency department diagnoses in identifying mental health-related presentations for public health surveillance.

PubMed

Liljeqvist, Henning T G; Muscatello, David; Sara, Grant; Dinh, Michael; Lawrence, Glenda L

2014-09-23

Syndromic surveillance in emergency departments (EDs) may be used to deliver early warnings of increases in disease activity, to provide situational awareness during events of public health significance, to supplement other information on trends in acute disease and injury, and to support the development and monitoring of prevention or response strategies. Changes in mental health related ED presentations may be relevant to these goals, provided they can be identified accurately and efficiently. This study aimed to measure the accuracy of using diagnostic codes in electronic ED presentation records to identify mental health-related visits. We selected a random sample of 500 records from a total of 1,815,588 ED electronic presentation records from 59 NSW public hospitals during 2010. ED diagnoses were recorded using any of ICD-9, ICD-10 or SNOMED CT classifications. Three clinicians, blinded to the automatically generated syndromic grouping and each other's classification, reviewed the triage notes and classified each of the 500 visits as mental health-related or not. A "mental health problem presentation" for the purposes of this study was defined as any ED presentation where either a mental disorder or a mental health problem was the reason for the ED visit. The combined clinicians' assessment of the records was used as reference standard to measure the sensitivity, specificity, and positive and negative predictive values of the automatic classification of coded emergency department diagnoses. Agreement between the reference standard and the automated coded classification was estimated using the Kappa statistic. Agreement between clinician's classification and automated coded classification was substantial (Kappa = 0.73. 95% CI: 0.58 - 0.87). The automatic syndromic grouping of coded ED diagnoses for mental health-related visits was found to be moderately sensitive (68% 95% CI: 46%-84%) and highly specific at 99% (95% CI: 98%-99.7%) when compared with the reference standard in identifying mental health related ED visits. Positive predictive value was 81% (95% CI: 0.57 - 0.94) and negative predictive value was 98% (95% CI: 0.97-0.99). Mental health presentations identified using diagnoses coded with various classifications in electronic ED presentation records offers sufficient accuracy for application in near real-time syndromic surveillance.

Trends in incidence and risk markers of student emergency department visits with alcohol intoxication in a U.S. public university-A longitudinal data linkage study.

PubMed

Ngo, Duc Anh; Rege, Saumitra V; Ait-Daoud, Nassima; Holstege, Christopher P

2018-05-08

To examine the trends in incidence and socio-demographic, organizational, academic, and clinical risk markers of student alcohol intoxication associated with emergency department (ED) visits. Student admission data from 2009 to 2015 were linked to primary healthcare data and subsequent ED visits with alcohol intoxication identified using ICD-9 codes within one year following the first (index) enrollment each year. Incidence rate per 10,000 person-years was calculated. Cox proportional hazard regression provided adjusted hazard ratios (HR) (95 % CIs) for the association between student characteristics and subsequent ED visits with alcohol intoxication. Of 177,128 students aged 16-49 enrolled, 889 had at least one ED visit with alcohol intoxication, resulting in an incidence rate of 59/10,000 person-years. Incidence increased linearly from 45/10,000 person-years in 2009-10 to 71/10,000 person-years in the 2014-15 academic year (p < 0.001). HRs (95%CIs) of student characteristics associated with this outcome were: males (versus females): 1.38 (1.21-1.58); below 20 years of age (versus 25-30 years): 3.36 (1.99-5.65); Hispanic (versus Asian) students: 1.61 (1.16-2.25); parental tax dependency: 1.49 (1.16-1.91); Greek life member: 1.96 (1.69-2.26); member of an athletic team: 0.51 (0.36-0.72); undergraduate (versus graduate) students: 2.65 (1.88-3.74). Past year alcohol use or having been diagnosed with depression or anxiety were also significant predictors. Adjustments for campus-related factors strongly attenuated the associations between student socio-demographic characteristics with this outcome. Linking student admission data with ED clinical data can help monitor student alcohol intoxication associated with ED visits and identify student groups at higher risk who subsequently can be targeted for intervention efforts. Copyright © 2018 Elsevier B.V. All rights reserved.

Utility of brief questionnaires of health-related quality of life (Airways Questionnaire 20 and Clinical COPD Questionnaire) to predict exacerbations in patients with asthma and COPD

PubMed Central

2013-01-01

Background There is some evidence that quality of life measured by long disease-specific questionnaires may predict exacerbations in asthma and COPD, however brief quality of life tools, such as the Airways Questionnaire 20 (AQ20) or the Clinical COPD Questionnaire (CCQ), have not yet been evaluated as predictors of hospital exacerbations. Objectives To determine the ability of brief specific health-related quality of life (HRQoL) questionnaires (AQ20 and CCQ) to predict emergency department visits (ED) and hospitalizations in patients with asthma and COPD, and to compare them to longer disease-specific questionnaires, such as the St George´s Respiratory Questionnaire (SGRQ), the Chronic Respiratory Disease Questionnaire (CRQ) and the Asthma Quality of Life Questionnaire (AQLQ). Methods We conducted a two-year prospective cohort study of 208 adult patients (108 asthma, 100 COPD). Baseline sociodemographic, clinical, functional and psychological variables were assessed. All patients completed the AQ20 and the SGRQ. COPD patients also completed the CCQ and the CRQ, while asthmatic patients completed the AQLQ. We registered all exacerbations that required ED or hospitalizations in the follow-up period. Differences between groups (zero ED visits or hospitalizations versus ≥ 1 ED visits or hospitalizations) were tested with Pearson´s X2 or Fisher´s exact test for categorical variables, ANOVA for normally distributed continuous variables, and Mann–Whitney U test for non-normally distributed variables. Logistic regression analyses were performed to estimate the predictive ability of each HRQoL questionnaire. Results In the first year of follow-up, the AQ20 scores predicted both ED visits (OR: 1.19; p = .004; AUC 0.723) and hospitalizations (OR: 1.21; p = .04; AUC 0.759) for asthma patients, and the CCQ emerged as independent predictor of ED visits in COPD patients (OR: 1.06; p = .036; AUC 0.651), after adjusting for sociodemographic, clinical, and psychological variables. Among the longer disease-specific questionnaires, only the AQLQ emerged as predictor of ED visits in asthma patients (OR: 0.9; p = .002; AUC 0.727). In the second year of follow-up, none of HRQoL questionnaires predicted exacerbations. Conclusions AQ20 predicts exacerbations in asthma and CCQ predicts ED visits in COPD in the first year of follow-up. Their predictive ability is similar to or even higher than that of longer disease-specific questionnaires. PMID:23706146

Variables associated with emergency department and/or unplanned hospital utilization for children with epilepsy.

PubMed

Patel, Anup D

2014-02-01

In the United States, approximately one million people are evaluated annually in an emergency department (ED) for the diagnosis of a seizure or epilepsy. The highest percentages of these patients are less than five years of age. No studies have been performed on assessing potential variables associated with recurrent ED visits and/or unplanned hospitalizations for children with epilepsy. Institutional review board approval from Nationwide Children's Hospital was obtained prior to study initiation. An accountable care organization (ACO), Partner for Kids (PFK), database was searched for patients with the highest and the lowest number of ED visits and/or unplanned hospitalizations from 2007 through 2011 using ICD-9 codes of 345.xx and 780.39. The patients were stratified into a high and a low utilizer group. The total number of visits and their associated health care costs were noted for each patient. In total, 120 patients were included for review. Information on the total number of no-shows to outpatient neurology clinic visits and telephone calls to neurology triage nursing was noted. A chart review was performed by a pediatric epileptologist to determine if each individual patient was an appropriate candidate for an emergency seizure treatment. The dose of emergency seizure medication was cross-checked to the patient's actual dose during the time of ED or hospital presentation to determine if the dose given was high, low, or accurate based on dosing recommendations. Multivariable logistic regression was used to test the effects of factors. When controlling for other factors, patients who were given an incorrect or no emergency seizure dosing had a high probability of having multiple ED visits/unplanned hospitalizations compared with patients who were given correct dosing (odds ratio=11.28, 95% CI of odds ratio=(2.42, 52.63), p value<0.01 (p=0.0021)). Using a similar model, patients who experienced a higher number of no-shows to clinic visits had a higher probability of having multiple ED visits/unplanned hospitalizations (odds ratio=5.73 per 1 more number of no-show, 95% CI of odds ratio=(1.78, 18.44), p value<0.01 (p=0.0034)). Future studies are planned to target these risk factors with the goal of decreased ED and/or hospital utilization for children with epilepsy. Copyright © 2013 Elsevier Inc. All rights reserved.

Impact of meteorological parameters and air pollution on emergency department visits for cardiovascular diseases in the city of Zagreb, Croatia.

PubMed

Pintarić, Sanja; Zeljković, Ivan; Pehnec, Gordana; Nesek, Višnja; Vrsalović, Mislav; Pintarić, Hrvoje

2016-09-01

The aim of this study was to investigate whether nitrogen dioxide (NO2), ozone (O3), and certain meteorological conditions had an impact on cardiovascular disease (CVD)-related emergency department (ED) visits in the metropolitan area of Zagreb. This retrospective, ecological study included 20,228 patients with a cardiovascular disease as their primary diagnosis who were examined in the EDs of two Croatian University Hospitals, Sisters of Charity and Holy Spirit, in the study period July 2008-June 2010. The median of daily CVD-related ED visits during the study period was 28 and was the highest during winter. A significant negative correlation was found between CVD-related emergency visits and air temperature measured no more than three days prior to the visit, and the highest negative correlation coefficient was measured two days earlier (R=0.266, p≤0.001). The number of CVD-related emergency visits significantly correlated with the average NO2 concentration on the same day (R=0.191, p<0.001). The results of multiple stepwise regression analysis showed that the number of CVD-related emergency visits depended on air temperature, and NO2 and O3 concentrations. The higher the air temperatures, the lower the number of daily CVD-related emergency visits (p<0.001). An increase in NO2 concentrations (p=0.005) and a decrease in O3 concentrations of two days earlier (p=0.006) led to an increase in CVD-related ED visits. In conclusion, the decrease in O3 concentrations and the increase in NO2, even if below the legally binding thresholds, could be associated with an increase in CVD-related emergency visits and a similar effect was observed with lower temperature measured no more than three days prior to the visit.

The effect of lifestyle choices on emergency department use in Australia.

PubMed

Johar, Meliyanni; Jones, Glenn; Savage, Elizabeth

2013-05-01

Much attention has been paid to patient access to emergency services, focusing on hospital reforms, yet very little is known about the characteristics of those presenting to emergency departments. By exploiting linkage of emergency records and a representative survey of the 45 and older population in Australia, we provide unique insights into the role of lifestyle in predicting emergency presentations. A generalized linear regression model is used to estimate the impact of lifestyles on emergency presentations one year ahead. We control for extensive individual characteristics and area fixed-effects. Not smoking, having healthy body weight, taking vitamins, and exercising vigorously and regularly can reduce emergency presentations and also prevent subsequent admissions from emergency. There is no evidence that heavy drinking leads to more frequent emergency visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of emergency visits. Targeted public health interventions on smoking, body mass and exercise may reduce emergency visits. Effective public health interventions which target body mass, exercise, current smoking and smoking initiation, may have the effect of reducing ED usage and subsequent admission. Individual-level data linking a survey of the population 45 and older in Australia with their emergency department (ED) records is exploited to provide unique insights into the role of lifestyle in predicting emergency care. Controlling for demographic and socioeconomic characteristics, as well as chronic conditions, we find that being a non-smoker, having a healthy body weight, taking vitamins, and doing a vigorous exercise at least once a week can prevent ED presentations. Being a non-smoker, taking vitamins and exercising also prevent subsequent admissions from ED. We do not find a similar protective effect from complying with dietary recommendations. There is no evidence that heavy drinking alone leads to more frequent ED visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of ED visits. These results suggest that targeted public health interventions on smoking, body mass and exercise can reduce ED visits. The use of linked data provides important insight into the characteristics of potential ED users which in turn is valuable for the planning of health services. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Evaluation of a pharmacist-managed asthma clinic in an Indian Health Service clinic.

PubMed

Pett, Ryan G; Nye, Shane

2016-01-01

To observe whether American Indian and Alaskan Native (AI/AN) patients at the Yakama Indian Health Service seen at the pharmacist-managed asthma clinic improved asthma outcomes. Retrospective chart review, single group, preintervention and postintervention. Pharmacist-managed asthma clinic at an Indian Health Service ambulatory care clinic. Sixty-one AI/AN patients who were seen at least once in the asthma clinic from 2010 to 2014. Pharmacist-provided asthma education and medication management. Asthma-related hospitalizations and emergency department or urgent care (ED) visits. The total number of asthma-related hospitalizations and ED visits between the 12-month periods preceding and following the initial asthma clinic visit were 11 versus 2 hospitalizations (P = 0.02) and 43 versus 25 ED visits (P = 0.02), respectively. Over the same period, asthma-related oral corticosteroid use showed a nonsignificant decrease in the number of prescriptions filled (n = 59, P = 0.08). In contrast, inhaled corticosteroid prescription fills significantly increased (n = 42, P = 0.01). A reduction of asthma-related hospitalizations and ED visits were observed during the course of the intervention. Increased access to formal asthma education and appropriate asthma care benefit the Yakama AI/AN people. A controlled trial is needed to confirm that the intervention causes the intended effect. Published by Elsevier Inc.

Emergency department patient satisfaction: customer service training improves patient satisfaction and ratings of physician and nurse skill.

PubMed

Mayer, T A; Cates, R J; Mastorovich, M J; Royalty, D L

1998-01-01

Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. This study investigates the effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level I trauma center. Analysis of patient complaints, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey increased dramatically in the study period; (2) patient complaints decreased by over 70 percent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits following customer service training; and (3) patient compliments increased more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results show that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive market advantage, as well as improve the patients' perception of quality and outcome.

The 2006 California Heat Wave: Impacts on Hospitalizations and Emergency Department Visits

PubMed Central

Knowlton, Kim; Rotkin-Ellman, Miriam; King, Galatea; Margolis, Helene G.; Smith, Daniel; Solomon, Gina; Trent, Roger; English, Paul

2009-01-01

Background Climate models project that heat waves will increase in frequency and severity. Despite many studies of mortality from heat waves, few studies have examined morbidity. Objectives In this study we investigated whether any age or race/ethnicity groups experienced increased hospitalizations and emergency department (ED) visits overall or for selected illnesses during the 2006 California heat wave. Methods We aggregated county-level hospitalizations and ED visits for all causes and for 10 cause groups into six geographic regions of California. We calculated excess morbidity and rate ratios (RRs) during the heat wave (15 July to 1 August 2006) and compared these data with those of a reference period (8–14 July and 12–22 August 2006). Results During the heat wave, 16,166 excess ED visits and 1,182 excess hospitalizations occurred statewide. ED visits for heat-related causes increased across the state [RR = 6.30; 95% confidence interval (CI), 5.67–7.01], especially in the Central Coast region, which includes San Francisco. Children (0–4 years of age) and the elderly (≥ 65 years of age) were at greatest risk. ED visits also showed significant increases for acute renal failure, cardiovascular diseases, diabetes, electrolyte imbalance, and nephritis. We observed significantly elevated RRs for hospitalizations for heat-related illnesses (RR = 10.15; 95% CI, 7.79–13.43), acute renal failure, electrolyte imbalance, and nephritis. Conclusions The 2006 California heat wave had a substantial effect on morbidity, including regions with relatively modest temperatures. This suggests that population acclimatization and adaptive capacity influenced risk. By better understanding these impacts and population vulnerabilities, local communities can improve heat wave preparedness to cope with a globally warming future. PMID:19165388

Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach.

PubMed

Baltrus, Peter; Xu, Junjun; Immergluck, Lilly; Gaglioti, Anne; Adesokan, Adeola; Rust, George

2017-01-02

Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.

National Trends in Emergency Room Visits of Dialysis Patients for Adverse Drug Reactions.

PubMed

Chan, Lili; Saha, Aparna; Poojary, Priti; Chauhan, Kinsuk; Naik, Nidhi; Coca, Steven; Garimella, Pranav S; Nadkarni, Girish N

2018-06-12

Various medications are cleared by the kidneys, therefore patients with impaired renal function, especially dialysis patients are at risk for adverse drug events (ADEs). There are limited studies on ADEs in maintenance dialysis patients. We utilized a nationally representative database, the Nationwide Emergency Department Sample, from 2008 to 2013, to compare emergency department (ED) visits for dialysis and propensity matched non-dialysis patients. Log binomial regression was used to calculate relative risk of hospital admission and logistic regression to calculate ORs for in-hospital mortality while adjusting for patient and hospital characteristics. While ED visits for ADEs decreased in both groups, they were over 10-fold higher in dialysis patients than non-dialysis patients (65.8-88.5 per 1,000 patients vs. 4.6-5.4 per 1,000 patients respectively, p < 0.001). The top medication category associated with ED visits for ADEs in dialysis patients is agents primarily affecting blood constituents, which has increased. After propensity matching, patient admission was higher in dialysis patients than non-dialysis patients, (88 vs. 76%, p < 0.001). Dialysis was associated with a 3% increase in risk of admission and 3 times the odds of in-hospital mortality (adjusted OR 3, 95% CI 2.7-2.3.3). ED visits for ADEs are substantially higher in dialysis patients than non-dialysis patients. In dialysis patients, ADEs associated with agents primarily affecting blood constituents are on the rise. ED visits for ADEs in dialysis patients have higher inpatient admissions and in-hospital mortality. Further studies are needed to identify and implement measures aimed at reducing ADEs in dialysis patients. © 2018 S. Karger AG, Basel.

Opioid-Induced "Likeability" and "Feeling Good" Are Not Associated With Return Visits to an ED Among Migraine Patients Administered IV Hydromorphone.

PubMed

Friedman, Benjamin W; Latev, Alexander; Campbell, Caron; White, Deborah

2018-05-01

Parenteral opioids are used in more than 50% of emergency department (ED) visits for migraine. Use of opioids for migraine has been associated with subsequent ED visits, perhaps because of opioid-induced euphoria. In this study, we quantify the extent to which nontherapeutic effects of opioids influence migraine outcomes. We hypothesized that "feeling good" and medication likeability would in fact be associated with receipt of opioids (rather than relief of migraine pain) and that receipt of opioids (rather than relief of migraine pain) would be associated with return visits to the ED. During an ED-based clinical trial, migraine patients were randomized to receive hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg IV. Thirty minutes after medication administration, we asked, (1) How much did you like the medication you received? and (2) How good did the medication make you feel? Participants were asked to provide answers on a 0-10 scale. We also determined 0-10 pain scores at baseline and 1 hour and number of return visits for headache during the subsequent month. Sixty-three patients received prochlorperazine and 64 hydromorphone. Prochlorperazine pain scores improved by 6.8 (SD: 2.6), hydromorphone by 4.7 (SD: 3.3) (95%CI for difference of 2.1: 1.0, 3.2). On the 0-10 likeability scale, prochlorperazine patients reported a mean of 7.2 (SD: 2.8), hydromorphone 6.9 (SD: 2.9) (95% CI for difference of 0.3: -0.7, 1.3). On the 0-10 feeling good scale, prochlorperazine patients reported a mean of 7.5 (SD: 2.3), hydromorphone 6.8 (SD: 2.8) (95%CI: for difference of 0.7: -0.2, 1.6). In the hydromorphone group, 8/57 (14%, 95%CI: 7, 26%) returned to the ED vs 5/63 (8%, 95%CI: 3,18%) in the prochlorperazine group. In regression modeling, feeling good was independently associated with pain relief (P < .01) but not with medication received (P = .67) or return visits (P = .12). Similarly, medication likeability was independently associated with pain relief (P < .01) but not medication received (P = .12) or return visits (P = .16). We did not detect an association between hydromorphone and medication likeability, feeling good, or return visits to the ED. Headache relief was associated with medication likeability and feeling good. © 2018 American Headache Society.

Asthma medication ratio predicts emergency department visits and hospitalizations in children with asthma.

PubMed

Andrews, Annie Lintzenich; Simpson, Annie N; Basco, William T; Teufel, Ronald J

2013-01-01

To determine if the asthma medication ratio predicts subsequent emergency department (ED) visits and hospital admissions in children. Retrospective cohort with two year pairs. 2007-2009 South Carolina Medicaid recipients with persistent asthma age 2-18. Controller-to-total asthma medication ratios were calculated for each patient in 2007 and 2008. Ratios range from 0-1 (1 = ideal, 0 = no controller). 2008 and 2009 asthma related ED visits, hospitalizations, and a combined outcome of ED visit or hospitalization in the subsequent 3, 6, and 12 month time periods. 19,512 patients were included. Mean age 8.9 years, 58% male, and 55% black. The ratio significantly predicted ED visits and hospitalizations over subsequent 3, 6, and 12 month time periods. The cut-point that maximized the ability to predict visits ranged from 0.4-0.6. A cutpoint of 0.5 was used in the final models. After controlling for age, race, gender, and rurality, patients with a ratio <0.5 were significantly more likely to have a subsequent emergent healthcare visit (OR 1.5-2.0). The ratio retained its predictive ability in both year-pairs for all three outcome variables, in all three time periods, with the exception of the 2008 ratio not predicting 2009 3-month and 6-month hospitalizations. The asthma medication ratio is a significant predictor of ED visits and hospitalizations in children. Using a cutoff of <0.5 to signal at-risk patients may be an effective way for populations who would benefit from increased use of controller medications to reduce future emergent asthma visits. CPT only copyright XXXX-2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. See attached CMS CPT 2013 end user license.

Impact of the EURO-2016 football cup on emergency department visits related to alcohol and injury.

PubMed

Noel, G N; Roch, A R; Michelet, P M; Boiron, L B; Gentile, S G; Viudes, G V

2018-06-01

In Marseille, the 2016 EURO football cup days were independently associated with a 43% increase in alcohol-related visits in the Emergency Department (ED). Patients admitted for alcohol consumption were younger (41 vs. 46.6; P < 0.001), more often male (82.8% vs. 60.1%; P < 0.001) and more often admitted as inpatients (24.0% vs. 16.5%; P = 0.03) than those admitted for injury. Unlike reported in previous studies, injury-related visits did not increase. This could be explained by coding practice variability between EDs (alcohol or injury). To account for this variability, both diagnosis groups must be separately included when using ED data for preparing and monitoring major gatherings.

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

PubMed

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

2017-01-01

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. We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 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 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. In the 6 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 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 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 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. 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. © 2016 by the Society for Academic Emergency Medicine.

Racial-Ethnic Differences in Health Service Use in a Large Sample of Homeless Adults With Mental Illness From Five Canadian Cities.

PubMed

Stergiopoulos, Vicky; Gozdzik, Agnes; Nisenbaum, Rosane; Vasiliadis, Helen-Maria; Chambers, Catharine; McKenzie, Kwame; Misir, Vachan

2016-09-01

This study examined factors associated with health care use in an ethnically diverse Canadian sample of homeless adults with mental illness, a particularly disadvantaged group. Baseline survey data were available from five sites across Canada for 2,195 At Home/Chez Soi demonstration project participants. Negative binomial regression models examined the relationship between racial-ethnic or cultural group membership (white, N=1,085; Aboriginal, N=476; black, N=244; and other ethnoracial minority groups, N=390) and self-reported emergency department (ED) visits and hospitalizations in the past six months and past-month visits to a medical, other clinical, or social service provider. Adjusted models included other predisposing, enabling, and need factors, based on Andersen's behavioral model for vulnerable populations. Compared with white participants, black participants had a lower rate of ED visits (adjusted rate ratio [ARR]=.54, 95% confidence interval [CI]=.43-.69) and Aboriginal participants had a lower rate of medical visits (ARR=.84, CI=.71-.99) and a higher rate of visits to social service providers (ARR=1.54, CI=1.18-2.01). Participants in other ethnoracial minority groups had a higher rate of social service provider visits than white participants (ARR=1.44, CI=1.10-1.89). Access to a family physician, having at least high school education, and high needs for mental health services were associated with greater use of ED and medical visits and hospitalizations. Rates of ED and medical visits were lower with increased age and better physical health. In a system of universal health insurance that prioritizes access to and quality of care, the presence of racial-ethnic disparities experienced by this vulnerable population merits further attention.

Potentially inappropriate prescribing according to STOPP and START and adverse outcomes in community‐dwelling older people: a prospective cohort study

PubMed Central

Bennett, Kathleen; Cahir, Caitriona; Kenny, Rose Anne; Fahey, Tom

2016-01-01

Aims This study aims to determine if potentially inappropriate prescribing (PIP) is associated with increased healthcare utilization, functional decline and reduced quality of life (QoL) in a community‐dwelling older cohort. Method This prospective cohort study included participants aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) with linked administrative pharmacy claims data who were followed up after 2 years. PIP was defined by the Screening Tool for Older Persons Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START). The association with number of emergency department (ED) visits and GP visits reported over 12 months was analyzed using multivariate negative binomial regression adjusting for confounders. Marginal structural models investigated the presence of time‐dependent confounding. Results Of participants followed up (n = 1753), PIP was detected in 57% by STOPP and 41.8% by START, 21.7% reported an ED visit and 96.1% visited a GP (median 4, IQR 2.5–6). Those with any STOPP criterion had higher rates of ED visits (adjusted incident rate ratio (IRR) 1.30, 95% confidence interval (CI) 1.02, 1.66) and GP visits (IRR 1.15, 95%CI 1.06, 1.24). Patients with two or more START criteria had significantly more ED visits (IRR 1.45, 95%CI 1.03, 2.04) and GP visits (IRR 1.13, 95%CI 1.01, 1.27) than people with no criteria. Adjusting for time‐dependent confounding did not affect the findings. Conclusions Both STOPP and START were independently associated with increased healthcare utilization and START was also related to functional decline and QoL. Optimizing prescribing to reduce PIP may provide an improvement in patient outcomes. PMID:27136457

Visiting again? Subjective well-being of children in elementary school and repeated visits to school health nurses.

PubMed

Leaver, Cynthia A

2014-05-01

Children with vague complaints are without chronic illness, and who repeatedly visit the school nurse may be at risk for limited academic success. This study compares student reports of subjective well-being between children who do and do not repeatedly visit the school nurse with vague complaints. Children in grades 4 through 6 completed the School Well-Being Profile-American English (SWBP-AE), a questionnaire with 4 well-being subscales: health status, school environment, social relationships, and school as a means of self-fulfillment. School nurses extracted data on clinic visits from clinic records. Logistic regression explored associations between well-being subscales and repeated visits to the school nurse. Of the 320 students participating in the study, 33 (12.04%) students made repeated visits to the school nurse. Perception of health status (OR = 2.072; 95% CI = 1.037, 4.163) was the only significant (p < .05) predictor of repeated visits to the nurse. Children with poor perception of their health status are more likely to repeatedly visit the school nurse. Children's perceptions of their school environment, social relationships, or school as a means of self-fulfillment are not statistically significant predictors of repeated visits to the school nurse. © 2014, American School Health Association.

The association of controlling pseudoephedrine availability on methamphetamine-related emergency department visits.

PubMed

Hendrickson, Robert G; Cloutier, Robert L; Fu, Rongwei

2010-11-01

Methamphetamine is a drug of abuse that has been manufactured locally by chemical conversion from the decongestant pseudoephedrine. In July 2006, an Oregon state law was enacted to establish pseudoephedrine as a schedule III drug and make it available by prescription only. This study sought to determine if this legislation altered the number of emergency department (ED) visits that are related to methamphetamine use. This was a retrospective analysis of a database created during a prospective study aimed at determining the effect of methamphetamine on ED visits. That prospective study was 1 year in duration and required ED clinicians to determine whether a patient's visit was related to methamphetamine and if the patient had confirmed use of methamphetamine. The clinicians received initial and continued education and training on methamphetamine during the study period. The questions were asked at every ED visit during the study period and were electronically linked to the patient's disposition and could not be circumvented. The study period was divided into prelegislation (February 5, 2006, to June 30, 2006) and postlegislation periods (July 1, 2006, to February 5, 2007). Over the 1-year study period, 37,625 patients were enrolled, 1.90% (n = 714) of patients had methamphetamine-related ED visits (MREDVs), and 1.65% (n = 620) had confirmed methamphetamine use. Patients with MREDVs were more likely than patients with non-MREDVs to be white and uninsured. The number and proportion of weekly MREDVs significantly decreased from the prelegislation period to the postlegislation period (mean number of weekly visits, 18.0 vs. 11.3, p = 0.001; mean proportion of weekly visits, 2.3% vs. 1.6%, p = 0.003). The number and proportion of weekly confirmed users of methamphetamine also significantly decreased during the study period (mean number of weekly users, 14.6 vs. 10.3, p = 0.004; mean proportion of weekly users, 1.9% vs. 1.4%, p = 0.017). There were no significant differences in the diagnoses of MREDVS between the pre- and postlegislation periods. This study found an association between the enactment of legislation that limits pseudoephedrine availability and a decrease in MREDVs and confirmed users of methamphetamine in the study ED. © 2010 by the Society for Academic Emergency Medicine.

Opioid pain medication prescriptions obtained through emergency medical visits in the Veterans Health Administration.

PubMed

Grasso, Michael A; Dezman, Zachary D W; Grasso, Clare T; Jerrard, David A

This study sought to characterize national patterns for opioid pain medication (OPM) prescriptions received during emergency medical encounters in the Veterans Health Administration (VA). The authors conducted a retrospective study of all emergency department (ED) visits by adults in the VA between January 2009 and June 2015. We examined demographics, comorbidities, utilization measures, diagnoses, and prescriptions. The percentage of ED visits that culminated in the receipt of a prescription for an OPM. There were 6,721,134 emergency medical visits by 1,708,545 individuals during the study period. An OPM was prescribed during 913,872 visits (13.6 percent), and 407,408 individuals (27.5 percent) received at least one OPM prescription. Prescriptions for OPMs peaked in 2011 at 14.5 percent, declining to 12.3 percent in 2015. The percentage of prescriptions limited to 12 pills increased from 25.0 to 32.4 percent. The heaviest users (top 1.5 percent, n = 7,247) received an average 602.5 total doses, and had at least 10 ED visits during the study period. The most frequently prescribed OPMs were acetaminophen/hydrocodone, followed by tramadol and acetaminophen/oxycodone. Receiving a prescription was associated with younger patients, musculoskeletal diagnoses, higher pain scores, a history of chronic pain, a history of mental illness, a history of substance abuse, prior heavy prescription OPM use, and lower participation in outpatient services. The writing of OPM prescriptions after an ED visit is on the decline in the VA. Compliance with prescribing guidelines is increasing, but is not yet at goal.

Radiology utilization in the emergency department: trends of the past 2 decades.

PubMed

Raja, Ali S; Ip, Ivan K; Sodickson, Aaron D; Walls, Ron M; Seltzer, Steven E; Kosowsky, Joshua M; Khorasani, Ramin

2014-08-01

The objective of our study was to assess radiology utilization trends for emergency department (ED) patients from 1993 through 2012. For this retrospective study, we reviewed radiology utilization at a 793-bed quaternary care academic medical center from January 1, 1993, through December 31, 2012, during which time the number of ED patient visits increased from approximately 48,000 to 61,000, and determined the number of imaging studies by modality (radiography, sonography, CT, MRI, other) and associated relative value units (RVUs). We used linear regression to assess for trends in the number of imaging RVUs and imaging accession numbers, our primary and secondary outcomes, respectively. The total RVUs attributable to ED imaging per 1000 ED visits increased 208% from 1993 to 2007 (p < 0.0001) and then decreased 24.7% by 2012 (p = 0.0019). The total number of imaging accession numbers per 1000 ED visits increased 47.8% from 1993 until 2005 (p = 0.0003) and then decreased 26.9% by 2012 (p < 0.0001). CT RVUs per 1000 ED visits increased 493% until 2007 (p < 0.0001) and then decreased 33.4% (p < 0.0001), and MRI RVUs increased 2475% until 2008 (p < 0.0001) and then decreased 20.6% (p < 0.0032). Sonography RVUs increased 75.7% over the study period (p < 0.0001), whereas radiography RVUs decreased 28.1% (p = 0.0009). After a period of substantial increase from 1993 to 2007, volume-adjusted ED imaging RVUs declined from 2007 through 2012, largely because of the decreasing use of CT and MRI. Additional studies are needed to determine the causes of this decline, which may include quality improvement activities, advocacy for appropriateness by leadership, concerns regarding radiation exposure and cost, and health information technology interventions.

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.

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.

Potentially Preventable Hospital and Emergency Department Events: Lessons from a Large Innovation Project.

PubMed

Solberg, Leif I; Ohnsorg, Kris A; Parker, Emily D; Ferguson, Robert; Magnan, Sanne; Whitebird, Robin R; Neely, Claire; Brandenfels, Emily; Williams, Mark D; Dreskin, Mark; Hinnenkamp, Todd; Ziegenfuss, Jeanette Y

2018-06-04

There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

A Consultation Phone Service for Patients With Total Joint Arthroplasty May Reduce Unnecessary Emergency Department Visits.

PubMed

Hällfors, Eerik; Saku, Sami A; Mäkinen, Tatu J; Madanat, Rami

2018-03-01

Different measures for reducing costs after total joint arthroplasty (TJA) have gained attention lately. At our institution, a free-of-charge consultation phone service was initiated that targeted patients with TJA. This service aimed at reducing unnecessary emergency department (ED) visits and, thus, potentially improving the cost-effectiveness of TJAs. To our knowledge, a similar consultation service had not been described previously. We aimed at examining the rates and reasons for early postdischarge phone calls and evaluating the efficacy of this consultation service. During a 2-month period, we gathered information on every call received by the consultation phone service from patients with TJAs within 90 days of the index TJA procedure. Patients were followed for 2 weeks after making a call to detect major complications and self-initiated ED visits. Data were collected from electronic medical charts regarding age, gender, type of surgery, date of discharge, and length of hospital stay. We analyzed 288 phone calls. Calls were mostly related to medication (41%), wound complications (17%), and mobilization issues (15%). Most calls were resolved in the phone consultation. Few patients (13%) required further evaluation in the ED. The consultation service failed to detect the need for an ED visit in 2 cases (0.7%) that required further care. The consultation phone service clearly benefitted patients with TJAs. The service reduced the number of unnecessary ED visits and functioned well in detecting patients who required further care. Most postoperative concerns were related to prescribed medications, wound complications, and mobilization issues. Copyright © 2017 Elsevier Inc. All rights reserved.

Improving acute patient flow and resolving emergency department overcrowding in New Zealand hospitals--the major challenges and the promising initiatives.

PubMed

Ardagh, Michael W; Tonkin, Gary; Possenniskie, Clare

2011-10-14

To determine the most common challenges to improving acute patient flow and resolving emergency department (ED) overcrowding in New Zealand hospitals, and to share some of the promising initiatives that have been implemented in response to them. To facilitate progress towards achievement of the Shorter Stays in Emergency Departments Health Target (the Target), the authors visited every District Health Board (DHB) in New Zealand. These visits followed a standardised visit format and subsequent to each visit a report was produced that noted the observed challenges, initiatives and successes in relation to the DHB's pursuit of the Target. Using these reports, the significant challenges and the promising initiatives across all of the DHBs were collated. Access to hospital beds, access to diagnostic tests and inpatient team delays were the most common challenges, followed by increased demand for ED services, ED facility deficiencies, ED staff deficiencies, delay to discharge of inpatients, difficulty engaging hospital clinical staff in changes, difficulty accessing aged care beds, and problems at nights and weekends. Promising initiatives were noted in relation to each of these. To improve acute care, resolve ED overcrowding and achieve the Target we need a comprehensive, whole of system approach and some significant changes to the way we use our physical and human resources. To address common challenges we need to share our experiences and expertise.

Adolescent Sexual Behavior and Emergency Department Use.

PubMed

Weisman, Julie; Chase, Alyse; Badolato, Gia M; Teach, Stephen J; Trent, Maria E; Chamberlain, James M; Goyal, Monika K

2018-03-28

The objective of this study was to determine whether adolescents in emergency departments (EDs) who report engaging in high-risk sexual behaviors are less likely to identify a primary care provider (PCP) and more likely to access the ED than their sexually inexperienced peers. This was a secondary analysis of adolescents presenting to a pediatric ED with non-sexually transmitted infection (STI)-related complaints who completed surveys to assess sexual behavior risk and health care access. We measured differences in self-reported PCP identification, preferential use of the ED, and number of ED visits over a 12-month period by sexual experience. Secondary outcomes included clinician documented sexual histories and STI testing. Of 758 patients meeting inclusion criteria, 341 (44.9%) were sexually experienced, and of those, 129 (37.8%) reported engaging in high-risk behavior. Participants disclosing high-risk behavior were less likely to identify a PCP (adjusted odds ratio, 0.5; 95% confidence interval [CI], 0.3-0.9), more likely to prefer the ED for acute care issues (adjusted odds ratio, 1.6; 95% CI, 1.0-2.6), and had a higher rate of ED visits (adjusted relative risk, 1.2; 95% CI, 1.0-1.3) compared with sexually inexperienced peers. Among patients disclosing high-risk behavior, 10.9% had clinician-documented sexual histories and 2.6% underwent STI testing. Adolescents who reported engaging in high-risk sexual behaviors were less likely to identify a PCP, as well as more likely to prefer ED-based care and make more ED visits. However, ED clinicians infrequently obtained sexual histories and performed STI testing in asymptomatic youth, thereby missing opportunities to screen high-risk adolescents who may lack access to preventive care.

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

Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments.

PubMed

White, Douglas A E; Giordano, Thomas P; Pasalar, Siavash; Jacobson, Kathleen R; Glick, Nancy R; Sha, Beverly E; Mammen, Priya E; Hunt, Bijou R; Todorovic, Tamara; Moreno-Walton, Lisa; Adomolga, Vincent; Feaster, Daniel J; Branson, Bernard M

2018-01-05

Newer combination HIV antigen-antibody tests allow detection of HIV sooner after infection than previous antibody-only immunoassays because, in addition to HIV-1 and -2 antibodies, they detect the HIV-1 p24 antigen, which appears before antibodies develop. We determine the yield of screening with HIV antigen-antibody tests and clinical presentations for new diagnoses of acute and established HIV infection across US emergency departments (EDs). This was a retrospective study of 9 EDs in 6 cities with HIV screening programs that integrated laboratory-based antigen-antibody tests between November 1, 2012, and December 31, 2015. Unique patients with newly diagnosed HIV infection were identified and classified as having either acute HIV infection or established HIV infection. Acute HIV infection was defined as a repeatedly reactive antigen-antibody test result, a negative HIV-1/HIV-2 antibody differentiation assay, or Western blot result, but detectable HIV ribonucleic acid (RNA); established HIV infection was defined as a repeatedly reactive antigen-antibody test result and a positive HIV-1/HIV-2 antibody differentiation assay or Western blot result. The primary outcomes were the number of new HIV diagnoses and proportion of patients with laboratory-defined acute HIV infection. Secondary outcomes compared reason for visit and the clinical presentation of acute HIV infection. In total, 214,524 patients were screened for HIV and 839 (0.4%) received a new diagnosis, of which 122 (14.5%) were acute HIV infection and 717 (85.5%) were established HIV infection. Compared with patients with established HIV infection, those with acute HIV infection were younger, had higher RNA and CD4 counts, and were more likely to have viral syndrome (41.8% versus 6.5%) or fever (14.3% versus 3.4%) as their reason for visit. Most patients with acute HIV infection displayed symptoms attributable to acute infection (median symptom count 5 [interquartile range 3 to 6]), with fever often accompanied by greater than or equal to 3 other symptoms (60.7%). ED screening using antigen-antibody tests identifies previously undiagnosed HIV infection at proportions that exceed the Centers for Disease Control and Prevention's screening threshold, with the added yield of identifying acute HIV infection in approximately 15% of patients with a new diagnosis. Patients with acute HIV infection often seek ED care for symptoms related to seroconversion. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond.

PubMed

Lovelace, Derenda; Hancock, Diane; Hughes, Sabrina S; Wyche, Phyllis R; Jenkins, Claire; Logan, Cindy

In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%. To examine the impact of the McGuire VAMC TCP on Veteran ED and hospital utilization and costs. Veterans being discharged to home following an inpatient admission, ED visit, and/or short rehab stay. The primary means of identifying patients for the program is through daily screening of the previous 24-hour admission and ED report, which the inpatient nurse practitioner performs. She completes an extensive review of each Veteran's electronic medical record to determine the number of ED visits and inpatient admissions at the VAMC and in the community. Initial criteria for consideration in the program included the following: more than two hospital admissions and/or ED visits in the past 90 days or at high risk for readmission based on a Care Assessment Need score of greater than 95. Two hundred Veterans participated in the program in fiscal year (FY) 2013, with 146 participating in FY 2014. A retrospective chart review of Veterans participating in the TCP in FYs 2013 and 2014 was conducted, with a focus on number of admissions and ED visits 90 days prior to admission to the TCP and 90 days following TCP admission. Average admission and ED costs for this VA were calculated to determine cost savings from pre- to post-90 days of admission and ED visits. Veterans who obtained TCP services in FYs 2013 and 2014 experienced a 67% decrease in hospital admissions and a 61% decrease in ED visits in the 90 days following participation in this program compared with the 90 days prior to participation. This produced an estimated net savings of $3,823,673 in medical center costs. In addition, registered nurse case managers (RN CMs) noted improved patient compliance and satisfaction with care and the licensed clinical social worker noted reduced caregiver burden. The results of this program demonstrate how using an interdisciplinary approach to develop patient-centered transition plans of care through intensive case management interventions improves resource utilization with substantial financial savings. This program represents a feasible option for other VAMCs as well as civilian hospitals seeking to provide cost-effective transitional care to patients upon discharge and prevent untimely readmissions. With an RN CM at the hub of patient care, this program successfully demonstrates the value of smooth care transitions.

Use of Emergency Departments among Working Age Adults with Disabilities: A Problem of Access and Service Needs

PubMed Central

Rasch, Elizabeth K; Gulley, Stephen P; Chan, Leighton

2013-01-01

Objective To examine the relationship between emergency department (ED) use and access to medical care and prescription medications among working age Americans with disabilities. Data Source Pooled data from the 2006–2008 Medical Expenditure Panel Survey (MEPS), a U.S. health survey representative of community-dwelling civilians. Study Design We compared the health and service utilization of two groups of people with disabilities to a contrast group without disability. We modeled ED visits on the basis of disability status, measures of health and health conditions, access to care, and sociodemographics. Data Extraction These variables were aggregated from the household component, the medical condition, and event files to provide average annual estimates for the period spanning 2006–2008. Principal Findings People with disabilities accounted for almost 40 percent of the annual visits made to U.S. EDs each year. Three key factors affect their ED use: access to regular medical care (including prescription medications), disability status, and the complexity of individuals’ health profiles. Conclusions Given the volume of health conditions among people with disabilities, the ED will always play a role in their care. However, some ED visits could potentially be avoided if ongoing care were optimized. PMID:23278461

Characteristics of unscheduled emergency department return visit patients within 48 hours in Thammasat University Hospital.

PubMed

Imsuwan, Intanon

2011-12-01

Auditing the return visit charts of patients who returned within 48 hours is a very important method of quality assurance. Several factors can be possible causes of unscheduled emergency return visits. Therefore, identifying these factors is critical to decreasing the number of unnecessary visits in this group. To determine rate, common initial presentation and cause of unscheduled emergency department return visits within 48 hours at Thammasat University Hospital. The present study design involves retrospective observational study of patients who returned to the Emergency department (ED) within 48 hours after being discharged from the ED. Data was collected from August 1, 2009 to July 31, 2010. Patient age, gender triage level, patient-in time, patient-out time, length of stay, chief complaint, first and second visit diagnoses and disposition after second visit were recorded by chart review. The factors and causes of revisits were classified by the author as illness-related, patient-related, doctor-related and/or healthcare system-related. A total of 307 (0.92%) patients returned visit to the ED within 48 hours during August 1, 2009 to July 31, 2010. The most common chief complaint were dyspnea (75 cases or 24.4%), abdominal pain (53 cases or 17.3%), bleeding per vagina (28 cases or 9.1%). The rates of revisit that were related to factors of illness, patients, doctors and healthcare system were 60.6, 8.5, 28.3 and 2.6, respectively. Chi-squared was used for categorical data. Unscheduled ED return visit patients represent high risk patients. Patients in this group are associated with various factors. The present study indicates that the most common factor behind return visits were illness-related. Illness-related and patient-related factors were significantly associated with discharged patient. Observational units could reduce unnecessary return visit in this group. Doctor-related and healthcare-related factors were significantly associated with admitted return visit patients. Emergency physician training system and guideline implementation for doctors could reduce unexpected early discharge in this group.

Burden of uncontrolled epilepsy in patients requiring an emergency room visit or hospitalization.

PubMed

Manjunath, Ranjani; Paradis, Pierre Emmanuel; Parisé, Hélène; Lafeuille, Marie-Hélène; Bowers, Brian; Duh, Mei Sheng; Lefebvre, Patrick; Faught, Edward

2012-10-30

To quantify the clinical and economic burden of uncontrolled epilepsy in patients requiring emergency department (ED) visit or hospitalization. Health insurance claims from a 5-state Medicaid database (1997Q1-2009Q2) and 55 self-insured US companies ("employer," 1999Q1 and 2008Q4) were analyzed. Adult patients with epilepsy receiving antiepileptic drugs (AED) were selected. Using a retrospective matched-cohort design, patients were categorized into cohorts of "uncontrolled" (≥ 2 changes in AED therapy, then ≥ 1 epilepsy-related ED visit/hospitalization within 1 year) and "well-controlled" (no AED change, no epilepsy-related ED visit/hospitalization) epilepsy. Matched cohorts were compared for health care resource utilization and costs using multivariate conditional regression models and nonparametric methods. From 110,312 (Medicaid) and 36,529 (employer) eligible patients, 3,454 and 602 with uncontrolled epilepsy were matched 1:1 to patients with well-controlled epilepsy, respectively. In both populations, uncontrolled epilepsy cohorts presented about 2 times more fractures and head injuries (all p values < 0.0001) and higher health care resource utilization (ranges of adjusted incidence rate ratios [IRRs] [all-cause utilization]: AEDs = 1.8-1.9, non-AEDs = 1.3-1.5, hospitalizations = 5.4-6.7, length of hospital stays = 7.3-7.7, ED visits = 3.7-5.0, outpatient visits = 1.4-1.7, neurologist visits = 2.3-3.1; all p values < 0.0001) than well-controlled groups. Total direct health care costs were higher in patients with uncontrolled epilepsy (adjusted cost difference [95% confidence interval (CI)] Medicaid = $12,258 [$10,482-$14,083]; employer = $14,582 [$12,019-$17,097]) vs well-controlled patients. Privately insured employees with uncontrolled epilepsy lost 2.5 times more work days, with associated indirect costs of $2,857 (95% CI $1,042-$4,581). Uncontrolled epilepsy in patients requiring ED visit or hospitalization was associated with significantly greater health care resource utilization and increased direct and indirect costs compared to well-controlled epilepsy in both publicly and privately insured settings.

Which Chart Elements Accurately Identify Emergency Department Visits for Suicidal Ideation or Behavior?

PubMed

Arias, Sarah A; Boudreaux, Edwin D; Chen, Elizabeth; Miller, Ivan; Camargo, Carlos A; Jones, Richard N; Uebelacker, Lisa

2018-05-23

In an emergency department (ED) sample, we investigated the concordance between identification of suicide-related visits through standardized comprehensive chart review versus a subset of three specific chart elements: ICD-9-CM codes, free-text presenting complaints, and free-text physician discharge diagnoses. Review of medical records for adults (≥18 years) at eight EDs across the United States. A total of 3,776 charts were reviewed. A combination of the three chart elements (ICD-9-CM, presenting complaints, and discharge diagnoses) provided the most robust data with 85% sensitivity, 96% specificity, 92% PPV, and 92% NPV. These findings highlight the use of key discrete fields in the medical record that can be extracted to facilitate identification of whether an ED visit was suicide-related.

Physicians' assessment of pediatric returns to the Emergency Department.

PubMed

Easter, Joshua S; Bachur, Richard

2013-03-01

Return visits to the Emergency Department (ED) requiring admission are frequently reviewed for the purpose of quality improvement. Treating physicians typically perform this review, but it is unclear if they accurately identify the reasons for the returns. To assess the characteristics of pediatric return visits to the ED, and the ability of treating physicians to identify the root causes for these return visits. This retrospective cohort study reviewed all returns within 96 h of an initial visit over a 2-year period at a tertiary care pediatric ED. Baseline characteristics were determined from review of patients' charts. The treating physicians, the primary author, and independent reviewers identified the root cause for the returns. There were 97,374 patients that presented to the ED during the study, and 1091 (1.1%) of these children returned to the ED and were admitted. Returns were most common among children aged<5 years, arriving between 3:00 p.m. and 11:00 p .m. via private transportation, with infectious diseases. The physician involved in the care of the patient attributed 3.1% of returns to potential deficiencies in medical management, whereas the independent reviewers attributed 13% to potential deficiencies. Both returns and the subset of returns due to potential deficiencies in management are more common than previously estimated, rendering review of returns a valuable quality improvement tool. However, EDs should not rely exclusively on the treating physicians to identify the reason for returns, as they seem to underestimate the frequency of returns due to potential deficiencies in medical management. Copyright © 2013 Elsevier Inc. All rights reserved.

A structured bowel management program for patients with severe functional constipation can help decrease emergency department visits, hospital admissions, and healthcare costs.

PubMed

Reck-Burneo, Carlos A; Vilanova-Sanchez, Alejandra; Gasior, Alessandra C; Dingemans, Alexander J M; Lane, Victoria A; Dyckes, Robert; Nash, Onnalisa; Weaver, Laura; Maloof, Tassiana; Wood, Richard J; Zobell, Sarah; Rollins, Michael D; Levitt, Marc A

2018-03-24

Published health-care costs related to constipation in children in the USA are estimated at $3.9 billion/year. We sought to assess the effect of a bowel management program (BMP) on health-care utilization and costs. At two collaborating centers, BMP involves an outpatient week during which a treatment plan is implemented and objective assessment of stool burden is performed with daily radiography. We reviewed all patients with severe functional constipation who participated in the program from March 2011 to June 2015 in center 1 and from April 2014 to April 2016 in center 2. ED visits, hospital admissions, and constipation-related morbidities (abdominal pain, fecal impaction, urinary retention, urinary tract infections) 12 months before and 12 months after completion of the BMP were recorded. One hundred eighty-four patients were included (center 1 = 96, center 2 = 88). Sixty-three (34.2%) patients had at least one unplanned visit to the ED before treatment. ED visits decreased to 23 (12.5%) or by 64% (p < 0.0005). Unplanned hospital admissions decreased from 65 to 28, i.e., a 56.9% reduction (p < 0.0005). In children with severe functional constipation, a structured BMP decreases unplanned visits to the ED, hospital admissions, and costs for constipation-related health care. 3. Copyright © 2018. Published by Elsevier Inc.

Pediatric psychiatric emergency department visits during a full moon.

PubMed

Kamat, Shyama; Maniaci, Vincenzo; Linares, Marc Yves-Rene; Lozano, Juan M

2014-12-01

This study aimed to verify the hypothesis that the lunar cycle influences the number of pediatric psychiatric emergency department (ED) visits. Pediatric psychiatric ED visits between 2009 and 2011 were obtained retrospectively. Patients aged between 4 and 21 years presenting to Miami Children's Hospital ED with a primary psychiatric complaint were included in the study. Patients with a concomitant psychiatric problem and a secondary medical condition were excluded. The number of psychiatric visits was retrieved for the full moon dates, control dates as well as the day before and after the full moon when the moon appears full to the naked eye (full moon effect). A comparison was made using the 2-sample independent t test. Between 2009 and 2011, 36 dates were considered as the true full moon dates and 108 dates as the "full moon effect." A total of 559 patients were included in the study. The 2-sample independent t tests were performed between the actual full moon date and control dates, as well as between the "full moon effect" dates and control dates. Our results failed to show a statistical significance when comparing the number of pediatric psychiatric patients presenting to a children's hospital ED during a full moon and a non-full moon date. Our study's results are in agreement with those involving adult patients. The full moon does not affect psychiatric visits in a children's hospital.

Evaluation of a programme for 'Rapid Assessment of Febrile Travelers' (RAFT): a clinic-based quality improvement initiative.

PubMed

Jazuli, Farah; Lynd, Terence; Mah, Jordan; Klowak, Michael; Jechel, Dale; Klowak, Stefanie; Ovens, Howard; Sabbah, Sam; Boggild, Andrea K

2016-07-29

Fever in the returned traveller is a potential medical emergency warranting prompt attention to exclude life-threatening illnesses. However, prolonged evaluation in the emergency department (ED) may not be required for all patients. As a quality improvement initiative, we implemented an algorithm for rapid assessment of febrile travelers (RAFT) in an ambulatory setting. Criteria for RAFT referral include: presentation to the ED, reported fever and travel to the tropics or subtropics within the past year. Exclusion criteria include Plasmodium falciparum malaria, and fulfilment of admission criteria such as unstable vital signs or significant laboratory derangements. We performed a time series analysis preimplementation and postimplementation, with primary outcome of wait time to tropical medicine consultation. Secondary outcomes included number of ED visits averted for repeat malaria testing, and algorithm adherence. From February 2014 to December 2015, 154 patients were seen in the RAFT clinic: 68 men and 86 women. Median age was 36 years (range 16-78 years). Mean time to RAFT clinic assessment was 1.2±0.07 days (range 0-4 days) postimplementation, compared to 5.4±1.8 days (range 0-26 days) prior to implementation (p<0.0001). The RAFT clinic averted 132 repeat malaria screens in the ED over the study period (average 6 per month). Common diagnoses were: traveller's diarrhoea (n=27, 17.5%), dengue (n=12, 8%), viral upper respiratory tract infection (n=11, 7%), chikungunya (n=10, 6.5%), laboratory-confirmed influenza (n=8, 5%) and lobar pneumonia (n=8, 5%). In addition to provision of more timely care to ambulatory febrile returned travellers, we reduced ED bed-usage by providing an alternate setting for follow-up malaria screening, and treatment of infectious diseases manageable in an outpatient setting, but requiring specific therapy. 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/

A retrospective descriptive study of the characteristics of deliberate self-poisoning patients with single or repeat presentations to an Australian emergency medicine network in a one year period

PubMed Central

2014-01-01

Background A proportion of deliberate self-poisoning (DSP) patients present repeatedly to the emergency department (ED). Understanding the characteristics of frequent DSP patients and their presentation is a first step to implementing interventions that are designed to prevent repeated self-poisoning. Methods All DSP presentations to three networked Australian ED’s were retrospectively identified from the ED electronic medical record and hospital scanned medical records for 2011. Demographics, types of drugs ingested, emergency department length of stay and disposition for the repeat DSP presenters were extracted and compared to those who presented once with DSP in a one year period. Logistic regression was used to analyse repeat versus single DSP data. Results The study determined 755 single presenters and 93 repeat DSP presenters. The repeat presenters contributed to 321 DSP presentations. They were more likely to be unemployed (61.0% versus 39.9%, p = 0.008) and have a psychiatric illness compared to single presenters (36.6% versus 15.5%, p < 0.001). Repeat presenters were less likely to receive a toxicology consultation (11.5% versus 27.3%, p < 0.001) and were more likely to abscond from the ED (7.5% versus 3.4%, p = 0.004). Repeat presenters were more likely to ingest paracetamol and antipsychotics than single presenters. The defined daily dose for the most common antipsychotic ingested, quetiapine, was less in the repeat presenter group (median 1.9 [IQR: 1.3-3.5]) compared with the single presenter group (4 [1.4-9.5]), (OR 0.85, 95% CI 0.74-0.99). Conclusion Patients who present repeatedly to the ED with DSP have pre-existing disadvantages, with increased likelihood of being unemployed and having a mental illness. These patients are also more likely to have health service inequities given the greater likelihood to abscond from the ED and lower likelihood of receiving toxicology consultation for their DSP. Early recognition of repeat DSP patients in the ED may facilitate the development of individualised care plans with the aim to reduce repeat episodes of self-poisoning and subsequent risk of successful suicide. PMID:25148692

Performance Measures of Diagnostic Codes for Detecting Opioid Overdose in the Emergency Department.

PubMed

Rowe, Christopher; Vittinghoff, Eric; Santos, Glenn-Milo; Behar, Emily; Turner, Caitlin; Coffin, Phillip O

2017-04-01

Opioid overdose mortality has tripled in the United States since 2000 and opioids are responsible for more than half of all drug overdose deaths, which reached an all-time high in 2014. Opioid overdoses resulting in death, however, represent only a small fraction of all opioid overdose events and efforts to improve surveillance of this public health problem should include tracking nonfatal overdose events. International Classification of Disease (ICD) diagnosis codes, increasingly used for the surveillance of nonfatal drug overdose events, have not been rigorously assessed for validity in capturing overdose events. The present study aimed to validate the use of ICD, 9th revision, Clinical Modification (ICD-9-CM) codes in identifying opioid overdose events in the emergency department (ED) by examining multiple performance measures, including sensitivity and specificity. Data on ED visits from January 1, 2012, to December 31, 2014, including clinical determination of whether the visit constituted an opioid overdose event, were abstracted from electronic medical records for patients prescribed long-term opioids for pain from any of six safety net primary care clinics in San Francisco, California. Combinations of ICD-9-CM codes were validated in the detection of overdose events as determined by medical chart review. Both sensitivity and specificity of different combinations of ICD-9-CM codes were calculated. Unadjusted logistic regression models with robust standard errors and accounting for clustering by patient were used to explore whether overdose ED visits with certain characteristics were more or less likely to be assigned an opioid poisoning ICD-9-CM code by the documenting physician. Forty-four (1.4%) of 3,203 ED visits among 804 patients were determined to be opioid overdose events. Opioid-poisoning ICD-9-CM codes (E850.2-E850.2, 965.00-965.09) identified overdose ED visits with a sensitivity of 25.0% (95% confidence interval [CI] = 13.6% to 37.8%) and specificity of 99.9% (95% CI = 99.8% to 100.0%). Expanding the ICD-9-CM codes to include both nonspecified and general (i.e., without a decimal modifier) drug poisoning and drug abuse codes identified overdose ED visits with a sensitivity of 56.8% (95% CI = 43.6%-72.7%) and specificity of 96.2% (95% CI = 94.8%-97.2%). Additional ICD-9-CM codes not explicitly relevant to opioid overdose were necessary to further enhance sensitivity. Among the 44 overdose ED visits, neither naloxone administration during the visit, whether the patient responded to the naloxone, nor the specific opioids involved were associated with the assignment of an opioid poisoning ICD-9-CM code (p ≥ 0.05). Tracking opioid overdose ED visits by diagnostic coding is fairly specific but insensitive, and coding was not influenced by administration of naloxone or the specific opioids involved. The reason for the high rate of missed cases is uncertain, although these results suggest that a more clearly defined case definition for overdose may be necessary to ensure effective opioid overdose surveillance. Changes in coding practices under ICD-10 might help to address these deficiencies. © 2016 by the Society for Academic Emergency Medicine.

Forecasting daily emergency department visits using calendar variables and ambient temperature readings.

PubMed

Marcilio, Izabel; Hajat, Shakoor; Gouveia, Nelson

2013-08-01

This study aimed to develop different models to forecast the daily number of patients seeking emergency department (ED) care in a general hospital according to calendar variables and ambient temperature readings and to compare the models in terms of forecasting accuracy. The authors developed and tested six different models of ED patient visits using total daily counts of patient visits to an ED in Sao Paulo, Brazil, from January 1, 2008, to December 31, 2010. The first 33 months of the data set were used to develop the ED patient visits forecasting models (the training set), leaving the last 3 months to measure each model's forecasting accuracy by the mean absolute percentage error (MAPE). Forecasting models were developed using three different time-series analysis methods: generalized linear models (GLM), generalized estimating equations (GEE), and seasonal autoregressive integrated moving average (SARIMA). For each method, models were explored with and without the effect of mean daily temperature as a predictive variable. The daily mean number of ED visits was 389, ranging from 166 to 613. Data showed a weekly seasonal distribution, with highest patient volumes on Mondays and lowest patient volumes on weekends. There was little variation in daily visits by month. GLM and GEE models showed better forecasting accuracy than SARIMA models. For instance, the MAPEs from GLM models and GEE models at the first month of forecasting (October 2012) were 11.5 and 10.8% (models with and without control for the temperature effect, respectively), while the MAPEs from SARIMA models were 12.8 and 11.7%. For all models, controlling for the effect of temperature resulted in worse or similar forecasting ability than models with calendar variables alone, and forecasting accuracy was better for the short-term horizon (7 days in advance) than for the longer term (30 days in advance). This study indicates that time-series models can be developed to provide forecasts of daily ED patient visits, and forecasting ability was dependent on the type of model employed and the length of the time horizon being predicted. In this setting, GLM and GEE models showed better accuracy than SARIMA models. Including information about ambient temperature in the models did not improve forecasting accuracy. Forecasting models based on calendar variables alone did in general detect patterns of daily variability in ED volume and thus could be used for developing an automated system for better planning of personnel resources. © 2013 by the Society for Academic Emergency Medicine.

Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort

PubMed Central

Mondor, Luke; Maxwell, Colleen J.; Hogan, David B.; Gruneir, Andrea

2017-01-01

Background For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships. Methods and findings A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine–Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC. Multimorbidity was highly prevalent, with 35% (n = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72–2.05, p < 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51–1.77, p < 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07–1.16, p < 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03–1.11, p = 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, p = 0.566 for hospitalization and p = 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions. Conclusions Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients’ risk of health outcomes. PMID:28267802

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.

Prescription of opioid and nonopioid analgesics for dental care in emergency departments: Findings from the National Hospital Ambulatory Medical Care Survey.

PubMed

Okunseri, Christopher; Okunseri, Elaye; Xiang, Qun; Thorpe, Joshua M; Szabo, Aniko

2014-01-01

The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates. We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997-2000 and 2003-2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, nonopioid analgesics, or a combination of both, compared with receiving no analgesics for NTDC-related visits. During 1997-2000 and 2003-2007, prescription of opioid analgesics and combinations of opioid and nonopioid analgesics increased, and that of no analgesics decreased over time. The prescription rates for opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics for NTDC-related visits in EDs were 43 percent, 20 percent, 12 percent, and 25 percent, respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and nonopioid analgesic combinations. Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and nonopioid analgesic combinations for NTDC-related visits with reported severe pain. © 2014 American Association of Public Health Dentistry.

Patient-Reported Geriatric Symptoms as Risk Factors for Hospitalization and Emergency Department Visits

PubMed Central

Chandra, Anupam; Crane, Sarah J; Tung, Ericka E; Hanson, Gregory J; North, Frederick; Cha, Stephen S; Takahashi, Paul Y

2015-01-01

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year. PMID:26029477

Professional Fee Ratios for US Hospital Discharge Data.

PubMed

Peterson, Cora; Xu, Likang; Florence, Curtis; Grosse, Scott D; Annest, Joseph L

2015-10-01

US hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians' charges). We aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data. The subjects consisted of a retrospective cohort of Truven Health MarketScan 2004-2012 inpatient admissions (n=23,594,605) and treat-and-release emergency department (ED) visits (n=70,771,576). PFR per visit was assessed as total payments divided by facility-only payments. Using ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis. Adjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n=2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n=816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n=8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n=2,994,696). Supplemental tables report 2004-2012 annual PFR estimates by clinical classifications. Adjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs.

Prescription of Opioid and Non-opioid Analgesics for Dental Care in Emergency Departments: Findings from the National Hospital Ambulatory Medical Care Survey

PubMed Central

Okunseri, Christopher; Okunseri, Elaye; Xiang, Qun; Thorpe, Joshua M.; Szabo, Aniko

2014-01-01

Objective The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, non-opioid analgesics, opioid and non-opioid analgesic combinations and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates. Methods We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997–2000 and 2003–2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, non-opioid analgesics, or a combination of both compared to receiving no analgesics for NTDC-related visits. Results During 1997–2000 and 2003–2007, prescription of opioid analgesics and combinations of opioid and non-opioid analgesics increased and that of no analgesics decreased over time. The prescription rates for opioid analgesics, non-opioid analgesics, opioid and non-opioid analgesic combinations and no analgesics for NTDC-related visits in EDs were 43%, 20%, 12% and 25% respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and non-opioid analgesic combinations. Conclusion Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and non-opioid analgesic combinations for NTDC-related visits with reported severe pain. PMID:24863407

Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina.

PubMed

Crane, Steven; Sailer, Douglas; Patch, Steven C

2011-01-01

In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. The Emergency Department Asthma Program was a quality-improvement initiative designed to better understand the population of patients who use the ED for asthma care in rural western North Carolina and to demonstrate whether EDs at small hospitals could, by implementing National Asthma Education and Prevention Program treatment guidelines, improve asthma care and reduce subsequent asthma-related ED visits. Eight hospitals in western North Carolina participated in the project, which lasted from November 2003 through December 2007. The intervention consisted of a series of individual and structured continuing medical education events directed at ED physicians and staff. Additionally, patients presenting to EDs for asthma-related problems were selected to receive a short patient questionnaire, to determine their basic understanding of asthma and barriers to asthma care; to undergo asthma staging by the treating physician; to receive focused bedside asthma education by a respiratory therapist; and, finally, at the treating physician's discretion, to receive a free packet of asthma medications, including rescue therapy with a beta-agonist and corticosteroid therapy delivered via a metered-dose inhaler, before discharge. During the 37-month project, a total of 1,739 patients presented to the participating EDs for 2,481 asthma-related episodes of care; at 11% of these visits, patients received the intervention, with nearly 100 ED physicians referring patients to the program. Most of the patients using the ED for asthma treatment were judged to have the mildest stages, and nearly half were uninsured or were covered by Medicaid. For only 20% of the visits was a primary care physician or practice identified. The patient intervention did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. Selection bias is likely, as patients enrolled in the study were more likely than patients in the target sample to be adults and insured. Because we did not measure ED staff attendance at educational sessions or their knowledge of and attitudes about asthma care before and after the educational program, we cannot draw conclusions about the effectiveness of the program to change their knowledge, attitudes, or behavior. Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach.

Assessing health impacts of the December 2013 Ice storm in Ontario, Canada.

PubMed

Rajaram, Nikhil; Hohenadel, Karin; Gattoni, Laera; Khan, Yasmin; Birk-Urovitz, Elizabeth; Li, Lennon; Schwartz, Brian

2016-07-11

Ice, or freezing rain storms have the potential to affect human health and disrupt normal functioning of a community. The purpose of this study was to assess acute health impacts of an ice storm that occurred in December 2013 in Toronto, Ontario, Canada. Data on emergency department visits were obtained from the National Ambulatory Care Reporting System. Rates of visits in Toronto during the storm period (December 21, 2013 - January 1, 2014) were compared to rates occurring on the same dates in the previous five years (historical comparison) and compared to those in a major unaffected city, Ottawa, Ontario (geographic comparison). Overall visits and rates for three categories of interest (cardiac conditions, environmental causes and injuries) were assessed. Rate ratios were calculated using Poisson regression with population counts as an offset. Absolute counts of carbon monoxide poisoning were compared descriptively in a sub-analysis. During the 2013 storm period, there were 34 549 visits to EDs in Toronto (12.46 per 1000 population) compared with 10 794 visits in Ottawa (11.55 per 1000 population). When considering year and geography separately, rates of several types of ED visits were higher in the storm year than in previous years in both Toronto and Ottawa. Considering year and geography together, rates in the storm year were higher for overall ED visits (RR: 1.10, 95 % CI: 1.09-1.11) and for visits due to environmental causes (RR: 2.52, 95 % CI: 2.21-2.87) compared to previous years regardless of city. For injuries, visit rates were higher in the storm year in both Toronto and Ottawa, but the increase in Toronto was significantly greater than the increase in Ottawa, indicating a significant interaction between geography and year (RR: 1.23, 95 % CI: 1.16-1.30). This suggests that the main health impact of the 2013 Ice Storm was an increase in ED visits for injuries, while other increases could have been due to severe weather across Ontario at that time. This study is one of the first to use a population-level database and regression modeling of emergency visit codes to identify acute impacts resulting from ice storms.

Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017

PubMed Central

Seth, Puja; Gladden, R. Matthew; Mattson, Christine L.; Baldwin, Grant T.; Kite-Powell, Aaron; Coletta, Michael A.

2018-01-01

Introduction From 2015 to 2016, opioid overdose deaths increased 27.7%, indicating a worsening of the opioid overdose epidemic and highlighting the importance of rapid data collection, analysis, and dissemination. Methods Emergency department (ED) syndromic and hospital billing data on opioid-involved overdoses during July 2016–September 2017 were examined. Temporal trends in opioid overdoses from 52 jurisdictions in 45 states were analyzed at the regional level and by demographic characteristics. To assess trends based on urban development, data from 16 states were analyzed by state and urbanization level. Results From July 2016 through September 2017, a total of 142,557 ED visits (15.7 per 10,000 visits) from 52 jurisdictions in 45 states were suspected opioid-involved overdoses. This rate increased on average by 5.6% per quarter. Rates increased across demographic groups and all five U.S. regions, with largest increases in the Southwest, Midwest, and West (approximately 7%–11% per quarter). In 16 states, 119,198 ED visits (26.7 per 10,000 visits) were suspected opioid-involved overdoses. Ten states (Delaware, Illinois, Indiana, Maine, Missouri, Nevada, North Carolina, Ohio, Pennsylvania, and Wisconsin) experienced significant quarterly rate increases from third quarter 2016 to third quarter 2017, and in one state (Kentucky), rates decreased significantly. The highest rate increases occurred in large central metropolitan areas. Conclusions and Implications for Public Health Practice With continued increases in opioid overdoses, availability of timely data are important to inform actions taken by EDs and public health practitioners. Increases in opioid overdoses varied by region and urbanization level, indicating a need for localized responses. Educating ED physicians and staff members about appropriate services for immediate care and treatment and implementing a post-overdose protocol that includes naloxone provision and linking persons into treatment could assist EDs with preventing overdose. PMID:29518069

Multicenter pathophysiologic investigation of erectile dysfunction in clinic outpatients in China.

PubMed

Li, Dongjie; Jiang, Xianzhen; Zhang, Xiaobo; Yi, Lu; Zhu, Xiangsheng; Zeng, Xiangyang; Guo, Xiaoliang; Tang, Yuxin

2012-03-01

To assess the pathophysiologic composition and age structure of erectile dysfunction (ED) in men visiting outpatient clinics in China. We studied 3327 consecutive ED outpatients (median age 39 years) from 2006 to 2010 in the 5 training hospitals in China. Every patient was independently evaluated by an experienced urologist/andrologist using comprehensive diagnostic procedures. The simplified International Index of Erectile Function was used to assess the severity of ED. Most patients (95.0%) were <60 years old, and none were >70 years old. The psychogenic patients were younger and had greater percentage than any other patients. Vasculogenic factors were a major etiology of organic ED. A significant difference was found in the age distribution between the patients with psychogenic ED and those with organic ED (P = .000). Diabetes, hypertension, coronary artery disease, and hyperlipidemia played significant roles in affecting the severity of ED in a statistical model, including age. The International Index of Erectile Function scores decreased with age (rs = -0.199, P = .000). Moreover, the percentage of severe and moderate cases increased with age (P = .003 and P = .002, respectively). However, the constituent ratio of patients sharply declined from 30.3% to 4.5% with age. The number of men visiting outpatient clinics with psychological ED is greater than the number with organic causes in China. The age of the Chinese patients with ED who seek medical help is young and this is mainly because of inadequate sex education to young men and because most older patients are reluctant to visit the hospital just for the loss of erectile function. Copyright © 2012 Elsevier Inc. All rights reserved.

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

PubMed

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

2017-10-01

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. 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. 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. 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.

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

Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making.

PubMed

Collins, Sean P; Storrow, Alan B

2013-08-01

Nearly 700,000 emergency department (ED) visits were due to acute heart failure (AHF) in 2009. Most visits result in a hospital admission and account for the largest proportion of a projected $70 billion to be spent on heart failure care by 2030. ED-based risk prediction tools in AHF rarely impact disposition decision making. This is a major factor contributing to the 80% admission rate for ED patients with AHF, which has remained unchanged over the last several years. Self-care behaviors such as symptom monitoring, medication taking, dietary adherence, and exercise have been associated with decreased hospital readmissions, yet self-care remains largely unaddressed in ED patients with AHF and thus represents a significant lost opportunity to improve patient care and decrease ED visits and hospitalizations. Furthermore, shared decision making encourages collaborative interaction between patients, caregivers, and providers to drive a care path based on mutual agreement. The observation that “difficult decisions now will simplify difficult decisions later” has particular relevance to the ED, given this is the venue for many such issues. We hypothesize patients as complex and heterogeneous as ED patients with AHF may need both an objective evaluation of physiologic risk as well as an evaluation of barriers to ideal self-care, along with strategies to overcome these barriers. Combining physician gestalt, physiologic risk prediction instruments, an evaluation of self-care, and an information exchange between patient and provider using shared decision making may provide the critical inertia necessary to discharge patients home after a brief ED evaluation.

Utilization of head CT during injury visits to United States emergency departments: 2012-2015.

PubMed

Yun, Brian J; Borczuk, Pierre; Zachrison, Kori S; Goldstein, Joshua N; Berlyand, Yosef; Raja, Ali S

2018-05-18

Studies have shown increasing utilization of head computed tomography (CT) imaging of emergency department (ED) patients presenting with an injury-related visit. Multiple initiatives, including the Choosing Wisely™ campaign and evidence-based clinical decision support based on validated decision rules, have targeted head CT use in patients with injuries. Therefore, we investigated national trends in the use of head CT during injury-related ED visits from 2012 to 2015. This was a secondary analysis of data from the annual United States (U.S.) National Hospital Ambulatory Medical Care Survey from 2012 to 2015. The study population was defined as injury-related ED visits, and we sought to determine the percentage in which a head CT was ordered and, secondarily, to determine both the diagnostic yield of clinically significant intracranial findings and hospital characteristics associated with increased head CT utilization. Between 2012 and 2015, 12.25% (95% confidence interval [CI] 11.48-13.02%) of injury-related visits received at least one head CT. Overall head CT utilization showed an increased trend during the study period (2012: 11.7%, 2015: 13.23%, p = 0.09), but the results were not statistically significant. The diagnostic yield of head CT for a significant intracranial injury over the period of four years was 7.4% (9.68% in 2012 vs. 7.67% in 2015, p = 0.23). Head CT use along with diagnostic yield has remained stable from 2012 to 2015 among patients presenting to the ED for an injury-related visit. Copyright © 2017 Elsevier Inc. All rights reserved.

Mobile health care operations and return on investment in predominantly underserved children with asthma: the breathmobile program.

PubMed

Morphew, Tricia; Scott, Lyne; Li, Marilyn; Galant, Stanley P; Wong, Webster; Garcia Lloret, Maria I; Jones, Felita; Bollinger, Mary Elizabeth; Jones, Craig A

2013-08-01

Underserved populations have limited access to care. Improved access to effective asthma care potentially improves quality of life and reduces costs associated with emergency department (ED) visits. The purpose of this study is to examine return on investment (ROI) for the Breathmobile Program in terms of improved patient quality-adjusted life years saved and reduced costs attributed to preventable ED visits for 2010, with extrapolation to previous years of operation. It also examines cost-benefit related to reduced morbidity (ED visits, hospitalizations, and school absenteeism) for new patients to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits). This is a retrospective analysis of data for 15,986 pediatric patients, covering 88,865 visits, participating in 4 Southern California Breathmobile Programs (November 16, 1995-December 31, 2010). The ROI calculation expressed the cost-benefit ratio as the net benefits (ED costs avoided+relative value of quality-adjusted life years saved) over the per annum program costs (∼$500,000 per mobile). The ROI across the 4 California programs in 2010 was $6.73 per dollar invested. Annual estimated emergency costs avoided in the 4 regions were $2,541,639. The relative value of quality-adjusted life years saved was $24,381,000. For patients new to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits), total annual morbidity costs avoided per patient were $1395. This study suggests that mobile health care is a cost-effective strategy to deliver medical care to underserved populations, consistent with the Triple Aims of Therapy.

Vital Signs: Health Burden and Medical Costs of Nonfatal Injuries to Motor Vehicle Occupants — United States, 2012

PubMed Central

Bergen, Gwen; Peterson, Cora; Ederer, David; Florence, Curtis; Haileyesus, Tadesse; Kresnow, Marcie-jo; Xu, Likang

2014-01-01

Background Motor vehicle crashes are a leading cause of death and injury in the United States. The purpose of this study was to describe the current health burden and medical and work loss costs of nonfatal crash injuries among vehicle occupants in the United States. Methods CDC analyzed data on emergency department (ED) visits resulting from nonfatal crash injuries among vehicle occupants in 2012 using the National Electronic Injury Surveillance System – All Injury Program (NEISS-AIP) and the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). The number and rate of all ED visits for the treatment of crash injuries that resulted in the patient being released and the number and rate of hospitalizations for the treatment of crash injuries were estimated, as were the associated number of hospital days and lifetime medical and work loss costs. Results In 2012, an estimated 2,519,471 ED visits resulted from nonfatal crash injuries, with an estimated lifetime medical cost of $18.4 billion (2012 U.S. dollars). Approximately 7.5% of these visits resulted in hospitalizations that required an estimated 1,057,465 hospital days in 2012. Conclusions Nonfatal crash injuries occur frequently and result in substantial costs to individuals, employers, and society. For each motor vehicle crash death in 2012, eight persons were hospitalized, and 100 were treated and released from the ED. Implications for Public Health Public health practices and laws, such as primary seat belt laws, child passenger restraint laws, ignition interlocks to prevent alcohol impaired driving, sobriety checkpoints, and graduated driver licensing systems have demonstrated effectiveness for reducing motor vehicle crashes and injuries. They might also substantially reduce associated ED visits, hospitalizations, and medical costs. PMID:25299606

The complex association of race and leaving the pediatric emergency department without being seen by a physician.

PubMed

Harrison, Blair; Finkelstein, Marsha; Puumala, Susan; Payne, Nathaniel R

2012-11-01

This study examined the influence of race and language on leaving the emergency department (ED) without complete evaluation and treatment (LWCET). This retrospective, case-cohort study examined LWCET among patients discharged home from 2 EDs between March 2, 2009, and March 31, 2010. Race and language were obtained by family self-report. We also explored wait time to see a physician as an explanation of racial disparities. One thousand two hundred eighty-five (1.7%) of 76,931 ED encounters ended in LWCET. Factors increasing LWCET were high ED activity, low acuity, and medical assistance (MA) insurance. American Indian, biracial, African American, and Hispanic races were also associated with higher odds of LWCET among visits by MA insurance patients compared with those of white patients on private insurance. Restricting the analysis to visits by MA insurance patients, only American Indian race was associated with LWCET compared with white race. Visits by patients using an interpreter or speaking a language other than English at home had lower odds of ending in LWCET. Sensitivity analyses in subgroups confirmed these findings. We developed a measure of ED activity that correlated well with wait time to see a physician (correlation coefficient = 0.993; P < 0.001). Among non-LWCET visits, wait time to see a practitioner did not correlate with racial disparities in LWCET. Race, language, and insurance status interact to form a complex relationship with LWCET. Medical assistance insurance status appears to account for much of the excessive instances of LWCET seen in nonwhites. After restricting the analysis to MA insurance patients, only visits by American Indian patients had higher odds of LWCET compared with whites on MA insurance. Wait time to see a physician did not explain racial differences in LWCET.

Outcomes of Nonoperative Management of Uncomplicated Appendicitis.

PubMed

Bachur, Richard G; Lipsett, Susan C; Monuteaux, Michael C

2017-07-01

Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization. Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up. 99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy. A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy. Copyright © 2017 by the American Academy of Pediatrics.

The Effect of the Affordable Care Act's Young Adult Insurance Expansions on Hospital-Based Behavioral Health Care

PubMed Central

Golberstein, Ezra; Busch, Susan H.; Zaha, Rebecca; Greenfield, Shelly F.; Beardslee, William R.; Meara, Ellen

2014-01-01

Objective Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children on parental policies until age 26 as dependents. This study estimated changes in young adults’ use of hospital-based services with diagnosis codes for mental illness and substance abuse associated with the dependent coverage provision. Method Quasi-experimental comparison of national sample of non-birth hospital inpatient admissions to general hospitals (n=2,670,463 total, n=430,583 with primary behavioral health diagnosis) and California emergency department (ED) visits with behavioral health diagnoses (n=11,139,689). Data spanned 2005 to 2011. Estimates compared young adults who were and were not targeted by the ACA dependent coverage provision (19 to 25 versus 26 to 29 year olds), estimating changes in utilization before and after 2010. Primary outcomes included: quarterly inpatient admissions for primary diagnosis of any behavioral health disorder per 1000 population; ED visits with any behavioral health diagnosis per 1000 population; and payer source. Results Dependent coverage expansion was associated with 0.14 per 1000 more (p<0.001) inpatient admissions for behavioral health for 19-25 (ACA covered) versus 26-29 (then ACA uncovered) year olds. The coverage expansion was associated with 0.45 fewer behavioral health ED visits per 1000 (p=0.001) in California. The probability that inpatient admissions nationally, and ED visits in California were uninsured, decreased significantly (p<0.001). Conclusions ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adult children nationally. Lower ED visit rates were observed in California. PMID:25263817

Evaluating Quality Metrics and Cost After Discharge: A Population-based Cohort Study of Value in Health Care Following Elective Major Vascular Surgery.

PubMed

de Mestral, Charles; Salata, Konrad; Hussain, Mohamad A; Kayssi, Ahmed; Al-Omran, Mohammed; Roche-Nagle, Graham

2018-04-18

Early readmission to hospital after surgery is an omnipresent quality metric across surgical fields. We sought to understand the relative importance of hospital readmission among all health services received after hospital discharge. The aim of this study was to characterize 30-day postdischarge cost and risk of an emergency department (ED) visit, readmission, or death after hospitalization for elective major vascular surgery. This is a population-based retrospective cohort study of patients who underwent elective major vascular surgery - carotid endarterectomy, EVAR, open AAA repair, bypass for lower extremity peripheral arterial disease - in Ontario, Canada, between 2004 and 2015. The outcomes of interest included quality metrics - ED visit, readmission, death - and cost to the Ministry of Health, within 30 days of discharge. Costs after discharge included those attributable to hospital readmission, ED visits, rehab, physician billing, outpatient nursing and allied health care, medications, interventions, and tests. Multivariable regression models characterized the association of pre-discharge characteristics with the above-mentioned postdischarge quality metrics and cost. A total of 30,752 patients were identified. Within 30 days of discharge, 2588 (8.4%) patients were readmitted to hospital and 13 patients died (0.04%). Another 4145 (13.5%) patients visited an ED without requiring admission. Across all patients, over half of 30-day postdischarge costs were attributable to outpatient care. Patients at an increased risk of an ED visit, readmission, or death within 30 days of discharge differed from those patients with relatively higher 30-day costs. Events occurring outside the hospital setting should be integral to the evaluation of quality of care and cost after hospitalization for major vascular surgery.

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

Using Chief Complaint in Addition to Diagnosis Codes to Identify Falls in the Emergency Department.

PubMed

Patterson, Brian W; Smith, Maureen A; Repplinger, Michael D; Pulia, Michael S; Svenson, James E; Kim, Michael K; Shah, Manish N

2017-09-01

To compare incidence of falls in an emergency department (ED) cohort using a traditional International Classification of Diseases, Ninth Revision (ICD-9) code-based scheme and an expanded definition that included chief complaint information and to examine the clinical characteristics of visits "missed" in the ICD-9-based scheme. Retrospective electronic record review. Academic medical center ED. Individuals aged 65 and older seen in the ED between January 1, 2013, and September 30, 2015. Two fall definitions were applied (individually and together) to the cohort: an ICD-9-based definition and a chief complaint definition. Admission rates and 30-day mortality (per encounter) were measured for each definition. Twenty-three thousand eight hundred eighty older adult visits occurred during the study period. Using the most-inclusive definition (ICD-9 code or chief complaint indicating a fall), 4,363 visits (18%) were fall related. Of these visits, 3,506 (80%) met the ICD-9 definition for a fall-related visit, and 2,664 (61%) met the chief complaint definition. Of visits meeting the chief complaint definition, 857 (19.6%) were missed when applying the ICD-9 definition alone. Encounters missed using the ICD-9 definition were less likely to lead to an admission (42.9%, 95% confidence interval (CI) = 39.7-46.3%) than those identified (54.4%, 95% CI = 52.7-56.0%). Identifying individuals in the ED who have fallen based on diagnosis codes underestimates the true burden of falls. Individuals missed according to the code-based definition were less likely to have been admitted than those who were captured. These findings call attention to the value of using chief complaint information to identify individuals who have fallen in the ED-for research, clinical care, or policy reasons. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Hospital based emergency department visits attributed to child physical abuse in United States: predictors of in-hospital mortality.

PubMed

Allareddy, Veerajalandhar; Asad, Rahimullah; Lee, Min Kyeong; Nalliah, Romesh P; Rampa, Sankeerth; Speicher, David G; Rotta, Alexandre T; Allareddy, Veerasathpurush

2014-01-01

To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome. We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008-2010. All ED visits and subsequent hospitalizations with a diagnosis of "Child physical abuse" (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors. Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child's parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81-0.96, p < 0.0001). Females (OR = 2.39, 1.07-5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57-154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24-11.07, p<0.0001) had higher odds of mortality compared to their male counterparts. In this large cohort of physically abused children, younger age, females and intracranial or crushing/internal injuries were independent predictors of mortality. Identification of high risk cohorts in the ED may enable strengthening of existing screening programs and optimization of outcomes.

The costs of respiratory illnesses arising from Florida gulf coast Karenia brevis blooms.

PubMed

Hoagland, Porter; Jin, Di; Polansky, Lara Y; Kirkpatrick, Barbara; Kirkpatrick, Gary; Fleming, Lora E; Reich, Andrew; Watkins, Sharon M; Ullmann, Steven G; Backer, Lorraine C

2009-08-01

Algal blooms of Karenia brevis, a harmful marine algae, occur almost annually off the west coast of Florida. At high concentrations, K. brevis blooms can cause harm through the release of potent toxins, known as brevetoxins, to the atmosphere. Epidemiologic studies suggest that aerosolized brevetoxins are linked to respiratory illnesses in humans. We hypothesized a relationship between K. brevis blooms and respiratory illness visits to hospital emergency departments (EDs) while controlling for environmental factors, disease, and tourism. We sought to use this relationship to estimate the costs of illness associated with aerosolized brevetoxins. We developed a statistical exposure-response model to express hypotheses about the relationship between respiratory illnesses and bloom events. We estimated the model with data on ED visits, K. brevis cell densities, and measures of pollen, pollutants, respiratory disease, and intra-annual population changes. We found that lagged K. brevis cell counts, low air temperatures, influenza outbreaks, high pollen counts, and tourist visits helped explain the number of respiratory-specific ED diagnoses. The capitalized estimated marginal costs of illness for ED respiratory illnesses associated with K. brevis blooms in Sarasota County, Florida, alone ranged from $0.5 to $4 million, depending on bloom severity. Blooms of K. brevis lead to significant economic impacts. The costs of illness of ED visits are a conservative estimate of the total economic impacts. It will become increasingly necessary to understand the scale of the economic losses associated with K. brevis blooms to make rational choices about appropriate mitigation.

Impact of a clinical pharmacy program on changes in hemoglobin A1c, diabetes-related hospitalizations, and diabetes-related emergency department visits for patients with diabetes in an underserved population.

PubMed

Chung, Nancy; Rascati, Karen; Lopez, Debra; Jokerst, Jason; Garza, Aida

2014-09-01

Diabetes mellitus is associated with substantial morbidity and mortality. With the rise in prevalence of diabetes, there has been an increased need for clinical pharmacy services focused on diabetes management in ambulatory clinics. However, more data IS needed to determine the overall impact that clinical pharmacists have on preventing diabetes-related inpatient admissions and emergency department (ED) visits for patients with diabetes, especially in an underserved population. To assess the impact of clinical pharmacy services on the change in hemoglobin A1c measurements, the number of diabetes-related hospitalizations, and the number of diabetes-related ED visits for patients with uncontrolled diabetes. This was a retrospective study that evaluated outcomes for patients referred to a clinical pharmacist for management of diabetes, compared with patients who were not seen by a clinical pharmacist. Adult patients aged between 18 and 89 years with a diagnosis of type 1 or type 2 diabetes mellitus were identified, using the electronic medical records from CommUnityCare outpatient clinics in central Texas during the period July 1, 2007, through July 1, 2011. Patients enrolled had poor glycemic control, defined as an A1c ≥9% at baseline (index), with at least 3 visits with a clinical pharmacist or 3 visits to usual care. Patients with at least 1 year of pre-index data, 1 year of post-index follow-up, and a post-index A1c measure were included in the study. Propensity score (PS) matching was used to create a 1:1 cohort. T-tests were used to calculate results for the main outcome variables (change in A1c, change in number of diabetes-related hospitalizations, and change in number of diabetes-related ED visits). In addition, general linear models (GLM) were used to control for baseline demographic and clinical characteristics. A total of 782 patients met inclusion criteria, 557 in the usual care (control) group and 225 in the clinical pharmacy (intervention) group. PS matching provided a 1:1 matched sample of 220 patients per cohort. When assessing the change in the number of diabetes-related hospitalizations from the pre-index year to the post-index year, patients in the control group had an increase of 8 hospitalizations (8 visits per 220 patients, mean = 0.036, SD = 0.284), while the intervention group had a decrease of 1 hospitalization (-1 visit per 220 patients, mean = -0.005, SD=0.278). Both the t-test (P = 0.06) and GLM model (P = 0.06) indicated that the difference was statistically significant. When assessing the change in the number of diabetes-related ED visits from the pre-index year to the post-index year, we found patients in the control group had an increase of 16 ED visits (16 visits per 220 patients, mean = 0.073, SD = 0.584), while the intervention group had an increase of 4 ED visits (4 visits per 220 patients, mean = -0.018, SD=0.641). Both the t-test (P = 0.18) and GLM model (P = 0.28) indicated that the difference was not statistically significant. A1c levels were reduced in the post-index period for both groups. For the control group, A1c reduction was 1.50 (from 11.17 to 9.67, SD = 2.49). For the intervention group, A1c reduction was 1.90 (from 11.09 to 9.19, SD = 2.44). Both the t-test (P = 0.04) and GLM model (P = 0.05) indicated that the A1c difference was statistically significant. Underserved patients with baseline uncontrolled diabetes who were managed by a clinical pharmacist in the outpatient setting had a higher decrease in A1c compared with usual care. The changes in diabetes-related hospitalizations and diabetes-related ED visits were in the hypothesized direction, but the comparison for ED visits was not statistically significant.

[Frequent attenders in Primary Health Care Centres and frequent attenders in Emergency Departments].

PubMed

Fernández Alonso, Cesáreo; Aguilar Mulet, Juan Mariano; Romero Pareja, Rodolfo; Rivas García, Arístides; Fuentes Ferrer, Manuel Enrique; González Armengol, Juan Jorge

2018-04-01

To identify predictors of frequent attenders (HF) in Primary Health Care (PHC) centres in a sample of frequent attenders (HF) in Emergency Departments (ED). This was an observational, retrospective, multicentre cohort study. The HF patients were selected from patients seen in the ED between January 1 and December 31, 2013. Setting Patients were recruited from 17 public hospitals of the Community of Madrid, Spain. Variables on the index visit to the ED were collected. The sample was analysed in terms of being or not being an HF user in PHC. An HF user is considered a patient who made at least 10 visits in each level of care for a year. A total of 1284 HF patients were included. An analysis was performed on 423 (32.9%) HF users in ED with 16 (12-25) visits to PHC vs. 861 (67.1%) non-HF users in ED, with 4 (2-6) visits to PHC. Independent predictors of HF in PHC: over 65 years (OR: 1.51; 95% CI: 1.07-2.13; P=.019), cognitive impairment (OR: 1.63; 95% CI: 1.01-2.65; P=.049), taking >3 drugs (OR: 1.56; 95% CI: 1.06-2.30; P=.025), and living in the community vs. nursing home or homeless (OR: 3.05; 95% CI: 1.14-8.16; P=.026). Among HF patients in the ED, the fact that of being over 65 years, taking 3or more drugs, suffering cognitive impairment, and living in the community, are also considered to be predictors of HF in PHC. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Trends in the Types of Usual Sources of Care: A Shift from People to Places or Nothing at All.

PubMed

Liaw, Winston; Jetty, Anuradha; Petterson, Stephen; Bazemore, Andrew; Green, Larry

2017-08-31

(1) To examine usual source of care (USC) trends across four categories (No USC, Person USC, Person, in Facility USC, and Facility USC), and (2) to determine whether USC types are associated with emergency department (ED) visits and hospital admissions. 1996-2014 Medical Expenditure Panel Surveys. We stratified each USC category, by age, region, gender, poverty, insurance, race/ethnicity, and education and used regression to determine the characteristics associated with USC types, ED visits, and hospital admissions. Those with No USC and Facility USCs increased 10 and 18 percent, respectively, while those with Person USCs decreased by 43 percent. Compared to those in the lowest income bracket, those in the highest income bracket were less likely to have a Facility USC. Among those with low incomes, individuals with No USC, Person, in Facility, and Facility USCs were more likely to have ED visits than those with Person USCs. A growing number are reporting facilities as their USCs or none at all. The impact of these trends is uncertain, although we found that some USC types are associated with ED visits and hospital admissions. Tracking USCs will be crucial to measuring progress toward enhanced care efficiency. © Health Research and Educational Trust.

[Patient complaints in a hospital emergency department in Belgium].

PubMed

Ngongo, B Tchuyap; Carlier, A; Mols, P

2011-04-01

Patients express their dissatisfaction through complaints. This study analyzed the frequency and chief complaints of patients presenting to the emergency department (ED). The end point was find ways to improve patient satisfaction after their ED visit. In this retrospective, seven years study, we reviewed 155 chief complaints of patients presenting to the ED of a university hospital. The chief complaints were either from the patients or a family member. One hundred and fifty five chief complaints collected from 496.816 patients presenting to the ED were reviewed over a period of seven years. Complaints case rate was 3.1 per 10.000 visits. Complaints came from patients between the age of 20 to 60 years old (75.0 percent). Complains involved a physician (79.0 percent). The complaints were related a lack of communication (39.0 percent), long waiting time (14.0 percent), wrong diagnosis (22.0 percent), wrong treatment (13.0 percent) and ED disposition of the patient (12.0 percent). Two types of pathology represented more than 15 percent of the complaints: the traumatology (22.0 percent) and the psychiatry (17.0 percent). The traumatology and psychiatry represented respectively 30.0 percent and 10.0 percent of ED visits. Most complaints were addressed and resolved through a hospital mediator, Chief of service or Chief of staff. The rate of complains is low. Most complaints can be prevented if the physician improves communication with patients.

Constipation Prophylaxis Is Rare for Adults Prescribed Outpatient Opioid Therapy From U.S. Emergency Departments.

PubMed

Hunold, Katherine M; Smith, Samantha A; Platts-Mills, Timothy F

2015-09-01

Constipation is a common and potentially serious side effect of oral opioids. Accordingly, most clinical guidelines suggest routine use of laxatives to prevent opioid-induced constipation. The objective was to characterize emergency provider prescribing of laxatives to prevent constipation among adults initiating outpatient opioid treatment. National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 were analyzed. Among visits by individuals aged 18 years and older discharged from the emergency department (ED) with opioid prescriptions, the authors estimated the survey-weighted proportion of visits in which laxatives were also prescribed. A subgroup analysis was conducted for individuals aged 65 years and older, as the potential risks associated with opioid-induced constipation are greater among older individuals. To examine a group expected to be prescribed laxative medication and confirm that NHAMCS captures prescriptions for these medications, the authors estimated the proportion of visits by individuals discharged with prescriptions for laxatives among those who presented with constipation. Among visits in 2010 by adults aged 18 years and older discharged from the ED with opioid prescriptions, 0.9% (95% confidence interval [CI] = 0.7% to 1.3%, estimated total n = 191,203 out of 21,075,050) received prescriptions for laxatives. Among the subset of visits by adults aged 65 years and older, 1.0% (95% CI = 0.5% to 2.0%, estimated total n = 18,681 out of 1,904,411) received prescriptions for laxatives. In comparison, among visits by individuals aged 18 years and older with constipation as a reason for visit, 42% received prescriptions for laxatives. In this nationally representative sample, laxatives were not routinely prescribed to adults discharged from the ED with prescriptions for opioid pain medications. Routine prescribing of laxatives for ED visits may improve the safety and effectiveness of outpatient opioid pain management. © 2015 by the Society for Academic Emergency Medicine.

Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department.

PubMed

Huang, I-Anne; Tuan, Pao-Lan; Jaing, Tang-Her; Wu, Chang-Teng; Chao, Minston; Wang, Hui-Hsuan; Hsia, Shao-Hsuan; Hsiao, Hsiang-Ju; Chang, Yu-Ching

2016-10-01

Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED). The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians. An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487-6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2-6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians. Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation. Copyright © 2016. Published by Elsevier B.V.

The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department.

PubMed

Scott, Halden F; Deakyne, Sara J; Woods, Jason M; Bajaj, Lalit

2015-04-01

This study sought to determine the prevalence, test characteristics, and severity of illness of pediatric patients with systemic inflammatory response syndrome (SIRS) vital signs among pediatric emergency department (ED) visits. This was a retrospective descriptive cohort study of all visits to the ED of a tertiary academic free-standing pediatric hospital over 1 year. Visits were included if the patient was <18 years of age and did not leave before full evaluation or against medical advice. Exclusion criteria were trauma diagnoses or missing documentation of vital signs. Data were electronically extracted from the medical record. The primary predictor was presence of vital signs meeting pediatric SIRS definitions. Specific vital sign pairs comprising SIRS were evaluated as predictors (temperature-heart rate, temperature-respiratory rate, and temperature-corrected heart rate, in which a formula was used to correct heart rate for degree of temperature elevation). The primary outcome measure was requirement for critical care (receipt of a vasoactive agent or intubation) within 24 hours of ED arrival. There were 56,210 visits during the study period; 40,356 met inclusion criteria. Of these, 6,596 (16.3%) visits had fever >38.5°C, and 6,122 (15.2% of included visits) met SIRS vital sign criteria. Among included visits, those with SIRS vital signs accounted for 92.8% of all visits with fever >38.5°C. Among patients with SIRS vital signs, 4993 (81.6%) were discharged from the ED without intravenous (IV) therapy and without 72-hour readmission. Critical care within the first 24 hours was present in 99 (0.25%) patients: 23 patients with and 76 without SIRS vital signs. Intensive care unit (ICU) admission was present in 126 (2.06%) with SIRS vital signs and 487 (1.42%) without SIRS vital signs. SIRS vital signs were associated with increased risk of critical care within 24 hours (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.06 to 2.70), ICU admission (RR = 1.45, 95% CI = 1.19 to 1.76), ED laboratory tests (RR = 1.41, 95% CI = 1.37 to 1.45), ED IV medication/fluid administration (RR = 2.54, 95% CI = 2.29 to 2.82), hospital admission (RR = 1.52, 95% CI = 1.42 to 1.63), and 72-hour readmission (RR = 1.31, 95% CI = 1.01 to 1.69). SIRS vital signs were not associated with 30-day in-hospital mortality (RR = 0.37, 95% CI = 0.05 to 2.82). SIRS vital signs had a low sensitivity for critical care requirement (23.2%, 95% CI = 15.3% to 32.8%). The pair of SIRS vital signs with the strongest association with critical care requirement was temperature and corrected heart rate (positive likelihood ratio = 2.74, 95% CI = 1.87 to 4.01). Systemic inflammatory response syndrome vital signs are common among medical pediatric patients presenting to an ED, and critical illness is rare. The majority of patients with SIRS vital signs were discharged without IV therapy and without readmission. Patients with SIRS vital signs had a statistically significant increased risk of critical care requirement, ED IV treatment, ED laboratory tests, admission, and readmission. However, SIRS vital sign criteria did not identify the majority of patients with mortality or need for critical care. SIRS vital signs had low sensitivity for critical illness, making it poorly suited for use in isolation in this setting as a test to detect children requiring sepsis resuscitation. © 2015 by the Society for Academic Emergency Medicine.

Emergency department visits by pediatric patients for poisoning by prescription opioids.

PubMed

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

2016-09-01

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. We sought to evaluate emergency department (ED) visits for poisoning by prescription opioids in pediatric patients. This retrospective study looked at clinical and demographic data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2012. 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. 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.

Pain One Week After an Emergency Department Visit for Acute Low Back Pain Is Associated With Poor Three-month Outcomes.

PubMed

Friedman, Benjamin W; Conway, John; Campbell, Caron; Bijur, Polly E; John Gallagher, E

2018-05-16

Low back pain (LBP) is responsible for more than 2.5 million visits to U.S. emergency departments (EDs) annually. Nearly 30% of patients who present to an ED with acute LBP report functional impairment or pain 3 months later. These patients are at risk of chronic LBP, a highly debilitating condition. In this study, we assessed whether three variables assessable shortly after symptom onset could independently predict poor 3-month outcomes among LBP patients who present to an ED. This was a planned analysis of data from two randomized comparative effectiveness studies of patients with acute, nontraumatic, nonradicular LBP. Patients were enrolled during an ED visit, contacted by telephone 1 week after the ED visit, and then followed up by telephone 3 months later. The coprimary 3-month outcomes were LBP-related functional impairment and persistent moderate or severe LBP. Two of the three hypothesized predictor variables were assessed during the index visit: 1) the STarT Back Screening Tool score, a nine-item, multidimensional tool validated and widely used in the outpatient setting, and 2) the patient's own anticipated duration of LBP. The third hypothesized predictor was presence of pain assessed by phone 1 week after the ED visit. We then determined whether these three predictor variables were independently associated with poor outcomes at 3 months, after controlling for medication received, age, and sex. A total of 354 patients were enrolled. Of these, 309 (87%) provided 3-month impairment data and 311 (88%) provided 3-month pain data. At 3 months, 122 of 309 (39%) patients reported functional impairment and 51 of 311(16%) patients reported moderate or severe LBP. Among the three hypothesized predictor variables, 58 of 352 (16%) patients with available data reported a moderate or high STarT Back Screening Tool score, 35 of 321 (11%) patients with available data reported anticipated duration of LBP > 1 week, and 235 of 346 (68%) patients reported pain at 1-week telephone follow-up. After age, sex, and medication received were controlled for in a multivariable logistic regression model, only pain at 1 week was independently associated with 3-month impairment (odds ratio [OR] = 2.42, 95% CI = 1.39-4.22) and 3-month moderate or severe pain (OR = 3.83, 95% CI = 1.53-9.58). More than one-third of patients reported functional impairment 3 months after an ED visit for acute, nontraumatic, nonradicular LBP. Moderate or severe LBP was less common, reported in about half as many patients (16%). Of the three hypothesized predictor variables, only persistent pain at 1 week was independently associated with poor outcomes at 3 months. Despite its important role in the outpatient setting, the STarT Back Tool was not associated with poor outcomes in this ED cohort. © 2018 by the Society for Academic Emergency Medicine.

Impact of Extreme Heat Events on Emergency Department Visits in North Carolina (2007-2011).

PubMed

Fuhrmann, Christopher M; Sugg, Margaret M; Konrad, Charles E; Waller, Anna

2016-02-01

Extreme heat is the leading cause of weather-related mortality in the U.S. Extreme heat also affects human health through heat stress and can exacerbate underlying medical conditions that lead to increased morbidity and mortality. In this study, data on emergency department (ED) visits for heat-related illness (HRI) and other selected diseases were analyzed during three heat events across North Carolina from 2007 to 2011. These heat events were identified based on the issuance and verification of heat products from local National Weather Service forecast offices (i.e. Heat Advisory, Heat Watch, and Excessive Heat Warning). The observed number of ED visits during these events were compared to the expected number of ED visits during several control periods to determine excess morbidity resulting from extreme heat. All recorded diagnoses were analyzed for each ED visit, thereby providing insight into the specific pathophysiological mechanisms and underlying health conditions associated with exposure to extreme heat. The most common form of HRI was heat exhaustion, while the percentage of visits with heat stroke was relatively low (<10%). The elderly (>65 years of age) were at greatest risk for HRI during the early summer heat event (8.9 visits per 100,000), while young and middle age adults (18-44 years of age) were at greatest risk during the mid-summer event (6.3 visits per 100,000). Many of these visits were likely due to work-related exposure. The most vulnerable demographic during the late summer heat event was adolescents (15-17 years of age), which may relate to the timing of organized sports. This demographic also exhibited the highest visit rate for HRI among all three heat events (10.5 visits per 100,000). Significant increases (p < 0.05) in visits with cardiovascular and cerebrovascular diseases were noted during the three heat events (3-8%). The greatest increases were found in visits with hypotension during the late summer event (23%) and sequelae during the early summer event (30%), while decreases were noted for visits with hemorrhagic stroke during the middle and late summer events (13-24%) and for visits with aneurysm during the early summer event (15%). Significant increases were also noted in visits with respiratory diseases (5-7%). The greatest increases in this category were found in visits with pneumonia and influenza (16%), bronchitis and emphysema (12%), and COPD (14%) during the early summer event. Significant increases in visits with nervous system disorders were also found during the early summer event (16%), while increases in visits with diabetes were noted during the mid-summer event (10%).

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010.

PubMed

Ware, Chelsea E; Ajabnoor, Yasser; Mullins, Peter M; Mazer-Amirshahi, Maryann; Pines, Jesse M; May, Larissa

2016-09-01

Sexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. This study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. We analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). Although patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured. Copyright © 2016 Elsevier Inc. All rights reserved.

Age-related variation in primary care-type presentations to emergency departments.

PubMed

Freed, Gary; Gafforini, Sarah; Carson, Norman

2015-08-01

A significant amount of attention has been paid to the increase in emergency department (ED) presentations in Australia. Questions have arisen regarding whether all of those presenting to the ED are actually in need of true emergency services. Under-standing the characteristics of those patients who may be cared for in non-emergency settings is important for future health system strategies. The aim of this study was to identify age-related variation in primary care type emergency department (ED) presentations over time. A secondary analysis of data from the Victorian emergency minimum dataset (VEMD) between 2002-13 was conducted. The main outcomes were patterns of primary care type ED presentations for different ages groups over time, age-specific patterns of specific primary care type exclusion criteria and primary care type ED presentations by residents from aged care facilities. The proportion of triage category 4 or 5 ED presentations that met the criteria for a primary care type visit was greatest in the 0-4-year age group and tended to decrease as the age of the patient increased. Triage category 4 or 5 presentation by ambulance was uncommon in the younger age groups, surpassed 10% in the 50-54-year age group, and was >70% for those aged >90 years. The greater proportion of residential aged care facility patients who arrived by ambulance resulted in a much smaller proportion of primary care type visits. There are marked differences by age in the proportion of triage category 4 or 5 ED presentations that met the criteria for primary care type visits. These results indicate it was primarily younger patients who presented to the ED with non-urgent conditions. Most might be able to safely receive care in a primary care setting.

Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital.

PubMed

Weiss, Marianne E; Costa, Linda L; Yakusheva, Olga; Bobay, Kathleen L

2014-02-01

To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits. A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. Prospective longitudinal design, multinomial logistic regression analysis. Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits. Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk. © Health Research and Educational Trust.

Missed Fractures in Infants Presenting to the Emergency Department With Fussiness.

PubMed

Kondis, Jamie S; Muenzer, Jared; Luhmann, Janet D

2017-08-01

The aim of this study was to evaluate incidence of prior fussy emergency visits in infants with subsequently diagnosed fractures suggestive of abuse. This was a retrospective chart review of infants younger than 6 months who presented to the pediatric emergency department (ED) between January 1, 2006, and December 31, 2011. Inclusion criteria included age 0 to 6 months, discharge diagnosis including "fracture," "broken" (or break), or "trauma" or any child abuse diagnosis or chief complaint of "fussy" or "crying" as documented in the electronic medical record by the triage nurse. Three thousand seven hundred thirty-two charts were reviewed, and 279 infants with fractures were identified. Eighteen (6.5%) of 279 infants had a prior ED visit for fussiness without an obvious source. Of these, 2 had a witnessed event causing their fracture, and therefore the fracture was not considered concerning for abuse. The remaining 16 had fractures concerning for abuse. Mean age was 2.5 (SD, 1.2) months. Fifteen (83%) of 18 infants were 3 months or younger at the time of the fussy visit. The mean interval between the first and second ED visits was 27 days (median, 20 days). Thirty-nine percent were evaluated by a pediatric emergency medicine-trained physician during their initial fussy visit, whereas 78% were evaluated by pediatric emergency medicine-trained physician during their subsequent visit. Most common injuries were multiple types of fractures followed by extremity and rib fractures. Fractures concerning for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse.

The Value of Electronically Extracted Data for Auditing Outpatient Antimicrobial Prescribing.

PubMed

Livorsi, Daniel J; Linn, Carrie M; Alexander, Bruce; Heintz, Brett H; Tubbs, Traviss A; Perencevich, Eli N

2018-01-01

OBJECTIVE The optimal approach to auditing outpatient antimicrobial prescribing has not been established. We assessed how different types of electronic data-including prescriptions, patient-visits, and International Classification of Disease, Tenth Revision (ICD-10) codes-could inform automated antimicrobial audits. DESIGN Outpatient visits during 2016 were retrospectively reviewed, including chart abstraction, if an antimicrobial was prescribed (cohort 1) or if the visit was associated with an infection-related ICD-10 code (cohort 2). Findings from cohorts 1 and 2 were compared. SETTING Primary care clinics and the emergency department (ED) at the Iowa City Veterans Affairs Medical Center. RESULTS In cohort 1, we reviewed 2,353 antimicrobial prescriptions across 52 providers. ICD-10 codes had limited sensitivity and positive predictive value (PPV) for validated cases of cystitis and pneumonia (sensitivity, 65.8%, 56.3%, respectively; PPV, 74.4%, 52.5%, respectively). The volume-adjusted antimicrobial prescribing rate was 13.6 per 100 ED visits and 7.5 per 100 primary care visits. In cohort 2, antimicrobials were not indicated in 474 of 851 visits (55.7%). The antimicrobial overtreatment rate was 48.8% for the ED and 59.7% for primary care. At the level of the individual prescriber, there was a positive correlation between a provider's volume-adjusted antimicrobial prescribing rate and the individualized rates of overtreatment in both the ED (r=0.72; P<.01) and the primary care setting (r=0.82; P=0.03). CONCLUSIONS In this single-center study, ICD-10 codes had limited sensitivity and PPV for 2 infections that typically require antimicrobials. Electronically extracted data on a provider's rate of volume-adjusted antimicrobial prescribing correlated with the frequency at which unnecessary antimicrobials were prescribed, but this may have been driven by outlier prescribers. Infect Control Hosp Epidemiol 2018;39:64-70.

Visiting Again? Subjective Well-Being of Children in Elementary School and Repeated Visits to School Health Nurses

ERIC Educational Resources Information Center

Leaver, Cynthia A.

2014-01-01

Background: Children with vague complaints are without chronic illness, and who repeatedly visit the school nurse may be at risk for limited academic success. This study compares student reports of subjective well-being between children who do and do not repeatedly visit the school nurse with vague complaints. Methods: Children in grades 4 through…

Collaborative effort in Washington state slashes non-essential use of the ED by Medicaid patients, delivering millions in projected savings.

PubMed

2013-04-01

Early data suggest a coordinated, state-wide effort has reduced non-essential use of the ED by 10% among Medicaid recipients in Washington state, and is projected to save the state an estimated $31 million in the first year of the approach. The effort includes the adoption of seven best practices by hospitals across the state.These include the creation of an Emergency Department Information Exchange, so that EDs can immediately access a patient's utilization history, strict narcotic prescribing guidelines, and regular feedback reports to hospitals regarding ED utilization patterns. The effort was prompted by threats by the state legislature to limit Medicaid payments for ED visits deemed not medically necessary in the emergency setting. The legislature backed down when emergency physicians in the state countered with their own proposal to reduce nonessential use of the ED. They worked with other health care groups in the state to develop the plan. Data on the first six months of the effort are included in a report to the state legislature by the Washington State Health Care Authority. Among the findings are a 23% reduction in ED visits among Medicaid recipients with five or more visits, a 250% increase in providers who have registered with the state's Prescription Monitoring Program, aimed at identifying patients with narcotic-seeking behavior, and a doubling in the number of shared care plans, intended to improve care coordination. Emergency providers say big challenges remain, including a need for more resources for patients with mental health and dental care needs.

Heroin and fentanyl overdoses in Kentucky: Epidemiology and surveillance.

PubMed

Slavova, Svetla; Costich, Julia F; Bunn, Terry L; Luu, Huong; Singleton, Michael; Hargrove, Sarah L; Triplett, Jeremy S; Quesinberry, Dana; Ralston, William; Ingram, Van

2017-08-01

The study aims to describe recent changes in Kentucky's drug overdose trends related to increased heroin and fentanyl involvement, and to discuss future directions for improved drug overdose surveillance. The study used multiple data sources (death certificates, postmortem toxicology results, emergency department [ED] records, law enforcement drug submissions, and prescription drug monitoring records) to describe temporal, geographic, and demographic changes in drug overdoses in Kentucky. Fentanyl- and heroin-related overdose death rates increased across all age groups from years 2011 to 2015 with the highest rates consistently among 25-34-year-olds. The majority of the heroin and fentanyl overdose decedents had histories of substantial exposures to legally acquired prescription opioids. Law enforcement drug submission data were strongly correlated with drug overdose ED and mortality data. The 2016 crude rate of heroin-related overdose ED visits was 104/100,000, a 68% increase from 2015 (62/100,000). More fentanyl-related overdose deaths were reported between October, 2015, and September, 2016, than ED visits, in striking contrast with the observed ratio of >10 to 1 heroin-related overdose ED visits to deaths. Many fatal fentanyl overdoses were associated with heroin adulterated with fentanyl; <40% of the heroin overdose ED discharge records listed procedure codes for drug screening. The lack of routine ED drug testing likely resulted in underreporting of non-fatal overdoses involving fentanyl and other synthetic drugs. In order to inform coordinated public health and safety responses, drug overdose surveillance must move from a reactive to a proactive mode, utilizing the infrastructure for electronic health records. Copyright © 2017 Elsevier B.V. All rights reserved.

Relationship of opioid prescription sales and overdoses, North Carolina.

PubMed

Modarai, F; Mack, K; Hicks, P; Benoit, S; Park, S; Jones, C; Proescholdbell, S; Ising, A; Paulozzi, L

2013-09-01

In the United States, fatal drug overdoses have tripled since 1991. This escalation in deaths is believed to be driven primarily by prescription opioid medications. This investigation compared trends and patterns in sales of opioids, opioid drug overdoses treated in emergency departments (EDs), and unintentional overdose deaths in North Carolina (NC). Our ecological study compared rates of opioid sales, opioid related ED overdoses, and unintentional drug overdose deaths in NC. Annual sales data, provided by the Drug Enforcement Administration, for select opioids were converted into morphine equivalents and aggregated by zip code. These opioid drug sales rates were trended from 1997 to 2010. In addition, opioid sales were correlated and compared to opioid related ED visits, which came from a Centers for Disease Control and Prevention syndromic surveillance system, and unintentional overdose deaths, which came from NC Vital Statistics, from 2008 to 2010. Finally, spatial cluster analysis was performed and rates were mapped by zip code in 2010. Opioid sales increased substantially from 1997 to 2010. From 2008 to 2010, the quarterly rates of opioid drug overdoses treated in EDs and opioid sales correlated (r=0.68, p=0.02). Specific regions of the state, particularly in the southern and western corners, had both high rates of prescription opioid sales and overdoses. Temporal trends in sales of prescription opioids correlate with trends in opioid related ED visits. The spatial correlation of opioid sales with ED visit rates shows that opioid sales data may be a timely way to identify high-risk communities in the absence of timely ED data. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Prevalence of Clostridium difficile infection presenting to US EDs.

PubMed

Smith, Aaron M; Wuerth, Brandon A; Wiemken, Timothy L; Arnold, Forest W

2015-02-01

The objective of the study is to determine the prevalence of Clostridium difficile infection (CDI) presenting to emergency departments (EDs) in the United States. Secondary objectives included defining the burden of CDI. This is a retrospective, observational cohort study of 2006-2010 Nationwide Emergency Department Sample database of 980 US hospital EDs in 29 states. Prevalence, mortality rate, length of stay, hospital charges, and endemicity were measured. A total of 474513 patients with CDI-related ED visits were identified. From 2006 to 2010, the prevalence of CDI increased from 26.2 to 33.1 per 100,000 population (P<.001). The number of CDI-related ED cases increased 26.1% (P<.001) over the study period: 18.6% from 2006 to 2007 (P<.001), 4.3% from 2007 to 2008 (P=.46), 1.8% from 2008 to 2009 (P=.73), and 0.13% from 2009 to 2010 (P=.95). Emergency department visits occurred more frequently with individuals 85 years or older (relative risk [RR], 13.74; P<.001), females (RR, 1.77; P<.001) and in the northeast United States (RR, 1.42; P<.001). From 2009 to 2010, the mortality rate decreased 17.9% (P=.01). The prevalence of CDI presenting to EDs increased each year from 2006 to 2010; however, the rate of increase slowed from each year to the next. The mortality rate increased from 2006 to 2009 and decreased significantly from 2009 to 2010. C difficile infection visits presenting to EDs occurred more frequently with older individuals, females, and in the northeast. Copyright © 2014 Elsevier Inc. All rights reserved.

Management and educational status of adult anaphylaxis patients at emergency department.

PubMed

Kim, Mi-Yeong; Park, Chan Sun; Jeong, Jae-Won

2017-12-28

We evaluated the management and educational status of adult anaphylaxis patients at emergency departments (EDs). Anaphylaxis patients who visited ED from 2011 to 2013 were enrolled from three hospitals. We analyzed clinical features, prior history of anaphylaxis, management and provided education for etiology and/or prevention. For analyzing associated factors with epinephrine injection, Pearson chi-square test was used by SPSS version 21 (IBM Co.). A total of 194 anaphylaxis patients were enrolled. Ninety-nine patients (51%) visited ED by themselves. Time interval from symptom onset to ED visit was 62 ± 70.5 minutes. Drug (56.2%) was the most frequent cause of anaphylaxis. Forty-seven patients (24.2%) had prior history of anaphylaxis and 33 patients had same suspicious cause with current anaphylaxis. Cutaneous (88.7%) and respiratory (72.7%) symptoms were frequent. Hypotension was presented in 114 patients (58.8%). Mean observation time in ED was 12 ± 25.7 hours and epinephrine was injected in 114 patients (62%). In 68 patients, epinephrine was injected intramuscularly with mean dose of 0.3 ± 0.10 mg. Associated factor with epinephrine injection was hypotension (p = 0.000). Twenty-three patients (13%) were educated about avoidance of suspicious agent. Epinephrine auto-injectors were prescribed only in five patients. Only 34 (19%) and 72 (40%) patients were consulted to allergist at ED and outpatient allergy department respectively. We suggested that management and education of anaphylaxis were not fully carried out in ED. An education and promotion program on anaphylaxis is needed for medical staff.

Emergency department visits and "vog"-related air quality in Hilo, Hawai'i.

PubMed

Michaud, Jon-Pierre; Grove, John Sinclair; Krupitsky, Dmitry

2004-05-01

Emergency department (ED) visits in Hilo, Hawai'i, from January 1997 to May 2001, were examined for associations with volcanic fog, or "vog", measured as sulfur dioxide (SO(2)) and submicrometer particulate matter (PM(1)). Exponential regression models were used with robust standard errors. Four diagnostic groups were examined: asthma/COPD; cardiac; flu, cold, and pneumonia; and gastroenteritis. Before adjustments, highly significant associations with vog-related air quality were seen for all diagnostic groups except gastroenteritis. After adjusting for month, year, and day of the week, only asthma/COPD had consistently positive associations with air quality. The strongest associations were for SO(2) with a 3-day lag (6.8% per 10 ppb; P=0.001) and PM(1), with a 1-day lag (13.8% per 10 microg/m(3); P=0.011). The association of ED visits for asthma/COPD with month of the year was stronger than associations seen with air quality. Although vog appears influential, non-vog factors dominated associations with the frequency of asthma/COPD ED visits.

The application of the interpersonal-psychological theory of suicide to a sample of Swiss patients attending a psychiatric emergency department for a non-lethal suicidal event.

PubMed

Baertschi, Marc; Costanza, Alessandra; Richard-Lepouriel, Hélène; Pompili, Maurizio; Sarasin, François; Weber, Kerstin; Canuto, Alessandra

2017-03-01

Visits to emergency departments (EDs) for suicidal ideation or a suicide attempt have increased in the past decades. Yet comprehensive models of suicide are scarce, potentially enhancing misunderstandings from health professionals. This study aimed to investigate the applicability of the interpersonal-psychological theory of suicide (IPTS) in a population visiting EDs for suicide-related issues. Three major hypotheses formulated by the IPTS were tested in a sample of 167 individuals visiting EDs for suicidal ideation or a suicide attempt. As predicted by the IPTS, greater levels of perceived burdensomeness (PB) were associated with presence of current suicidal ideation. However, contrary to the theory assumptions, thwarted belongingness (TB) was not predictive of current suicidal ideation (Hypothesis 1). Similarly, the interaction between PB, TB and hopelessness did not account for the transition from passive to active suicidal ideation (Hypothesis 2). The interaction between active suicidal ideation and fearlessness of death did not either predict the transition from active suicidal ideation to suicidal intent (Hypothesis 3). The cross-sectional design limited the interpretation of causal hypotheses. Patients visiting EDs during nights and weekends were underrepresented. A general measure of hopelessness was considered, not a measure of hopelessness specifically related to PB and TB. Although the three hypotheses were only partially verified, health professionals might consider the IPTS as useful for the management of patient with suicide-related issues. Clinical intervention based on perceived burdensomeness could notably be proposed shortly after ED admission. Copyright © 2017 Elsevier B.V. All rights reserved.

The Costs of Respiratory Illnesses Arising from Florida Gulf Coast Karenia brevis Blooms

PubMed Central

Hoagland, Porter; Jin, Di; Polansky, Lara Y.; Kirkpatrick, Barbara; Kirkpatrick, Gary; Fleming, Lora E.; Reich, Andrew; Watkins, Sharon M.; Ullmann, Steven G.; Backer, Lorraine C.

2009-01-01

Background Algal blooms of Karenia brevis, a harmful marine algae, occur almost annually off the west coast of Florida. At high concentrations, K. brevis blooms can cause harm through the release of potent toxins, known as brevetoxins, to the atmosphere. Epidemiologic studies suggest that aerosolized brevetoxins are linked to respiratory illnesses in humans. Objectives We hypothesized a relationship between K. brevis blooms and respiratory illness visits to hospital emergency departments (EDs) while controlling for environmental factors, disease, and tourism. We sought to use this relationship to estimate the costs of illness associated with aerosolized brevetoxins. Methods We developed a statistical exposure–response model to express hypotheses about the relationship between respiratory illnesses and bloom events. We estimated the model with data on ED visits, K. brevis cell densities, and measures of pollen, pollutants, respiratory disease, and intra-annual population changes. Results We found that lagged K. brevis cell counts, low air temperatures, influenza outbreaks, high pollen counts, and tourist visits helped explain the number of respiratory-specific ED diagnoses. The capitalized estimated marginal costs of illness for ED respiratory illnesses associated with K. brevis blooms in Sarasota County, Florida, alone ranged from $0.5 to $4 million, depending on bloom severity. Conclusions Blooms of K. brevis lead to significant economic impacts. The costs of illness of ED visits are a conservative estimate of the total economic impacts. It will become increasingly necessary to understand the scale of the economic losses associated with K. brevis blooms to make rational choices about appropriate mitigation. PMID:19672403

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.

Emergency Department Evaluation of Traumatic Brain Injury in the United States, 2009–2010

PubMed Central

Korley, Frederick K.; Kelen, Gabor D.; Jones, Courtney M.; Diaz-Arrastia, Ramon

2015-01-01

Objective Determine the dimensions of traumatic brain injury (TBI) evaluation in U.S. emergency department (EDs) to inform potential application of novel diagnostic tests. Setting United States EDs. Participants National Hospital Ambulatory Medical Care Survey of ED visits in 2009 and 2010 where TBI was evaluated (1) and diagnosed clinically, or (2) with head CT scan. Design Retrospective cross-sectional. Results TBI was evaluated during 4.8 (95% CI: 4.2–5.4) million visits/year; and head CT scan was performed in 82% of TBI evaluations (3.9 [95% CI: 3.4–4.4] million visits/year). TBI was diagnosed in 52% of evaluations (2.5 [95% CI: 2.1–2.8] million visits/year). Among those who received head CTs, 9% had CT evidence of traumatic abnormalities. Among patients evaluated for TBI who had a Glasgow Coma Scale recorded, 94.5% were classified as mild TBI, 2.1% as moderate TBI and 3.5% as severe TBI. Among patients with ICD9-C-M codes permitting the calculation of Head AIS scores 9.0%, 85.0%, 2.5%, 3.2%, 0.3% and 0% had Head AIS scores of 1,2,3,4,5,6 respectively. Of patients evaluated for TBI, 31% had other head/face/neck injuries; 10% had spine and back injuries; 7% had torso injuries; and 14% had extremity injuries. Conclusion The ED is the main gateway to medical care for millions of patients evaluated for TBI each year. Novel diagnostic tests are need to improve ED diagnosis and management of TBI. PMID:26360006

Injuries and illnesses of big game hunters in western Colorado: a 9-year analysis.

PubMed

Reishus, Allan D

2007-01-01

The purpose of this study was to characterize big game hunter visits to a rural hospital's emergency department (ED). Using data collected on fatalities, injuries, and illnesses over a 9-year period, trends were noted and comparisons made to ED visits of alpine skiers, swimmers, and bicyclists. Out-of-hospital hunter fatalities reported by the county coroner's office were also reviewed. Cautionary advice is offered for potential big game hunters and their health care providers. Self-identified hunters were noted in the ED log of a rural Colorado hospital from 1997 to 2005, and injury or illness and outcome were recorded. Additional out-of-hospital mortality data were obtained from the county coroner's office. The estimated total number of big game hunters in the hospital's service area and their average days of hunting were reported by the Colorado Division of Wildlife. The frequencies of hunters' illnesses, injuries, and deaths were calculated. A total of 725 ED visits--an average of 80 per year--were recorded. Nearly all visits were in the prime hunting months of September to November. Twenty-seven percent of the hunter ED patients were Colorado residents, and 73% were from out of state. Forty-five percent of the visits were for trauma, 31% for medical illnesses, and 24% were labeled "other." The most common medical visits (105) were for cardiac signs and symptoms, and all of the ED deaths (4) were attributed to cardiac causes. The most common trauma diagnosis was laceration (151), the majority (113) of which came from accidental knife injuries, usually while the hunter was field dressing big game animals. Gunshot wounds (4, < 1%) were rare. Horse-related injuries to hunters declined while motor vehicle- and all-terrain vehicle (ATV)-related injuries increased. The five out-of-hospital deaths were cardiac related (3), motor vehicle related (1), and firearm related (1). Fatal outcomes in big game hunters most commonly resulted from cardiac diseases. Gunshot injuries and mortalities were very low in this population. Knife injuries were common. Hunters and their health care providers should consider a thorough cardiac evaluation prior to big game hunts. Hunter safety instructors should consider teaching aspects of safe knife use. Consideration should be given to requiring and improving ATV driver education.

Inappropriately Timed Pediatric Orthopaedic Referrals From the Emergency Department Result in Unnecessary Appointments and Financial Burden for Patients.

PubMed

Jackson, Taylor J; Blumberg, Todd J; Shah, Apurva S; Sankar, Wudbhav N

2018-03-01

Musculoskeletal injuries are among the most common reasons for emergency department (ED) visits in the pediatric population. Many such injuries can be managed with a single follow-up outpatient visit. However, untimely (ie, premature) referrals by emergency physicians to orthopaedic surgeons are common and may inadvertently create need for a second visit, generating unnecessary expenditures. We sought to elucidate the cost of premature musculoskeletal follow-up visits to the patients, families, and the health care system. We performed a retrospective review of pediatric patients with acute musculoskeletal injuries referred from our ED (without a formal orthopaedic consult) to our outpatient clinic. Patients were retrospectively reviewed in a consecutive fashion. The appropriateness of the recommended follow-up time interval was determined for each patient, and the direct and indirect cost of the inappropriate services were calculated utilizing a combination of traditional cost accounting techniques and time-driven activity-based costing. The characteristics of patients with appropriate and untimely follow-up referrals were compared. Two hundred consecutive referrals from the ED were reviewed. Overall, 96.5% of the follow-up visits recommended by the ED were premature, which led 106 (53%) patients to require a second visit to complete their clinical care. Patients who required a second visit were significantly younger (P=0.005), more likely to be male (P=0.042), more likely to have a fracture (P<0.001), and less likely to have a sprain (P<0.001) or dislocation/subluxation (P<0.001). Over 40% of second visits were accounted for by 3 diagnoses (distal radius buckle fractures, nondisplaced Salter-Harris 1 fractures of the ankle, and buckle fractures of the finger). Across the whole cohort, the total financial impact of untimely visits was $36,265.78, representing an average cost of $342.93 per patient. Untimely referrals for follow-up of acute pediatric musculoskeletal conditions are very common and represent a significant financial burden to patients, families, and the health care system. Over 40% of unnecessary visits resulted from just 3 diagnoses. Improved orthopaedic follow-up guidelines, particularly for these readily recognizable conditions, and feedback to referring providers may reduce poorly timed clinic visits and decrease costs in the treatment of common orthopaedic injuries in pediatric patients. Level III.

Air pollution and emergency department visits for cardiac and respiratory conditions: a multi-city time-series analysis

PubMed Central

2009-01-01

Background Relatively few studies have been conducted of the association between air pollution and emergency department (ED) visits, and most of these have been based on a small number of visits, for a limited number of health conditions and pollutants, and only daily measures of exposure and response. Methods A time-series analysis was conducted on nearly 400,000 ED visits to 14 hospitals in seven Canadian cities during the 1990s and early 2000s. Associations were examined between carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), sulfur dioxide (SO2), and particulate matter (PM10 and PM2.5), and visits for angina/myocardial infarction, heart failure, dysrhythmia/conduction disturbance, asthma, chronic obstructive pulmonary disease (COPD), and respiratory infections. Daily and 3-hourly visit counts were modeled as quasi-Poisson and analyses controlled for effects of temporal cycles, weather, day of week and holidays. Results 24-hour average concentrations of CO and NO2 lag 0 days exhibited the most consistent associations with cardiac conditions (2.1% (95% CI, 0.0–4.2%) and 2.6% (95% CI, 0.2–5.0%) increase in visits for myocardial infarction/angina per 0.7 ppm CO and 18.4 ppb NO2 respectively; 3.8% (95% CI, 0.7–6.9%) and 4.7% (95% CI, 1.2–8.4%) increase in visits for heart failure). Ozone (lag 2 days) was most consistently associated with respiratory visits (3.2% (95% CI, 0.3–6.2%), and 3.7% (95% CI, -0.5–7.9%) increases in asthma and COPD visits respectively per 18.4 ppb). Associations tended to be of greater magnitude during the warm season (April – September). In particular, the associations of PM10 and PM2.5with asthma visits were respectively nearly three- and over fourfold larger vs. all year analyses (14.4% increase in visits, 95% CI, 0.2–30.7, per 20.6 μg/m3 PM10 and 7.6% increase in visits, 95% CI, 5.1–10.1, per 8.2 μg/m3 PM2.5). No consistent associations were observed between three hour average pollutant concentrations and same-day three hour averages of ED visits. Conclusion In this large multicenter analysis, daily average concentrations of CO and NO2 exhibited the most consistent associations with ED visits for cardiac conditions, while ozone exhibited the most consistent associations with visits for respiratory conditions. PM10 and PM2.5 were strongly associated with asthma visits during the warm season. PMID:19515235

Risk for poor outcomes in older patients discharged from an emergency department: feasibility of four screening instruments.

PubMed

Buurman, Bianca M; van den Berg, Wendy; Korevaar, Johanna C; Milisen, Koen; de Haan, Rob J; de Rooij, Sophia E

2011-08-01

To compare the prognostic value of four screening instruments used to detect the risk for poor outcomes [in terms of likelihood of recurrent emergency department (ED) visits, hospitalizations, or mortality] for older patients discharged home from an ED in the Netherlands. This is a prospective cohort study, which included all consecutive patients of at least 65 years discharged from the ED of a university teaching hospital in the Netherlands, between 1 December 2005, and 1 November 2006. Four screening instruments were tested: the identification of seniors at risk, the triage risk screening tool, and the Runciman and Rowland questionnaires. The cutoff of the Runciman questionnaire was adapted and the age cutoff was adapted for the other instruments. Recurrent ED visits, subsequent hospitalization, and mortality within 30 and 120 days after the index visit were collected from administrative data. In total, 381 patients were included, with a mean age of 79.1 years. Within 120 days, 14.7% of the patients returned to ED, 17.2% were hospitalized, and 2.9% died. The area under the curve was low for all instruments (between 0.43 and 0.60), indicating poor discriminatory power. Older ED patients discharged home are at higher risk of poor outcomes. None of the instruments were able to clearly discriminate between patients with and without poor outcomes. Differences in organization of the health care systems might influence the prognostic abilities of screening instruments.

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study.

PubMed

Kauppila, Timo; Seppänen, Katri; Mattila, Juho; Kaartinen, Johanna

2017-06-01

Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system. An observational study. Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city. Patients who consulted different doctors in a local health care unit. Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage. The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased. The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.

Impact of Middle East respiratory syndrome outbreak on the use of emergency medical resources in febrile patients.

PubMed

Jeong, Hyunho; Jeong, Sikyoung; Oh, Juseok; Woo, Seon Hee; So, Byung Hak; Wee, Jeong Hee; Kim, Ji Hoon; Im, Ji Yong; Choi, Seung Pill; Park, Kyoungnam; Cho, Byul Nim Hee; Hong, Sungyoup

2017-06-01

Outbreaks of transmissible respiratory infection are suspected to have significant effects on the health of pediatric and geriatric patients. The objective was to assess the impact of the Middle East respiratory syndrome (MERS) outbreak on the use of emergency resources. An ecologic analysis of emergency department (ED) records between September and December 2015, was performed. Data was obtained from the National Emergency Department Information System database for Korea. All demographic and diagnostic data from patients presenting with febrile symptoms as a main complaint were collected. The data were compared to the equivalent period in the three years preceding the MERS outbreak in Korea. Following the MERS outbreak, there was an increase in overall ED visits by febrile patients and the proportion of visits by febrile patients, relative to total ED attendances. This effect was more prominent in the children under five years. The duration of the chief complaint before ED arrival and the length of ED stay were significantly increased among younger pediatric patients. Decreased body temperature on arrival was observed in younger pediatric patients. MERS outbreak appears to have had a significant effects on ED use by febrile patients. The use of emergency care services by pediatric patients makes them more vulnerable to an outbreak of a transmissable disease. An effective strategy to control emergency center visits by non-urgent febrile patients and provide proper medical services is urgently needed.

Parental Decisions regarding pre-hospital therapy and costing of the Emergency Department Visit.

PubMed

McGovern, M; Kernan, R; O'Neill, M B

2017-02-10

Paediatric patients represent a large percentage of Emergency Department (ED) visits and there is often a perception that the acuity of these presentations is low. The decision-making process that results in parents attending the ED is poorly understood. We designed a cross-sectional cohort study to explore the reasons for attendance, the treatment initiated at home and to assess parental perception of the economic cost of attendance. Data was collected on 200 patients using a survey administered to parents in ED with a follow-up phone call 4-6 weeks later. Our results suggest that attendances are often prompted by parental anxiety rather than clinical deterioration and that prior ED usage is common among those presenting for assessment. Many parents had attempted community therapy with 128/200 patients (64%) having been referred by a healthcare professional and medical therapy at home having been employed by 114/200 (57%) parents before attendance. Parental knowledge of the safety of over-the-counter medications was variable the economic cost of an ED visit was poorly understood by participants. The results of our study suggest that parental desire for control over worrisome symptoms drives much of their management strategy prior to hospital attendance. Strategies in the ED may need to focus more on managing parental expectations than on managing the illness itself and management strategies employed should focus not only on medical therapy of the child's illness but on educating and empowering the parent.

Toward reliable and repeatable automated STEM-EDS metrology with high throughput

NASA Astrophysics Data System (ADS)

Zhong, Zhenxin; Donald, Jason; Dutrow, Gavin; Roller, Justin; Ugurlu, Ozan; Verheijen, Martin; Bidiuk, Oleksii

2018-03-01

New materials and designs in complex 3D architectures in logic and memory devices have raised complexity in S/TEM metrology. In this paper, we report about a newly developed, automated, scanning transmission electron microscopy (STEM) based, energy dispersive X-ray spectroscopy (STEM-EDS) metrology method that addresses these challenges. Different methodologies toward repeatable and efficient, automated STEM-EDS metrology with high throughput are presented: we introduce the best known auto-EDS acquisition and quantification methods for robust and reliable metrology and present how electron exposure dose impacts the EDS metrology reproducibility, either due to poor signalto-noise ratio (SNR) at low dose or due to sample modifications at high dose conditions. Finally, we discuss the limitations of the STEM-EDS metrology technique and propose strategies to optimize the process both in terms of throughput and metrology reliability.

Repeat retail clinic visits: impact of insurance coverage and age of patient.

PubMed

Angstman, Kurt B; Bernard, Matthew E; Rohrer, James E; Garrison, Gregory M; Maclaughlin, Kathy L

2012-12-01

As retail clinics provide a less costly alternative for health care, it would be reasonable to expect an increase in multiple (repeat) retail visits by those patients who may have expenses for receiving primary care. If costs were not a significant factor, then repeat visits should not be significantly different between these patients and those with coverage for primary care visits. The hypothesis for this study was that patients with the potential for out-of-pocket expenses would have a higher frequency of repeat retail clinic visits within 180 days compared to those with primary care coverage. A retrospective chart review was conducted of 5703 patients utilizing a retail clinic in Rochester, Minnesota from January 1, 2009 through June 30, 2009. The first visit to the retail clinic was considered the index visit and the chart was reviewed for repeat retail clinic visits within the next 180 days. Using a multiple logistic regression model, the odds of a pediatric patient (N=2344) having a repeat retail visit within 180 days of the index visit were not significantly impacted by insurance coverage (P=0.4209). Of the 3359 adult patients, those with unknown coverage had a 25.6% higher odds ratio of repeat retail clinic visits than those with insurance coverage (odds ratio 1.2557, confidence interval 1.0421-1.5131). This study suggested that when cost is an issue, the adult patient may favor retail clinics for episodic, low-acuity health care. In contrast, the pediatric population did not, suggesting that other factors, such as convenience, may play more of a role in the choice of episodic health care for this age group.

Professional Fee Ratios for US Hospital Discharge Data

PubMed Central

Peterson, Cora; Xu, Likang; Florence, Curtis; Grosse, Scott D.; Annest, Joseph L.

2015-01-01

Background US hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians’ charges). Objectives We aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data. Subjects The subjects consisted of a retrospective cohort of Truven Health MarketScan 2004–2012 inpatient admissions (n = 23,594,605) and treat-and-release emergency department (ED) visits (n = 70,771,576). Measures PFR per visit was assessed as total payments divided by facility-only payments. Research Design Using ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis. Results Adjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n = 2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n = 816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n = 8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n = 2,994,696). Supplemental tables report 2004–2012 annual PFR estimates by clinical classifications. Conclusions Adjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs. PMID:26340662

Integrated satellite imaging and syndromic surveillance reveal ...

EPA Pesticide Factsheets

Rationale: Wildfire smoke often impacts rural areas without air quality monitors, limiting assessment of health impacts. A 2008 wildfire in Pocosin Lakes National Wildlife Refuge produced massive quantities of smoke affecting eastern NC, a rural area with limited air quality monitoring. To assess the association between smoke exposure and adverse health effects, we evaluated the rates of asthma-and other respiratory-related emergency department (ED) visits in the affected counties during and after the fire. Methods: Aerosol optical depth (AOD) from the Geostationary Operational Environmental Satellite was used to determine the location and extent of the smoke plume. Individual-level ED data, obtained from the NC Disease Event Tracking and Epidemiologic Collection Tool, included the visit date, list of chief complaints, up to 11 discharge ICD-9-CM codes, gender, age, and county of residence. We used Poisson regression to model the expected daily number of ED visits as a function of the dichotomous exposure predictor, adjusted for weekend and county-level disease rates. Results: Carbon particles in the smoke permitted satellite AOD to trace the plume. Exposure to wildfire smoke increased the relative risk for asthma-related ED visits by 12.4% (95% CI 0-26.4%) at lag 0 (today) and a 9.6% (95% CI 0-22%) at lag 1 (yesterday). Conclusions: Satellite data and syndromic surveillance can be combined to assess the health impacts of smoke in rural counties. Short-term

Magnet ingestions in children presenting to US emergency departments, 2002-2011.

PubMed

Abbas, Mazen I; Oliva-Hemker, Maria; Choi, Joon; Lustik, Michael; Gilger, Mark A; Noel, R Adam; Schwarz, Kathleen; Nylund, Cade M

2013-07-01

In the last 10 years, there have been an increasing number of case reports concerning gastrointestinal injury related to magnet ingestions; however, the magnitude of the problem remains to be clearly defined. The aim of the study was to examine the epidemiology of magnet ingestion-related emergency department (ED) visits among children in the United States. We performed a trend analysis using a nationally representative sample from the US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS) database for ED visits involving magnet ingestion in children younger than 18 years from 2002 to 2011. A national estimate of 16,386 (95% CI 12,175-20,598) children younger than 18 years presented to EDs in the United States during the 10-year study period with possible magnet ingestion. The incidence of visits increased 8.5-fold (from 0.45/100,000 to 3.75/100,000) from 2002 to 2011 with a 75% average annual increase per year. The majority of patients reported to have ingested magnets were younger than 5 years (54.7%). From 2009 to 2011 there was an increase in older children ingesting multiple small and/or round magnets, with a mean average age of 7.1 ± 0.56 years during the study period. There has been an alarming increase in ED visits for magnet ingestion in children. Increased public education and prevention efforts are needed.

Systematic review of frequent users of emergency departments in non-US hospitals: state of the art.

PubMed

van Tiel, Sofie; Rood, Pleunie P M; Bertoli-Avella, Aida M; Erasmus, Vicky; Haagsma, Juanita; van Beeck, Ed; Patka, Peter; Polinder, Suzanne

2015-10-01

This review focuses on frequent users (FUs) of the emergency department (ED). Elucidation of the characteristics of frequent ED users will help to improve healthcare services. A systematic review of the literature (from 1999 onwards) on frequent ED users in non-US hospitals was performed. Twenty-two studies were included. FUs are responsible for a wide variety of 1-31% of ED visits depending on the FU definition used. They have a mean age between 40 and 50 years and are older than nonfrequent users. Chronic physical and mental diseases seem to be the main reasons for frequent ED visits. In terms of social characteristics, lacking a partner is more frequently reported among FUs in some studies. The absence of a universal definition for FUs complicates the determination of the burden on emergency healthcare services. FUs are a heterogeneous group of patients with genuine medical needs and high consumption of other healthcare services.

The Association Between Limited English Proficiency and Unplanned Emergency Department Revisit Within 72 Hours.

PubMed

Ngai, Ka Ming; Grudzen, Corita R; Lee, Roy; Tong, Vicky Y; Richardson, Lynne D; Fernandez, Alicia

2016-08-01

Language barriers are known to negatively affect many health outcomes among limited English proficiency patient populations, but little is known about the quality of care such patients receive in the emergency department (ED). This study seeks to determine whether limited English proficiency patients experience different quality of care than English-speaking patients in the ED, using unplanned revisit within 72 hours as a surrogate quality indicator. We conducted a retrospective cohort study in an urban adult ED in 2012, with a total of 41,772 patients and 56,821 ED visits. We compared 2,943 limited English proficiency patients with 38,829 English-speaking patients presenting to the ED after excluding patients with psychiatric complaints, altered mental status, and nonverbal states, and those with more than 4 ED visits in 12 months. Two main outcomes-the risk of inpatient admission from the ED and risk of unplanned ED revisit within 72 hours-were measured with odds ratios from generalized estimating equation multivariate models. Limited English proficiency patients were more likely than English speakers to be admitted (32.0% versus 27.2%; odds ratio [OR]=1.20; 95% confidence interval [CI] 1.11 to 1.30). This association became nonsignificant after adjustments (OR=1.04; 95% CI 0.95 to 1.15). Included in the analysis of ED revisit within 72 hours were 32,857 patients with 45,546 ED visits; 4.2% of all patients (n=1,380) had at least 1 unplanned revisit. Limited English proficiency patients were more likely than English speakers to have an unplanned revisit (5.0% versus 4.1%; OR=1.19; 95% CI 1.02 to 1.45). This association persisted (OR=1.24; 95% CI 1.02 to 1.53) after adjustment for potential confounders, including insurance status. We found no difference in hospital admission rates between limited English proficiency patients and English-speaking patients. Yet limited English proficiency patients were 24% more likely to have an unplanned ED revisit within 72 hours, with an absolute difference of 0.9%, suggesting challenges in ED quality of care. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

National study of health insurance type and reasons for emergency department use.

PubMed

Capp, Roberta; Rooks, Sean P; Wiler, Jennifer L; Zane, Richard D; Ginde, Adit A

2014-04-01

The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown. We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED. This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n = 4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues). We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics. Overall, 65.0% (95% CI 63.0-66.9) of adults reported ≥ 1 acuity issue and 78.9% (95% CI 77.3-80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2% reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95% CI 0.79-1.40) and those with Medicare (OR 0.98; 95% CI 0.66-1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95% CI 1.06-2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95% CI 1.18-3.19) were more likely than those with private insurance to seek ED care for access issues. Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.

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

Cloning and expression of chitinases of Entamoebae.

PubMed

de la Vega, H; Specht, C A; Semino, C E; Robbins, P W; Eichinger, D; Caplivski, D; Ghosh, S; Samuelson, J

1997-04-01

Entamoeba histolytica (Eh) and Entamoeba dispar (Ed) are protozoan parasites that infect hundreds of millions of persons. In the colonic lumen, amebae form chitin-walled cysts, the infectious stage of the parasite. Entamoeba invadens (Ei), which infects reptiles and is a model for amebic encystation, produces chitin synthase and chitinase during encystation. Ei cysts formation is blocked by the chitinase-inhibitor allosamidin. Here molecular cloning techniques were used to identify homologous genes of Eh, Ed, and Ei that encode chitinases (EC 3.2.1.14). The Eh gene (Eh cht1) predicts a 507-amino acid (aa) enzyme, which has 93 and 74% positional identities with Ed and Ei chitinases, respectively. The Entamoeba chitinases have signal sequences, followed by acidic and hydrophilic sequences composed of multiple tandemly arranged 7-aa repeats (Eh and Ed) or repeats varying in length (Ei). The aa compositions of the chitinase repeats are similar to those of the repeats of the Eh and Ed Ser-rich proteins. The COOH-terminus of each chitinase has a catalytic domain, which resembles those of Brugia malayi (33% positional identity) and Manduca sexta (29%). Recombinant entamoeba chitinases are precipitated by chitin and show chitinase activity with chitooligosacharide substrates. Consistent with previous biochemical data, chitinase mRNAs are absent in Ei trophozoites and accumulate to maximal levels in Ei encysting for 48 h.

Efficacy of scheduled return visits for emergency department patients with non-specific abdominal pain.

PubMed

Boendermaker, Annemieke E; Coolsma, Constant W; Emous, Marloes; Ter Avest, Ewoud

2018-06-02

Many patients presenting with abdominal pain to emergency departments (EDs) are discharged without a definitive diagnosis. For these patients, often designated as having non-specific abdominal pain, re-evaluation is often advocated. We aimed to investigate how often re-evaluation changes the diagnosis and clinical management and discern factors that could help identify patients likely to benefit from re-evaluation. This was a retrospective study conducted in the Netherlands between 1 January 2014 and 31 December 2015 of patients asked to return to the ED after an initial presentation with acute non-traumatic abdominal pain. The primary outcome was a clinically relevant change in treatment (surgery, endoscopy during admission and/or hospitalisation) and diagnosis at ED re-evaluation within 30 hours. During the 2-year study period, 358 ED patients with non-specific abdominal pain were scheduled for re-evaluation. Of these, 14% (11%-18%)) did not present for re-evaluation. Re-evaluation resulted in a clinically relevant change in diagnosis and treatment in, respectively, 21.3% (17%-29%)) and 22.3% (18%-27%)) of the subjects. Of the clinical, biochemical and radiological factors available at the index visit, C reactive protein (CRP) at the index visit predicted a change in treatment (CRP >27 mg/L likelihood ratio (LR)+ 1.69 (1.21-2.36)), while an increase in CRP of >25 mg/L between index and re-evaluation visit (LR+ 2.85 (1.88-4.32)) and the conduct of radiological studies at the re-evaluation visit were associated with changes in treatment (LR+ 3.05 (2.41-3.86)). Re-evaluation within 30 hours for ED patients discharged with non-specific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost one-quarter of patients. Elevated CRP at the index visit might assist in correctly identifying patients with a greater likelihood of needing treatment in follow-up, and a low threshold for radiological studies should be considered during re-evaluation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Comprehensive long-term management program for asthma: effect on outcomes in adult African-Americans.

PubMed

Kelso, T M; Abou-Shala, N; Heilker, G M; Arheart, K L; Portner, T S; Self, T H

1996-06-01

To determine if a comprehensive long-term management program, emphasizing inhaled corticosteroids and patient education, would improve outcomes in adult African-American asthmatics a nonrandomized control trial with a 2-year intervention was performed in a university-based clinic. Inclusion criteria consisted of (> or = 5) emergency department (ED) visits or hospitalizations (> or = 2) during the previous 2 years. Intervention patients were volunteers; a comparable control group was identified via chart review at hospitals within the same area and time period as the intervention patients. Individualized doses of beclomethasone with a spacer, inhaled albuterol "as needed," and crisis prednisone were the primary therapies. Environmental control, peak flow monitoring, and a partnership with the patient were emphasized. Detailed patient education was an integral part of management. Control patients received usual care from local physicians. ED visits and hospitalizations for 2 years before and 2 years during the intervention period were compared. Quality of life (QOL) measurements were made at baseline and every 6 months in the intervention group. Study group (n = 21) had a significant reduction in ED visits (2.3 +/- 0.2 pre-intervention versus 0.6 +/- 0.2 post-intervention; P = 0.0001). Control group (n = 18) did not have a significant change in ED visits during the 2-year post-intervention period (2.6 +/- 0.2 pre-intervention versus 2.0 +/- 0.2 post-intervention; P = 0.11). Both groups had significant reductions in hospitalizations, but the study group had a greater reduction. Sixty-two percent of study patients had complete elimination of ED visits and hospitalizations, whereas no control patients had total elimination of the need for institutional acute care. QOL in the study patients revealed significant improvements for most parameters. A comprehensive long-term management program emphasizing inhaled corticosteroids combined with other state-of-the-art management, including intensive patient education, improves outcomes in adult African-American asthmatics.

Screening injured children for physical abuse or neglect in emergency departments: a systematic review.

PubMed

Woodman, J; Lecky, F; Hodes, D; Pitt, M; Taylor, B; Gilbert, Ruth

2010-03-01

Screening markers are used in emergency departments (EDs) to identify children who should be assessed for possible physical abuse and neglect. We conducted three systematic reviews evaluating age, repeat attendance and injury type as markers for physical abuse or neglect in injured children attending EDs. We included studies comparing markers in physically abused or neglected children and non-abused injured children attending ED or hospital. We calculated likelihood ratios (LRs) for age group, repeat attendance and injury type (head injury, bruises, fractures, burns or other). Given the low prevalence of abuse or neglect, we considered that an LR of 10 or more would be clinically useful. All studies were poor quality. Infancy increased the risk of physical abuse or neglect in severely injured or admitted children (LRs 7.7-13.0, 2 studies) but was not strongly associated in children attending the ED (LR 1.5, 95% CI: 0.9, 2.8; one study). Repeat attendance did not substantially increase the risk of abuse or neglect and may be confounded by chronic disease and socio-economic status (LRs 0.8-3.9, 3 studies). One study showed no evidence that the type of injury substantially increased the risk of physical abuse or neglect in severely injured children. There was no evidence that any of the markers (infancy, type of injury, repeated attendance) were sufficiently accurate (i.e. LR >or= 10) to screen injured children in the ED to identify those requiring paediatric assessment for possible physical abuse or neglect. Clinicians should be aware that among injured children at ED a high proportion of abused children will present without these characteristics and a high proportion of non-abused children will present with them. Information about age, injury type and repeat attendances should be interpreted in this context.

The effect of a class IV hurricane on emergency department operations.

PubMed

Sheppa, C M; Stevens, J; Philbrick, J T; Canada, M

1993-09-01

The objective of this study was to determine the impact on emergency department (ED) operations of Hurricane Hugo, a class IV hurricane that struck Charleston, South Carolina, on September 21, 1989. The study design was a retrospective record-based descriptive study and mail survey of the ED of a 300-bed regional medical center directly in the path of the storm. During the 3 weeks after the storm, ED patient volume increased 19% over that of the 3 weeks before the storm. Increased visit volumes were evident for at least 3 months. Compared with a similar period of the previous year, there was an increase in the proportion of patients seen for lacerations of all types, puncture wounds, stings, and falls. Sixty-two percent of physician offices were still closed 7 days after the storm. The direct effects of a class IV hurricane on ED operations included major alterations in the volume and types of patient visits. Because of the evacuation of approximately 40% of the coastal population and storm damage hindering travel, the increase in visit volume was less in magnitude but of longer duration has been reported in class III hurricanes.

A Comparison of Parallel and Integrated Models for Implementation of Routine HIV Screening in a Large, Urban Emergency Department.

PubMed

Hankin, Abigail; Freiman, Heather; Copeland, Brittney; Travis, Natasha; Shah, Bijal

2016-01-01

This study compared two approaches for implementation of non-targeted HIV screening in the emergency department (ED): (1) designated HIV counselors screening in parallel with ED care and (2) nurse-based screening integrated into patient triage. A retrospective analysis was performed to compare parallel and integrated screening models using data from the first 12 months of each program. Data for the parallel screening model were extracted from information collected by HIV test counselors and the electronic medical record (EMR). Integrated screening model data were extracted from the EMR and supplemented by data collected by HIV social workers during patient interaction. For both programs, data included demographics, HIV test offer, test acceptance or declination, and test result. A Z-test between two proportions was performed to compare screening frequencies and results. During the first 12 months of parallel screening, approximately 120,000 visits were made to the ED, with 3,816 (3%) HIV tests administered and 65 (2%) new diagnoses of HIV infection. During the first 12 months of integrated screening, 111,738 patients were triaged in the ED, with 16,329 (15%) patients tested and 190 (1%) new diagnoses. Integrated screening resulted in an increased frequency of HIV screening compared with parallel screening (0.15 tests per ED patient visit vs. 0.03 tests per ED patient visit, p<0.001) and an increase in the absolute number of new diagnoses (190 vs. 65), representing a slight decrease in the proportion of new diagnoses (1% vs. 2%, p=0.007). Non-targeted, integrated HIV screening, with test offer and order by ED nurses during patient triage, is feasible and resulted in an increased frequency of HIV screening and a threefold increase in the absolute number of newly identified HIV-positive patients.

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

Low-acuity presentations to the emergency department in Canada: exploring the alternative attempts to avoid presentation.

PubMed

Krebs, Lynette D; Kirkland, Scott W; Chetram, Rajiv; Nikel, Taylor; Voaklander, Britt; Davidson, Alan; Holroyd, Bryn; Villa-Roel, Cristina; Crick, Katelynn; Couperthwaite, Stephanie; Alexiu, Chris; Cummings, Garnet; Rowe, Brian H

2017-04-01

ED visits have been rising year on year worldwide. It has been suggested that some of these visits could be avoided if low-acuity patients had better primary care access. This study explored patients' efforts to avoid ED presentation and alternative care sought prior to presentation. Consecutive adult patients presenting to three urban EDs in Edmonton, Canada, completed a questionnaire collecting demographics, actions attempted to avoid presentation and reasons for presentation. Survey data were cross-referenced to a minimal patient dataset containing ED and demographic information. A total of 1402 patients (66.5%) completed the survey. Although 89.3% of the patients felt that the ED was their best care option, the majority of patients (60.1%) sought alternative care or advice prior to presentation. Men, individuals who presented with injury only, and individuals with less than a high school education were all less likely to seek alternative care. Alternative care actions included visiting a physician (54.1%) or an alternative healthcare professional (eg, chiropractor, physiotherapist, etc; 21.2%), calling physician offices (47%) or the regional health information line (13%). Of those who called their physicians, the majority received advice to present to the ED (67.5%). Most low-acuity patients attempt to avoid ED presentation by seeking alternative care. This analysis identifies groups of individuals in the study region who are less likely to seek alternative care first and may benefit from targeted interventions/education. Other regions may wish to complete a similar profile to determine which patients are less likely to seek alternative care first. 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/.

What Parents Want: Does Provider Knowledge of Written Parental Expectations Improve Satisfaction in the Emergency Department?

PubMed

Zoltowski, Kathleen S W; Mistry, Rakesh D; Brousseau, David C; Whitfill, Travis; Aronson, Paul L

2016-01-01

Satisfaction is an important measure of care quality. Interventions to improve satisfaction in the pediatric emergency department (ED) are limited, especially for patients with nonurgent conditions. Our objective was to determine if clinician knowledge of written parental expectations improves parental satisfaction for nonurgent ED visits. This randomized controlled trial was conducted in a tertiary-care pediatric ED. Parents of children presenting for nonurgent visits (Emergency Severity Index level 4 or 5) were randomized into 3 groups: 1) the intervention group completed an expectation survey on arrival, which was reviewed by the clinician, 2) the control group completed the expectation survey, which was not reviewed, and 3) the baseline group did not complete an expectation survey. At ED disposition, all groups completed a 3-item satisfaction survey, scored using 5-point Likert scales (1 = very poor, 5 = very good). The primary outcome was rating of "overall care." Secondary outcomes included likelihood of recommending the ED and staff sensitivity to concerns. Proportions were compared by chi-square test. A total of 304 subjects were enrolled. The proportion of parents rating 5 of 5 for overall care did not differ among the baseline, control, and intervention groups (74.8% vs 73.2% vs 69.2%, P = .56). The proportion of parents rating 5 of 5 also did not differ for likelihood of recommending the ED (77.7% vs 72.2% vs 70.2%, P = .45) or staff sensitivity to concerns (78.6% vs 78.4% vs 78.8%, P = .71). For nonurgent pediatric ED visits, clinician knowledge of written parental expectations does not improve parental satisfaction. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Comparison of Canadian versus American emergency department visits for acute asthma

PubMed Central

Rowe, Brian H; Bota, Gary W; Clark, Sunday; Camargo, Carlos A

2007-01-01

BACKGROUND: Acute asthma is a common emergency department (ED) presentation in both Canada and the United States. OBJECTIVE: To compare ED asthma management and outcomes between Canada and the United States. MEHODS: A prospective cohort study of 69 American and eight Canadian EDs was conducted. Patients aged two to 54 years who presented with acute asthma underwent a structured ED interview and telephone follow-up two weeks later. RESULTS: A total of 3031 patients were enrolled. Canadian patients were more likely to be white (89% versus 22%; P<0.001), have health insurance (100% versus 69%; P<0.001) and identify a primary care provider (89% versus 64%; P<0.001) than American patients. In addition, Canadian patients were more likely to be using inhaled corticosteroids (63% versus 44%; P<0.001) and had higher initial peak expiratory flow (61% versus 48%; P<0.001). In the ED, Canadians received fewer beta-agonist (one versus two; P<0.001) and more anticholinergic (two versus one; P<0.001) treatments in the first hour; use of systemic corticosteroids was similar (60% versus 68%; P=0.13). Canadians were less likely to be hospitalized (11% versus 21%; P=0.02). Corticosteroids were prescribed similarly at discharge (60% versus 69%; P=0.13); however, Canadians were discharged more commonly on inhaled corticosteroids (63% versus 11%; P<0.001) and relapses were similar. CONCLUSIONS: Canadian patients with acute asthma have fewer barriers to primary care and are more likely to be on preventive medications, both before the ED visit and following discharge. Admissions rates are higher in the United States; however, relapse after discharge is similar between countries. These findings highlight the influences of preventive practices and heath care systems on ED visits for asthma. PMID:17885692

Acute Care Utilization by Patients After Graduation of Their Resident Primary Care Physicians.

PubMed

Solomon, Sonja R; Gooding, Holly C; Reyes Nieva, Harry; Linder, Jeffrey A

2015-11-01

The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes. Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents' primary care patients. This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012. We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating. Our study population comprised 90 residents, 4018 unique patients, and 5988 resident-patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, -2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31). Acute care utilization by residents' patients did not increase or decrease after graduation. Acute care utilization was high before and after graduation. Interventions to decrease the need for acute care should be employed throughout the year.

Temporal Trends in Epinephrine Dispensing and Allergy/Immunology Follow-up Among Emergency Department Anaphylaxis Patients in the United States, 2005-2014.

PubMed

Motosue, Megan S; Bellolio, M Fernanda; Van Houten, Holly K; Shah, Nilay D; Bellamkonda, Venkatesh R; Nestler, David M; Campbell, Ronna L

Anaphylaxis is a potentially life-threatening allergic reaction; measures including prescription of an epinephrine autoinjector (EAI) and allergy/immunology (A/I) follow-up may prevent future morbidity. The objective of this study was to evaluate trends in outpatient management of anaphylaxis by studying EAI dispensing and A/I follow-up among patients seen in the emergency department (ED) for anaphylaxis from 2005 through 2014. We analyzed administrative claims data from the OptumLabs Data Warehouse database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. The study cohort comprised 18,279 patients with a mean age of 39 years; 58% were female, and 86% were discharged from an ED. Within 1 year after discharge, 46% had filled an EAI prescription and 29% had A/I follow-up. Overall, from 2005 to 2014, annual rates of filled EAI prescriptions and A/I follow-up did not change. Among children (aged <18 years), rates increased for filled EAI prescriptions (16.1% increase; P = .02 for trend) and A/I follow-up (18.8% increase; P = .048 for trend). Rates decreased for A/I follow-up among adults (15.4% decrease; P = .002 for trend). Overall rates of filled EAI prescriptions were highest in those with venom-induced (73.9 per 100 ED visits) and food-induced anaphylaxis (69.4 per 100 ED visits); the lowest rates were among those with medication-related anaphylaxis (18.2 per 100 ED visits). Over the past decade, rates of EAI dispensing and A/I follow-up after an ED visit for anaphylaxis have remained low, suggesting that patients may not be prepared to manage future episodes. Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse.

PubMed

Singhal, Astha; Tien, Yu-Yu; Hsia, Renee Y

2016-01-01

Prescription drug abuse is a growing problem nationally. In an effort to curb this problem, emergency physicians might rely on subjective cues such as race-ethnicity, often unknowingly, when prescribing opioids for pain-related complaints, especially for conditions that are often associated with drug-seeking behavior. Previous studies that examined racial-ethnic disparities in opioid dispensing at emergency departments (EDs) did not differentiate between prescriptions at discharge and drug administration in the ED. We examined racial-ethnic disparities in opioid prescription at ED visits for pain-related complaints often associated with drug-seeking behavior and contrasted them with conditions objectively associated with pain. We hypothesized a priori that racial-ethnic disparities will be present among opioid prescriptions for conditions associated with non-medical use, but not for objective pain-related conditions. Using data from the National Hospital Ambulatory Medical Care Survey for 5 years (2007-2011), the odds of opioid prescription during ED visits made by non-elderly adults aged 18-65 for 'non-definitive' conditions (toothache, back pain and abdominal pain) or 'definitive' conditions (long-bone fracture and kidney stones) were modeled. Opioid prescription at discharge and opioid administration at the ED were the primary outcomes. We found significant racial-ethnic disparities, with non-Hispanic Blacks being less likely (adjusted odds ratio ranging from 0.56-0.67, p-value < 0.05) to receive opioid prescription at discharge during ED visits for back pain and abdominal pain, but not for toothache, fractures and kidney stones, compared to non-Hispanic whites after adjusting for other covariates. Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for disproportionate burden of opioid abuse among whites. The findings have important implications for medical provider education to include sensitization exercises towards their inherent biases, to enable them to consciously avoid these biases from defining their practice behavior.

The frequency of asthma exacerbations and healthcare utilization in patients with asthma from the UK and USA.

PubMed

Suruki, Robert Y; Daugherty, Jonas B; Boudiaf, Nada; Albers, Frank C

2017-04-27

Asthma exacerbations are frequent in patients with severe disease. This report describes results from two retrospective cohort studies describing exacerbation frequency and risk, emergency department (ED)/hospital re-admissions, and asthma-related costs by asthma severity in the US and UK. Patients with asthma in the US-based Clinformatics™ DataMart Multiplan IMPACT (2010-2011; WEUSKOP7048) and the UK-based Clinical Practice Research Datalink (2009-2011; WEUSKOP7092) databases were categorized by disease severity (Global Initiative for Asthma [GINA]; Step and exacerbation history) during the 12 months pre-asthma medical code (index date). Outcomes included: frequency of exacerbations (asthma-related ED visit, hospitalization, or oral corticosteroid use with an asthma medical code recorded within ±2 weeks) 12 months post-index, asthma-related ED visits/hospitalization, and asthma-related costs 30 days post-index. Risk of a subsequent exacerbation was determined by proportional hazard model. Of the 222,817 and 211,807 patients with asthma included from the US and UK databases, respectively, 12.5 and 8.4% experienced ≥1 exacerbation during the follow-up period. Exacerbation frequency increased with disease severity. Among the 5,167 and 2,904 patients with an asthma-related ED visit/hospitalization in the US and UK databases, respectively, 9.2 and 4.7% had asthma-related re-admissions within 30 days. Asthma-related re-admission rates and costs increased with disease severity, approximately doubling between GINA Step 1 and 5 and in patients with ≥2 versus <2 exacerbations in the previous year. Risk of a subsequent exacerbation increased 32-35% for an exacerbation requiring ED visit/hospitalization versus oral corticosteroids. Increased disease severity was associated with higher exacerbation frequency, ED/hospitalization re-admission, costs and risk of subsequent exacerbation, indicating that these patients require high-intensity post-exacerbation management.

The impact of heatwaves on emergency department visits in Brisbane, Australia: a time series study.

PubMed

Toloo, Ghasem Sam; Yu, Weiwei; Aitken, Peter; FitzGerald, Gerry; Tong, Shilu

2014-04-09

The acute health effects of heatwaves in a subtropical climate and their impact on emergency departments (ED) are not well known. The purpose of this study is to examine overt heat-related presentations to EDs associated with heatwaves in Brisbane. Data were obtained for the summer seasons (December to February) from 2000-2012. Heatwave events were defined as two or more successive days with daily maximum temperature ≥34°C (HWD1) or ≥37°C (HWD2). Poisson generalised additive model was used to assess the effect of heatwaves on heat-related visits (International Classification of Diseases (ICD) 10 codes T67 and X30; ICD 9 codes 992 and E900.0). Overall, 628 cases presented for heat-related illnesses. The presentations significantly increased on heatwave days based on HWD1 (relative risk (RR) = 4.9, 95% confidence interval (CI): 3.8, 6.3) and HWD2 (RR = 18.5, 95% CI: 12.0, 28.4). The RRs in different age groups ranged between 3-9.2 (HWD1) and 7.5-37.5 (HWD2). High acuity visits significantly increased based on HWD1 (RR = 4.7, 95% CI: 2.3, 9.6) and HWD2 (RR = 81.7, 95% CI: 21.5, 310.0). Average length of stay in ED significantly increased by >1 hour (HWD1) and >2 hours (HWD2). Heatwaves significantly increase ED visits and workload even in a subtropical climate. The degree of impact is directly related to the extent of temperature increases and varies by socio-demographic characteristics of the patients. Heatwave action plans should be tailored according to the population needs and level of vulnerability. EDs should have plans to increase their surge capacity during heatwaves.

Lack of agreement in pediatric emergency department discharge diagnoses from clinical and administrative data sources.

PubMed

Gorelick, Marc H; Knight, Stacey; Alessandrini, Evaline A; Stanley, Rachel M; Chamberlain, James M; Kuppermann, Nathan; Alpern, Elizabeth R

2007-07-01

Diagnosis information from existing data sources is used commonly for epidemiologic, administrative, and research purposes. The quality of such data for emergency department (ED) visits is unknown. To determine the agreement on final diagnoses between two sources, electronic administrative sources and manually abstracted medical records, for pediatric ED visits, in a multicenter network. This was a cross sectional study at 19 EDs nationwide. The authors obtained data from two sources at each ED during a three-month period in 2003: administrative sources for all visits and abstracted records for randomly selected visits during ten days over the study period. Records were matched using unique identifiers and probabilistic linkage. The authors recorded up to three diagnoses from each abstracted medical record and up to ten for the administrative data source. Diagnoses were grouped into 104 groups using a modification of the Clinical Classification System. A total of 8,860 abstracted records had at least one valid diagnosis code (with a total of 12,895 diagnoses) and were successfully matched to records in the administrative source. Overall, 67% (95% confidence interval = 66% to 68%) of diagnoses from the administrative and abstracted sources were within the same diagnosis group. Agreement varied by site, ranging from 54% to 77%. Agreement varied substantially by diagnosis group; there was no difference by method of linkage. Clustering clinically similar diagnosis groups improved agreement between administrative and abstracted data sources. ED diagnoses retrieved from electronic administrative sources and manual chart review frequently disagree, even if similar diagnosis codes are grouped. Agreement varies by institution and by diagnosis. Further work is needed to improve the accuracy of diagnosis coding; development of a grouping system specific to pediatric emergency care may be beneficial.

Elevated lactate during psychogenic hyperventilation.

PubMed

ter Avest, E; Patist, F M; Ter Maaten, J C; Nijsten, M W N

2011-04-01

Elevated arterial lactate levels are closely related to morbidity and mortality in various patient categories. In the present retrospective study, the relation between arterial lactate, partial pressure of carbon dioxide (Pco(2)) and pH was systematically investigated in patients who visited the emergency department (ED) with psychogenic hyperventilation. Over a 5-month period, all the patients who visited the ED of a university hospital with presumed psychogenic hyperventilation were evaluated. Psychogenic hyperventilation was presumed to be present when an increased respiratory rate (>20 min) was documented at or before the ED visit and when somatic causes explaining the hyperventilation were absent. Arterial blood gas and lactate levels (reference values 0.5-1.5 mmol/l) were immediately measured by a point-of-care analyser that was managed and calibrated by the central laboratory. During the study period, 46 patients were diagnosed as having psychogenic hyperventilation. The median (range) Pco(2) for this group was 4.3 (2.0-5.5) kPa, the pH was 7.47 (7.40-7.68) and the lactate level was 1.2 (0.5-4.4) mmol/l. 14 participants (30%) had a lactate level above the reference value of 1.5 mmol/l. Pco(2) was the most important predictor of lactate in multivariate analysis. None of the participants underwent any medical treatment other than observation at the ED or had been hospitalised after their ED visit. In patients with psychogenic hyperventilation, lactate levels are frequently elevated. Whereas high lactates are usually associated with acidosis and an increased risk of poor outcome, in patients with psychogenic hyperventilation, high lactates are associated with hypocapnia and alkalosis. In this context, elevated arterial lactate levels should not be regarded as an adverse sign.

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.

Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss.

PubMed

Mahmoudi, Elham; Zazove, Philip; Meade, Michelle; McKee, Michael M

2018-04-26

Hearing loss (HL) is common among older adults and is associated with poorer health and impeded communication. Hearing aids (HAs), while helpful in addressing some of the outcomes of HL, are not covered by Medicare. To determine whether HA use is associated with health care costs and utilization in older adults. This retrospective cohort study used nationally representative 2013-2014 Medical Expenditure Panel Survey data to evaluate the use of HAs among 1336 adults aged 65 years or older with HL. An inverse propensity score weighting was applied to adjust for potential selection bias between older adults with and without HAs, all of whom reported having HL. The mean treatment outcomes of HA use on health care utilization and costs were estimated. Encounter with the US health care system. (1) Total health care, Medicare, and out-of-pocket spending; (2) any emergency department (ED), inpatient, and office visit; and (3) number of ED visits, nights in hospital, and office visits. Of the 1336 individuals included in the study, 574 (43.0%) were women; mean (SD) age was 77 (7) years. Adults without HAs (n = 734) were less educated, had lower income, and were more likely to be from minority subpopulations. The mean treatment outcomes of using HAs per participant were (1) higher total annual health care spending by $1125 (95% CI, $1114 to $1137) and higher out-of-pocket spending by $325 (95% CI, $322 to $326) but lower Medicare spending by $71 (95% CI, -$81 to -$62); (2) lower probability of any ED visit by 2 percentage points (PPs) (24% vs 26%; 95% CI, -2% to -2%) and lower probability of any hospitalization by 2 PPs (20% vs 22%; 95% CI, -3% to -1%) but higher probability of any office visit by 4 PPs (96% vs 92%; 95% CI, 4% to 4%); and (3) 1.40 more office visits (95% CI, 1.39 to 1.41) but 0.46 (5%) fewer number of hospital nights (95% CI, -0.47 to -0.44), with no association with the number of ED visits, if any (95% CI, 0.01 to 0). This study demonstrates the beneficial outcomes of use of HAs in reducing the probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital. Although use of HAs reduced total Medicare costs, it significantly increased total and out-of-pocket health care spending. This information may have implications for Medicare regarding covering HAs for patients with HL.

Treatment of panic in chest pain patients from emergency departments: efficacy of different interventions focusing on panic management.

PubMed

Marchand, André; Belleville, Geneviève; Fleet, Richard; Dupuis, Gilles; Bacon, Simon L; Poitras, Julien; Chauny, Jean-Marc; Vadeboncoeur, Alain; Lavoie, Kim L

2012-01-01

The aim was to assess the efficacy of two brief cognitive-behavioral therapy (CBT)-based interventions (7×1-h sessions and 1×2-h session) and a pharmacological treatment (paroxetine), compared to supportive usual care, initiated in the emergency department (ED) for individuals suffering from panic disorder (PD) with a chief complain of noncardiac chest pain (NCCP). We hypothesized that the interventions would be more efficacious than supportive usual care on all outcomes. A 12-month follow-up study of patients who received a diagnosis of NCCP in the ED and who met diagnostic criteria for PD (n=71) was performed. Assessments included several psychological questionnaires and a structured interview. A series of repeated-measures analyses of variances, using a split-plot design, were conducted, as well as planned comparisons to examine the differences. The seven-session CBT (n=19), one-session panic management (n=24) and pharmacotherapy (n=13) led to greater improvements in PD severity (primary outcome) compared to supportive usual care (n=15) at posttest, and no significant difference was noted between the three active interventions. On the other measures, patients improved in all conditions, and the therapeutic gains were maintained up to 1 year following the visit to the ED. These results suggests that early intervention, in particular seven sessions of CBT, one session of PM or pharmacotherapy (generic paroxetine), should be considered for the treatment of PD patients consulting the ED with a discharge diagnosis of NCCP. Copyright © 2012 Elsevier 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

Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study.

PubMed

Berkowitz, Seth A; Meigs, James B; DeWalt, Darren; Seligman, Hilary K; Barnard, Lily S; Bright, Oliver-John M; Schow, Marie; Atlas, Steven J; Wexler, Deborah J

2015-02-01

Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear. To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources. Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%). The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits). Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39 [95% CI, 1.18-1.63]) and increased use of health care resources (IRR for outpatient visits, 1.09 [95% CI, 1.03-1.15]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]). Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.

Ambient Ozone and Emergency Department Visits for Cellulitis

PubMed Central

Szyszkowicz, Mieczysław; Porada, Eugeniusz; Kaplan, Gilaad G.; Rowe, Brian H.

2010-01-01

Objectives were to assess and estimate an association between exposure to ground-level ozone and emergency department (ED) visits for cellulitis. All ED visits for cellulitis in Edmonton, Canada, in the period April 1992–March 2002 (N = 69,547) were examined. Case-crossover design was applied to estimate odds ratio (OR, and 95% confidence interval) per one interquartile range (IQR) increase in ozone concentration (IQR = 14.0 ppb). Delay of ED visit relating to exposure was probed using 0- to 5-day exposure lags. For all patients in the all months (January–December) and lags 0 to 2 days, OR = 1.05 (1.02, 1.07). For male patients during the cold months (October–March): OR = 1.05 (1.02, 1.09) for lags 0 and 2 and OR = 1.06 (1.02, 1.10) for lag 3. For female patients in the warm months (April–September): OR = 1.12 (1.06, 1.18) for lags 1 and 2. Cellulitis developing on uncovered (more exposed) skin was analyzed separately, observed effects being stronger. Cellulitis may be associated with exposure to ambient ground level ozone; the exposure may facilitate cellulitis infection and aggravate acute symptoms. PMID:21139878

A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients.

PubMed

Fox, Timothy R; Li, James; Stevens, Sandra; Tippie, Tracy

2013-09-01

In an effort to reduce prescription opioid abuse originating from our institution, we implement and measure the effect of a prescribing guideline on the rate of emergency department (ED) opioid prescriptions written for patients presenting with dental pain, a complaint previously associated with drug-seeking behavior. After implementing a departmental guideline on controlled substance prescriptions, we performed a structured before-and-after chart review of dental pain patients aged 16 and older. Before the guideline, the rate of opioid prescription was 59% (302/515). After implementation, the rate was 42% (65/153). The absolute decrease in rates was 17% (95% confidence interval 7% to 25%). Additionally, in comparing the 12-month period before and after implementation, the dental pain visit rate decreased from 26 to 21 per 1,000 ED visits (95% confidence interval of decrease 2 to 9 visits/1,000). A performance improvement program involving a departmental prescribing guideline was associated with a reduction in the rate of opioid prescriptions and visits for ED patients presenting with dental pain. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Mobile integrated health to reduce post-discharge acute care visits: A pilot study.

PubMed

Siddle, Jennica; Pang, Peter S; Weaver, Christopher; Weinstein, Elizabeth; O'Donnell, Daniel; Arkins, Thomas P; Miramonti, Charles

2018-05-01

Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90days before MIH intervention to 90days after. Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p=0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p=0.98; observation stays 95 to 106, p=0.30) Primary care visits increased 15% (p=0.11). In this pilot before/after study, MIH significantly reduces acute care hospitalizations. Copyright © 2017 Elsevier Inc. All rights reserved.

The Decline in Hydrocodone/Acetaminophen Prescriptions in Emergency Departments in the Veterans Health Administration Between 2009 to 2015.

PubMed

Grasso, Michael A; Dezman, Zachary D W; Comer, Angela C; Jerrard, David A

2016-07-01

The purpose of the study was to measure national prescribing patterns for hydrocodone/acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance. We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions. During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=-0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a pain score≥7 (OR 3.199, CI [3.192-3.205]), a musculoskeletal (OR 1.622, CI [1.615-1.630]) or soft tissue (OR 1.656, CI [1.649-1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271-1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833-1.853]). Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal.

"Beaned": A 5-Year Analysis of Baseball-Related Injuries of the Face.

PubMed

Carniol, Eric T; Shaigany, Kevin; Svider, Peter F; Folbe, Adam J; Zuliani, Giancarlo F; Baredes, Soly; Eloy, Jean Anderson

2015-12-01

Baseball remains one of the most popular and safest games played by children and adults in America and worldwide. Rules and equipment changes have continued to make the game safer. For youth leagues, pitching restrictions, safety balls, helmets, and face mask equipment continue to make the game safer. With increased utilization of safety equipment, the objective was to analyze recent trends in baseball-related facial injuries. Cross-sectional analysis of a national database. The National Electronic Injury Surveillance System was searched for baseball-related facial injuries with analysis of incidence, age, and sex and specific injury diagnoses, mechanisms, and facial locations. From 2009 to 2013, there were 5270 cases entries, or 187,533 estimated emergency department (ED) visits, due to baseball-related facial injuries. During this time, there was a significant decline in the incidence of ED visits (P = .014). Inclusion criteria were met by 3208 visits. The majority of injuries occurred in patients ≤18 years old (81.5%). The most common injury was laceration (33.2%), followed by contusion (29.7%) and fracture (26.9%), while the most common injury site on the face was the nose (24.9%). The injuries were most commonly due to impact from a baseball (70%) or a bat (12.5%). The overall incidence of ED visits due to baseball-related facial injuries has decreased over the past 5 years, concurrent with increased societal use of protective equipment. Nonetheless, these injuries remain a common source for ED visits, and a continued effort to utilize safety measures should be made, particularly in youth leagues. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology.

PubMed

Gilbert, John W; Johnson, Kevin M; Larkin, Gregory L; Moore, Christopher L

2012-07-01

To estimate recent trends in CT/MRI utilisation among patients seeking emergency care for atraumatic headache in the USA and to identify factors associated with a diagnosis of significant intracranial pathology (ICP) in these patients. Data were obtained from the USA National Hospital Ambulatory Medical Care Survey of emergency department (ED) visits between 1998 and 2008. A cohort of atraumatic headache-related visits were identified using preassigned 'reason-for-visit' codes. Sample visits were weighted to provide national estimates. Between 1998 and 2008 the percentage of patients presenting to the ED with atraumatic headache who underwent imaging increased from 12.5% to 31.0% (p < 0.01) while the prevalence of ICP among those visits decreased from 10.1% to 3.5% (p < 0.05). The length of stay in the ED was 4.6 h (95% CI 4.4 to 4.8) for patients with headache who received imaging compared with 2.7 (95% CI 2.6 to 2.9) for those who did not. Of 18 factors evaluated in patients with headache, 10 were associated with a significantly increased odds of an ICP diagnosis: age ≥ 50 years, arrival by ambulance, triage immediacy <15 min, systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg and disturbance in sensation, vision, speech or motor function including neurological weakness. The use of CT/MRI for evaluation of atraumatic headache increased dramatically in EDs in the USA between 1998 and 2008. The prevalence of ICP among patients who received CT/MRI declined concurrently, suggesting a role for clinical decision support to guide more judicious use of imaging.

A clinical trial of nurse practitioner care in residential aged care facilities.

PubMed

Arendts, Glenn; Deans, Pamela; O'Brien, Keith; Etherton-Beer, Christopher; Howard, Kirsten; Lewin, Gill; Sim, Moira

2018-05-04

Optimising quality of life and reducing hospitalisation for people living in residential aged care facilities (RACF) are important health policy goals. A cluster controlled clinical trial of nurse practitioner care in RACF. Six facilities were included: three randomly allocated to intervention where nurse practitioners working with general practitioners and using a best practice guide were responsible for care, and three control. Participants were followed up for a minimum of 12 months unless dead or transferred to another facility. We enrolled two hundred patients (101 intervention and 99 control) with a mean (SD) follow up of 604 (276) days. There were 98 ED visits by intervention participants, resulting in 56 hospitalisations, compared with 121 ED visits and 70 hospitalisations for controls (risk reduction = 8%, 95% CI = -1% -17%, p = 0.10). For the pre-specified secondary outcomes of transfers within the first 12 months of enrolment, the number of residents making at least one visit (46 in each study arm) and rate of ED attendance (0.66 visits per intervention resident versus 0.70 visits per control resident) was not affected by the intervention. After adjusting for dependency and comorbidity, the intervention group had non-significantly lower transfers (OR 0.7, 95% CI 0.3-1.5, p = 0.34). There was a reduction in the rate of decline in the quality of life of intervention compared to control residents. Nurse practitioner care coordination resulted in no statistically significant change in rates of ED transfer or health care utilisation, but better maintained resident quality of life. Copyright © 2018 Elsevier B.V. All rights reserved.

Complications following prostate needle biopsy requiring hospital admission or emergency department visits - experience from 1000 consecutive cases.

PubMed

Pinkhasov, G Igor; Lin, Yu-Kuan; Palmerola, Ricardo; Smith, Paul; Mahon, Frank; Kaag, Matthew G; Dagen, J Edward; Harpster, Lewis E; Reese, Carl T; Raman, Jay D

2012-08-01

• To review a contemporary cohort of patients undergoing a transrectal ultrasound-guided prostate needle biopsy (TRUS PNBx) at a single centre to determine the incidence of major complications necessitating hospital admission or emergency department (ED) visits. • The charts of 1000 consecutive patients undergoing TRUS PNBx were reviewed. • All patients received peri-procedural antibiotic prophylaxis with either ciprofloxacin or co-trimoxazole. • Hospital admission and ED visits within 30 days of the procedure were identified for indication, management and outcome. • Patient comorbidities and biopsy characteristics were reviewed for association with complications. • Of the 1000 patients, 25 (2.5%) had post-biopsy complications requiring hospital admission or an ED visit. • Indications included twelve patients (1.2%) with urosepsis, eight (0.8%) with acute urinary retention requiring urethral catheterization, four (0.4%) with gross haematuria requiring bladder irrigation for <24 h, and one (0.1%) with a transient ischaemia attack 1 day after biopsy. • Patients with urosepsis had an average hospitalization of 5 days, and 75% carried quinolone-resistant Escherichia coli organisms. • All patients with urinary retention had catheters removed within 10 days. No patients with haematuria required a blood transfusion. • No demographic or biopsy variables were particularly associated with development of a post-procedure complication. • In this large contemporary series of TRUS PNBx, we observed a 2.5% rate of major complications requiring hospital admission or an ED visit. • No clinical or biopsy variables were directly associated with development of complications. • These data may be valuable when counselling patients before biopsy. © 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.

Effects of the August 2003 blackout on the New York City healthcare delivery system: a lesson for disaster preparedness.

PubMed

Prezant, David J; Clair, John; Belyaev, Stanislav; Alleyne, Dawn; Banauch, Gisela I; Davitt, Michelle; Vandervoorts, Kathy; Kelly, Kerry J; Currie, Brian; Kalkut, Gary

2005-01-01

On August 14, 2003, the United States and Canada suffered the largest power failure in history. We report the effects of this blackout on New York City's healthcare system by examining the following: 1) citywide 911 emergency medical service (EMS) calls and ambulance responses; and 2) emergency department (ED) visits and hospital admissions to one of New York City's largest hospitals. Citywide EMS calls and ambulance responses were categorized by 911 call type. Montefiore Medical Center (MMC) ED visits and hospital admissions were categorized by diagnosis and physician-reviewed for relationship to the blackout. Comparisons were made to the week pre- and postblackout. Citywide EMS calls numbered 5,299 on August 14, 2003, and 5,021 on August 15, 2003, a 58% increase (p < .001). During the blackout, there were increases in "respiratory" (189%; p < .001), "cardiac" (68%; p = .016), and "other" (40%; p < .001) EMS call categories, but when expressed as a percent of daily totals, "cardiac" was no longer significant. The MMC-ED reflected this surge with only "respiratory" visits significantly increased (expressed as percent of daily total visits; p < .001). Respiratory device failure (mechanical ventilators, positive pressure breathing assist devices, nebulizers, and oxygen compressors) was responsible for the greatest burden (65 MMC-ED visits, with 37 admissions) as compared with 0 pre- and postblackout. The blackout dramatically increased EMS and hospital activity, with unexpected increases resulting from respiratory device failures in community-based patients. Our findings suggest that current capacity to respond to public health emergencies could be easily overwhelmed by widespread/prolonged power failure(s). Disaster preparedness planning would be greatly enhanced if fully operational, backup power systems were mandated, not only for acute care facilities, but also for community-based patients dependent on electrically powered lifesaving devices.

Low-intensity extracorporeal shock wave therapy--a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy.

PubMed

Gruenwald, Ilan; Appel, Boaz; Vardi, Yoram

2012-01-01

Low-intensity shock wave therapy (LI-ESWT) has been reported as an effective treatment in men with mild and moderate erectile dysfunction (ED). The aim of this study is to determine the efficacy of LI-ESWT in severe ED patients who were poor responders to phosphodiesterase type 5 inhibitor (PDE5i) therapy. This was an open-label single-arm prospective study on ED patients with an erection hardness score (EHS) ≤ 2 at baseline. The protocol comprised two treatment sessions per week for 3 weeks, which were repeated after a 3-week no-treatment interval. Patients were followed at 1 month (FU1), and only then an active PDE5i medication was provided for an additional month until final follow-up visit (FU2). At each treatment session, LI-ESWT was applied on the penile shaft and crus at five different anatomical sites (300 shocks, 0.09 mJ/mm(2) intensity at 120 shocks/min). Each subject underwent a full baseline assessment of erectile function using validated questionnaires and objective penile hemodynamic testing before and after LI-ESWT. Outcome measures used are changes in the International Index of Erectile Function-erectile function domain (IIEF-ED) scores, the EHS measurement, and the three parameters of penile hemodynamics and endothelial function. Twenty-nine men (mean age of 61.3) completed the study. Their mean IIEF-ED scores increased from 8.8 ± 1 (baseline) to 12.3 ± 1 at FU1 (P = 0.035). At FU2 (on active PDE5i treatment), their IIEF-ED further increased to 18.8 ± 1 (P < 0.0001), and 72.4% (P < 0.0001) reached an EHS of ≥ 3 (allowing full sexual intercourse). A significant improvement (P = 0.0001) in penile hemodynamics was detected after treatment and this improvement significantly correlated with increases in the IIEF-ED (P < 0.05). No noteworthy adverse events were reported. Penile LI-ESWT is a new modality that has the potential to treat a subgroup of severe ED patients. These preliminary data need to be reconfirmed by multicenter sham control studies in a larger group of ED patients. © 2011 International Society for Sexual Medicine.

A Comprehensive Evaluation of the Burden of Heat-Related Illness and Death within the Florida Population.

PubMed

Harduar Morano, Laurel; Watkins, Sharon; Kintziger, Kristina

2016-05-31

The failure of the human body to thermoregulate can lead to severe outcomes (e.g., death) and lasting physiological damage. However, heat-related illness (HRI) is highly preventable via individual- and community-level modification. A thorough understanding of the burden is necessary for effective intervention. This paper describes the burden of severe HRI morbidity and mortality among residents of a humid subtropical climate. Work-related and non-work-related HRI emergency department (ED) visits, hospitalizations, and deaths among Florida residents during May to October (2005-2012) were examined. Sub-groups susceptible to HRI were identified. The age-adjusted rates/100,000 person-years for non-work-related HRI were 33.1 ED visits, 5.9 hospitalizations, and 0.2 deaths, while for work-related HRI/100,000 worker-years there were 8.5 ED visits, 1.1 hospitalizations, and 0.1 deaths. The rates of HRI varied by county, data source, and work-related status, with the highest rates observed in the panhandle and south central Florida. The sub-groups with the highest relative rates regardless of data source or work-relatedness were males, minorities, and rural residents. Those aged 15-35 years had the highest ED visit rates, while for non-work-related hospitalizations and deaths the rates increased with age. The results of this study can be used for targeted interventions and evaluating changes in the HRI burden over time.

A Comprehensive Evaluation of the Burden of Heat-Related Illness and Death within the Florida Population

PubMed Central

Harduar Morano, Laurel; Watkins, Sharon; Kintziger, Kristina

2016-01-01

The failure of the human body to thermoregulate can lead to severe outcomes (e.g., death) and lasting physiological damage. However, heat-related illness (HRI) is highly preventable via individual- and community-level modification. A thorough understanding of the burden is necessary for effective intervention. This paper describes the burden of severe HRI morbidity and mortality among residents of a humid subtropical climate. Work-related and non-work-related HRI emergency department (ED) visits, hospitalizations, and deaths among Florida residents during May to October (2005–2012) were examined. Sub-groups susceptible to HRI were identified. The age-adjusted rates/100,000 person-years for non-work-related HRI were 33.1 ED visits, 5.9 hospitalizations, and 0.2 deaths, while for work-related HRI/100,000 worker-years there were 8.5 ED visits, 1.1 hospitalizations, and 0.1 deaths. The rates of HRI varied by county, data source, and work-related status, with the highest rates observed in the panhandle and south central Florida. The sub-groups with the highest relative rates regardless of data source or work-relatedness were males, minorities, and rural residents. Those aged 15–35 years had the highest ED visit rates, while for non-work-related hospitalizations and deaths the rates increased with age. The results of this study can be used for targeted interventions and evaluating changes in the HRI burden over time. PMID:27258296

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.

Predictive validity of the identification of seniors at risk screening tool in a German emergency department setting.

PubMed

Singler, Katrin; Heppner, Hans Jürgen; Skutetzky, Andreas; Sieber, Cornel; Christ, Michael; Thiem, Ulrich

2014-01-01

The identification of patients at high risk for adverse outcomes [death, unplanned readmission to emergency department (ED)/hospital, functional decline] plays an important role in emergency medicine. The Identification of Seniors at Risk (ISAR) instrument is one of the most commonly used and best-validated screening tools. As to the authors' knowledge so far there are no data on any screening tool for the identification of older patients at risk for a negative outcome in Germany. To evaluate the validity of the ISAR screening tool in a German ED. This was a prospective single-center observational cohort study in an ED of an urban university-affiliated hospital. Participants were 520 patients aged ≥75 years consecutively admitted to the ED. The German version of the ISAR screening tool was administered directly after triage of the patients. Follow-up telephone interviews to assess outcome variables were conducted 28 and 180 days after the index visit in the ED. The primary end point was death from any cause or hospitalization or recurrent ED visit or change of residency into a long-term care facility on day 28 after the index ED visit. The mean age ± SD was 82.8 ± 5.0 years. According to ISAR, 425 patients (81.7%) scored ≥2 points, and 315 patients (60.5%) scored ≥3 points. The combined primary end point was observed in 250 of 520 patients (48.1%) on day 28 and in 260 patients (50.0%) on day 180. Using a continuous ISAR score the area under the curve on day 28 was 0.621 (95% confidence interval, CI 0.573-0.669) and 0.661 (95% CI 0.615-0.708) on day 180, respectively. The German version of the ISAR screening tool acceptably identified elderly patients in the ED with an increased risk of a negative outcome. Using the cutoff ≥3 points instead of ≥2 points yielded better overall results.

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.

[Use of emergency departments in rural and urban areas in Spain].

PubMed

Sarría-Santamera, A; Prado-Galbarro, J; Ramallo-Farina, Y; Quintana-Díaz, M; Martínez-Virto, A; Serrano-Aguilar, P

2015-03-01

Describe the use of emergency departments (ED), and analyse the differences in use between residents in rural and urban areas. Using data from the National Health Survey of 2006 and 2011, the profiles of patients with ED visits by population size of place of residence were obtained. The variables associated with making one visit to the ED were also evaluated, in order to determine the effect of the population size of place of residence. A higher use of ED is observed in persons with a higher frequency of use of Primary Care and hospital admissions, and increases with worse self-perceived health and functional status, with more chronic diseases, in people from lower social classes, and younger ages. Adjusting for the other variables, residents in larger cities have a higher use of ED than residents in rural areas, who show a higher use of public and non-hospital based ED, than residents in urban areas. There is a higher use of ED by inhabitants of urban areas that cannot be justified by a worst health status of that population. This tends to indicate that the use of ED is not under-used in rural areas, but overused in urban areas. Copyright © 2013 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.

A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families

PubMed Central

Rangachari, Pavani

2017-01-01

Asthma is associated with substantial health care expenditures, including an estimated US$56 billion per year in direct costs. A recurring theme in the asthma management literature is that costly asthma symptoms, including hospitalizations and multiple emergency department (ED)/outpatient visits, can often be prevented through patient/family adherence to the national (National Institutes of Health Expert Panel Report-3) guidelines for effective self-management of asthma, specifically 1) medication adherence and 2) environmental trigger avoidance, as outlined in the patient’s personalized Asthma-Action Plan. It is important to note however that while effective self-management of asthma is known to reduce ED visits and hospitalizations, the relationship between asthma self-management effectiveness and outpatient visit frequency remains ambiguous, reflecting a gap in the literature. For instance, do patients/families who self-manage effectively visit outpatient clinics more frequently for asthma care (compared to those who do not self-manage effectively), after accounting for differences in asthma severity, demographic characteristics, and risk factors? Do patients/families who visit outpatient clinics more frequently for asthma care, in turn have fewer ED and inpatient encounters for asthma? On the other hand, do patients/families who do not revisit outpatient clinics regularly have higher ED visits and hospitalizations? It is important to address these gaps, in order to reduce the costs and public health burden of asthma. This paper provides a foundation for addressing these gaps, by conducting an integrative review of the asthma management literature, to develop a conceptual framework for measuring self-management effectiveness and health care use among pediatric asthma patients/families. In doing so, the paper lays the groundwork for future research seeking to explicate the relationship between asthma self-management effectiveness and health care use, which in turn has potential to engage asthma providers in promoting ideal self-management and optimal health care use for pediatric asthma, in accordance with national evidence-based guidelines for asthma management. PMID:28442924

Self-rated health predicts healthcare utilization in heart failure.

PubMed

Chamberlain, Alanna M; Manemann, Sheila M; Dunlay, Shannon M; Spertus, John A; Moser, Debra K; Berardi, Cecilia; Kane, Robert L; Weston, Susan A; Redfield, Margaret M; Roger, Véronique L

2014-05-28

Heart failure (HF) patients experience impaired functional status, diminished quality of life, high utilization of healthcare resources, and poor survival. Yet, the identification of patient-centered factors that influence prognosis is lacking. We determined the association of 2 measures of self-rated health with healthcare utilization and skilled nursing facility (SNF) admission in a community cohort of 417 HF patients prospectively enrolled between October 2007 and December 2010 from Olmsted County, MN. Patients completed a 12-item Short Form Health Survey (SF-12). Low self-reported physical functioning was defined as a score ≤ 25 on the SF-12 physical component. The first question of the SF-12 was used as a measure of self-rated general health. After 2 years, 1033 hospitalizations, 1407 emergency department (ED) visits, and 19,780 outpatient office visits were observed; 87 patients were admitted to a SNF. After adjustment for confounding factors, an increased risk of hospitalizations (1.52 [1.17 to 1.99]) and ED visits (1.48 [1.04 to 2.11]) was observed for those with low versus moderate-high self-reported physical functioning. Patients with poor and fair self-rated general health also experienced an increased risk of hospitalizations (poor: 1.73 [1.29 to 2.32]; fair: 1.46 [1.14 to 1.87]) and ED visits (poor: 1.73 [1.16 to 2.56]; fair: 1.48 [1.13 to 1.93]) compared with good-excellent self-rated general health. No association between self-reported physical functioning or self-rated general health with outpatient visits and SNF admission was observed. In community HF patients, self-reported measures of physical functioning predict hospitalizations and ED visits, indicating that these patient-reported measures may be useful in risk stratification and management in HF. © 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

The effect of a telephone-based health coaching disease management program on Medicaid members with chronic conditions.

PubMed

Lin, Wen-Chieh; Chien, Hung-Lun; Willis, Georgianna; O'Connell, Elizabeth; Rennie, Kate Staunton; Bottella, Heather M; Ferris, Timothy G

2012-01-01

Despite the growing popularity of disease management programs for chronic conditions, evidence regarding the effect of these programs has been mixed. In addition, few peer-reviewed studies have examined the effect of these programs on publicly insured populations. To examine the effect of a telephone-based health coaching disease management program on healthcare utilization and expenditures in Medicaid members with chronic conditions. Using a difference-in-differences analysis, we examined changes in hospitalizations, emergency department (ED) visits, ambulatory care visits, and Medicaid expenditures among program members for 1 year before and 2 years after their enrollment compared with a matched comparison group. Medicaid members aged 18 to 64 with a diagnosis of qualifying chronic conditions and 2 acute health service events of hospitalizations and/or ED visits within a 12-month period. Changes in acute hospitalizations, ambulatory care visits, and Medicaid expenditures before and after program enrollment were similar between the 2 study groups. However, during the second year after enrollment, program members had a significantly smaller decrease in ED visits than the comparisons (8% in program members and 23% in comparisons, P value=0.03). Compared with a matched comparison group, the telephone-based health coaching disease management program did not demonstrate significant effects on healthcare utilization and expenditures in Medicaid members with chronic conditions.

Do diabetes group visits lead to lower medical care charges?

PubMed

Clancy, Dawn E; Dismuke, Clara E; Magruder, Kathryn Marley; Simpson, Kit N; Bradford, David

2008-01-01

To evaluate whether attending diabetes group visits (GVs) leads to lower medical care charges for inadequately insured patients with type 2 diabetes mellitus (DM). Randomized controlled clinical trial. Data were abstracted from financial records for 186 patients with uncontrolled type 2 DM randomized to receive care in GVs or usual care for 12 months. Mann-Whitney tests for differences of means for outpatient visits (primary and specialty care), emergency department (ED) visits, and inpatient stays were performed. Separate charge models were developed for primary and specialty outpatient visits. Because GV adherence is potentially dependent on unobserved patient characteristics, treatment effect models of outpatient charges and specialty care visits were estimated using maximum likelihood methods. Mann-Whitney test results indicated that GV patients had reduced ED and total charges but more outpatient charges than usual care patients. Ordinary least squares estimations confirmed that GVs increased outpatient visit charges; however, controlling for endogeneity by estimating a treatment effect model of outpatient visit charges showed that GVs statistically significantly reduced outpatient charges (P <.001). Estimation of a separate treatment effect model of specialty care visits confirmed that GV effects on outpatient visit charges occurred via a reduction in specialty care visits. After controlling for endogeneity via estimation of a treatment effect model, GVs statistically significantly reduced outpatient visit charges. Estimation of a separate treatment effect model of specialty care visits indicated that GVs likely substitute for more expensive specialty care visits.

Trends in Sports- and Recreation-Related Traumatic Brain Injuries Treated in US Emergency Departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012.

PubMed

Coronado, Victor G; Haileyesus, Tadesse; Cheng, Tabitha A; Bell, Jeneita M; Haarbauer-Krupa, Juliet; Lionbarger, Michael R; Flores-Herrera, Javier; McGuire, Lisa C; Gilchrist, Julie

2015-01-01

Sports- and recreation-related traumatic brain injuries (SRR-TBIs) are a growing public health problem affecting persons of all ages in the United States. To describe the trends of SRR-TBIs treated in US emergency departments (EDs) from 2001 to 2012 and to identify which sports and recreational activities and demographic groups are at higher risk for these injuries. Data on initial ED visits for an SRR-TBI from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for 2001-2012 were analyzed. NEISS-AIP data are drawn from a nationally representative sample of hospital-based EDs. Cases of TBI were identified from approximately 500,000 annual initial visits for all causes and types of injuries treated in EDs captured by NEISS-AIP. Numbers and rates by age group, sex, and year were estimated. Aggregated numbers and percentages by discharge disposition were produced. Approximately 3.42 million ED visits for an SRR-TBI occurred during 2001-2012. During this period, the rates of SRR-TBIs treated in US EDs significantly increased in both males and females regardless of age (all Ps < .001). For males, significant increases ranged from a low of 45.8% (ages 5-9) to a high of 139.8% (ages 10-14), and for females, from 25.1% (ages 0-4) to 211.5% (ages 15-19) (all Ps < .001). Every year males had about twice the rates of SRR-TBIs than females. Approximately 70% of all SRR-TBIs were reported among persons aged 0 to 19 years. The largest number of SRR-TBIs among males occurred during bicycling, football, and basketball. Among females, the largest number of SRR-TBIs occurred during bicycling, playground activities, and horseback riding. Approximately 89% of males and 91% of females with an SRR-TBI were treated and released from EDs. The rates of ED-treated SRR-TBIs increased during 2001-2012, affecting mainly persons aged 0 to 19 years and males in all age groups. Increases began to appear in 2004 for females and 2006 for males. Activities associated with the largest number of TBIs varied by sex and age. Reasons for the reported increases in ED visits are unknown but may be associated with increased awareness of TBI through increased media exposure and from campaigns, such as the Centers for Disease Control and Prevention's Heads Up. Prevention efforts should be targeted by sports and recreational activity, age, and sex.

Impact of Standardizing Management of Atrial Fibrillation with Rapid Heart Rate in the Emergency Department

PubMed Central

de Leon, Ernesto; Duan, Lewei; Rippenberger, Ellen; Sharp, Adam L

2018-01-01

Context There is substantial variation in the emergency treatment of atrial fibrillation with tachycardia. A standardized treatment approach at an academic center decreased admissions without adverse outcomes, but this approach has not been evaluated in a community Emergency Department (ED). Objective To evaluate the implementation of a standardized treatment guideline for patients with atrial fibrillation and a rapid heart rate in a community ED. Design An observational pre-/postimplementation (August 2013 to July 2014 and August 2014 to July 2015, respectively) study at a community ED. The standardized treatment guideline encouraged early oral treatment with rate control medication, outpatient echocardiogram, and early follow-up. A multiple logistic regression model adjusting for patient characteristics was generated to investigate the association between the intervention and ED discharge rate. Main Outcome Measures The primary measure was ED discharge. Secondary measures included stroke or death, ED return visit, hospital readmission, length of stay, and use of oral rate control medications. Results A total of 199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate control medications increased by 19.4% (p < 0.01). Adjusted multivariate results showed a nearly 2-fold likelihood of ED discharge after guideline implementation (odds ratio = 1.97, 95%confidence interval = 1.07–3.63). Length of stay, return visits, and hospital readmissionswere similar. Conclusion A standardized approach to ED patients with atrial fibrillation and tachycardia is associated with a decrease in hospital admissions without adversely affecting patient safety. PMID:29401054

Community characteristics affecting emergency department use by Medicaid enrollees.

PubMed

Lowe, Robert A; Fu, Rongwei; Ong, Emerson T; McGinnis, Paul B; Fagnan, Lyle J; Vuckovic, Nancy; Gallia, Charles

2009-01-01

In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr. Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

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

Using Syndromic Surveillance to Investigate Tattoo-Related Skin Infections in New York City

PubMed Central

Kotzen, Mollie; Sell, Jessica; Mathes, Robert W.; Dentinger, Catherine; Lee, Lillian; Schiff, Corinne; Weiss, Don

2015-01-01

In response to two isolated cases of Mycobacterium chelonae infections in tattoo recipients where tap water was used to dilute ink, the New York City (NYC) Department of Health and Mental Hygiene conducted an investigation using Emergency Department (ED) syndromic surveillance to assess whether an outbreak was occuring. ED visits with chief complaints containing the key word “tattoo” from November 1, 2012 to March 18, 2013 were selected for study. NYC laboratories were also contacted and asked to report skin or soft tissue cultures in tattoo recipients that were positive for non-tuberculosis mycobacterial infection (NTM). Thirty-one TREDV were identified and 14 (45%) were interviewed to determine if a NTM was the cause for the visit. One ED visit met the case definition and was referred to a dermatologist. This individual was negative for NTM. No tattoo-associated NTM cases were reported by NYC laboratories. ED syndromic surveillance was utilized to investigate a non-reportable condition for which no other data source existed. The results were reassuring that an outbreak of NTM in tattoo recipients was not occurring. In response to concerns about potential NTM infections, the department sent a letter to all licensed tattoo artists advising them not to dilute tattoo ink with tap water. PMID:26076006

Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO.

PubMed

Hsu, John; Price, Mary; Vogeli, Christine; Brand, Richard; Chernew, Michael E; Chaguturu, Sreekanth K; Weil, Eric; Ferris, Timothy G

2017-05-01

Accountable care organizations (ACOs) appear to lower medical spending, but there is little information on how they do so. We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending. We used data for the period 2009-14, exploiting naturally staggered program entry to create concurrent controls to help isolate the program effects. The care management program (the ACO's primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs. Project HOPE—The People-to-People Health Foundation, Inc.

Frequent Use of Emergency Departments by the Elderly Population When Continuing Care Is Not Well Established.

PubMed

Legramante, Jacopo M; Morciano, Laura; Lucaroni, Francesca; Gilardi, Francesco; Caredda, Emanuele; Pesaresi, Alessia; Coscia, Massimo; Orlando, Stefano; Brandi, Antonella; Giovagnoli, Germano; Di Lecce, Vito N; Visconti, Giuseppe; Palombi, Leonardo

2016-01-01

The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with "elderly frequent users". A retrospective study was performed during the calendar year 2014 (1st January 2014 - 31st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models. A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4-1.7) and hospitalization (OR 3.8: CI 3.7-4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9-3.2). Older patients presented clinical and social characteristics related to the definition of "elderly frail frequent users". The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established. Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.

The interaction of serum testosterone levels and androgen receptor CAG repeat polymorphism on the risk of erectile dysfunction in aging Taiwanese men.

PubMed

Liu, C C; Lee, Y C; Tsai, V F S; Cheng, K H; Wu, W J; Bao, B Y; Huang, C N; Yeh, H C; Tsai, C C; Wang, C J; Huang, S P

2015-09-01

Testosterone has been found to play important roles in men's sexual function. However, the effects of testosterone can be modulated by androgen receptor (AR) CAG repeat polymorphism. It could also contribute to the risk of erectile dysfunction (ED). The aim of this study is to evaluate the interaction of serum testosterone levels and AR CAG repeat polymorphism on the risk of ED in aging Taiwanese men. This cross-sectional data of Taiwanese men older than 40 years were collected from a free health screening held between August 2010 and August 2011 in Kaohsiung city, Taiwan. All participants completed a health questionnaires included five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptoms Score, received a detailed physical examination and provided 20 cm3 whole blood samples for biochemical and genetic evaluation. The IIEF-5 was used to evaluate ED. Serum albumin, total testosterone (TT), and sex hormone-binding globulin levels were measured. Free testosterone level was calculated. AR gene CAG repeat polymorphism was determined by direct sequencing. Finally, 478 men with the mean age of 55.7 ± 4.8 years were included. When TT levels were above 330 ng/dL, the effect of testosterone level on erectile function seemed to reach a plateau and a significantly negative correlation between AR CAG repeat length and the score of IIEF-5 was found (r = -0.119, p = 0.034). After adjusting for other covariates, the longer AR CAG repeat length was still an independent risk factor for ED in subjects with TT above 330 ng/dL (p = 0.006), but not in TT of 330 ng/dL or below. In conclusion, both serum testosterone levels and AR CAG repeat polymorphism can influence erectile function concomitantly. In subjects with normal TT concentration, those with longer AR CAG repeat lengths have a higher risk of developing ED. © 2015 American Society of Andrology and European Academy of Andrology.

Feasibility, acceptability, and preliminary effectiveness of patient advocates for improving adult asthma outcomes

PubMed Central

Apter, Andrea J.; Wan, Fei; Reisine, Susan; Bogen, Daniel K.; Rand, Cynthia; Bender, Bruce; Bennett, Ian M.; Gonzalez, Rodalyn; Priolo, Chantel; Sonnad, Seema S.; Bryant-Stephens, Tyra; Ferguson, Monica; Boyd, Rhonda C.; Have, Thomas Ten; Roy, Jason

2014-01-01

Background Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers. Objective To conduct a pilot study to assess feasibility, acceptability, and preliminary evidence of effectiveness. Methods A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a nonprofessional, modeled preparations for a medical visit, attended the visit, and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage, and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid adherence, asthma control, quality of life, FEV1, ED visits, and hospitalizations. Mixed-effects models guided an intention-to-treat analysis. Results 100 adults participated: age 47±14 years, 75% female, 71% African American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p= 0.001) but not significantly in the PA group (p=.30). Both PA and MI groups demonstrated improved asthma control (p=0.01 in both) and quality of life (p=0.001, p=0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups. Conclusion The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life. PMID:23800333

Nystagmus Assessments Documented by Emergency Physicians in Acute Dizziness Presentations: A Target for Decision Support?

PubMed Central

Kerber, Kevin A.; Morgenstern, Lewis B.; Meurer, William J.; McLaughlin, Thomas; Hall, Pamela A.; Forman, Jane; Fendrick, A. Mark; Newman-Toker, David E.

2011-01-01

Objectives Dizziness is a common presenting complaint to the emergency department (ED), and emergency physicians (EPs) consider these presentations a priority for decision support. Assessing for nystagmus and defining its features are important steps for any acute dizziness decision algorithm. The authors sought to describe nystagmus documentation in routine ED care to determine if nystagmus assessments might be an important target in decision support efforts. Methods Medical records from ED visits for dizziness were captured as part of a surveillance study embedded within an ongoing population-based cohort study. Visits with documentation of a nystagmus assessment were reviewed and coded for presence or absence of nystagmus, ability to draw a meaningful inference from the description, and coherence with the final EP diagnosis when a peripheral vestibular diagnosis was made. Results Of 1,091 visits for dizziness, 887 (81.3%) documented a nystagmus assessment. Nystagmus was present in 185 out of 887 (20.9%) visits. When nystagmus was present, no further characteristics were recorded in 48 of the 185 visits (26%). The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits. The nystagmus description conflicted with the EP diagnosis in 113 (80.7%) of the 140 visits that received a peripheral vestibular diagnosis. Conclusions Nystagmus assessments are frequently documented in acute dizziness presentations, but details do not generally enable a meaningful inference. Recorded descriptions usually conflict with the diagnosis when a peripheral vestibular diagnosis is rendered. Nystagmus assessments might be an important target in developing decision support for dizziness presentations. PMID:21676060

Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors.

PubMed

Shaw, Paul B; Delate, Thomas; Lyman, Alfred; Adams, Jody; Kreutz, Heather; Sanchez, Julia K; Dowd, Mary Beth; Gozansky, Wendolyn

2016-02-01

This study assesses outcomes associated with the implementation of an emergency department (ED) for seniors in which a clinical pharmacy specialist, with specialized geriatric training that included medication management training, is a key member of the ED care team. This was a retrospective cohort analysis of patients aged 65 years or older who presented at an ED between November 1, 2012, and May 31, 2013. Three groups of seniors were assessed: treated by the clinical pharmacy specialist in the ED for seniors, treated in the ED for seniors but not by the clinical pharmacy specialist, and not treated in the ED for seniors. Outcomes included rates of an ED return visit, mortality and hospital admissions, and follow-up total health care costs. Multivariable regression modeling was used to adjust for any potential confounders in the associations between groups and outcomes. A total of 4,103 patients were included, with 872 (21%) treated in the ED for seniors and 342 (39%) of these treated by the clinical pharmacy specialist. Groups were well matched overall in patient characteristics. Patients who received medication review and management by the clinical pharmacy specialist did not experience a reduction in ED return visits, mortality, cost of follow-up care, or hospital admissions compared with the other groups. Of the patients treated by the clinical pharmacy specialist, 154 (45.0%) were identified as having at least 1 medication-related problem. Although at least 1 medication-related problem was identified in almost half of patients treated by the clinical pharmacy specialist in the ED for seniors, incorporation of a clinical pharmacy specialist into the ED staff did not improve clinical outcomes. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Hospital admission rates and emergency department use in relation to glycated hemoglobin in people with diabetes mellitus: a linkage study using electronic medical record and administrative data in Ontario

PubMed Central

Birtwhistle, Richard; Green, Michael E.; Frymire, Eliot; Dahrouge, Simone; Whitehead, Marlo; Khan, Shahriar; Greiver, Michelle; Glazier, Richard H.

2017-01-01

Background: The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) collects extensive data on primary care patients but it currently does not gather reliable information on outcomes in other settings. The objectives of this study were to link electronic medical record (EMR) data from Ontario patients in the CPCSSN with administrative data from the Institute for Clinical Evaluative Sciences (ICES), to assess the representativeness of the CPCSSN population, and to identify people with diabetes in the CPCSSN data and describe their emergency department (ED) visits and hospital admissions over a 2-year period (2010-2012) by HbA1c level. Methods: We conducted a cross-sectional study linking 2014 Ontario CPCSSN data with ICES administrative data and a retrospective cohort study using the 2014 data extraction linked with data from the Ontario health care registry, hospital discharge abstracts and a database of emergency department visits. Demographics of CPCSSN patients were compared with those of the Ontario population. Patients with a CPCSSN diagnosis of diabetes were compared by HbA1c category for ED visits, hospital admissions and diagnosis of diabetes-related complications. Results: The linkage rate was 99%. We identified 12 358 patients with diabetes, 2356 of whom were missing data on HbAIc, for a final sample of 10 002. Patients with diabetes had a mean age of 64 years. Those with a higher HbA1c were younger, more likely to be male, had a lower income, had more comorbidities and were more likely to live in rural or suburban areas than patients with a lower HbA1c. Over the study period 31.8% of patients had 1 or more ED visits and 13.7% had a hospital admission for a diabetes-related complication. Patients with HbA1c greater than 8 had significantly more hospital admissions, ED visits and diabetes-related complications than patients with a lower HbA1c . Interpretation: The linkage between EMR and administrative data was successful. In this study population, higher HbA1c values were associated with increased ED visits and hospital admissions, with an increasing gradient as HbA1c increased from less than 7% to greater than 8%. PMID:28701374

Older Adults with Mental Disorders: What Factors Distinguish Those Who Present to Emergency Departments for Mental Health Reasons from Those Who Do Not?

PubMed

Walsh, Patrick G; Currier, Glenn W; Shah, Manish N; Friedman, Bruce

2015-11-01

To identify among older adults with mental disorders factors associated with those who present to emergency departments (EDs) for mental health reasons versus those who do not. The authors conducted a secondary, cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS), which comprises a representative sample of the U.S. civilian noninstitutionalized population. Of the MEPS participants ages 66 and older on December 31 of the survey years 2000-2005, the analysis sample (2,757) included the 177 persons with at least one mental health ED visit and the 2,580 persons with mental disorders without such a visit. The three categories of the Andersen behavioral model for healthcare services utilization-predisposing, enabling, and need factors-were used as the theoretical framework for the independent variables. Logistic regression analysis indicated that four need factors (adjustment disorder [OR: 3.42], psychosis [OR: 2.68], fair perceived physical health status [OR: 2.24], and anxiety disorder [OR: 1.85]) and two predisposing characteristics (widowed and living alone [OR: 1.68] and female [OR: 1.56]) were significantly associated with older adults with mental disorders who present to an ED for mental health reasons. Good perceived mental health status (OR: 0.55) was protective against presenting to an ED. EDs that serve populations with higher proportions of older persons that are women, widowed and living alone, with adjustment disorder, psychosis, anxiety disorders, or fair perceived physical health should expect to have a greater likelihood of older persons visiting the ED for mental health reasons. Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

Impact of Superstorm Sandy on Medicare Patients' Utilization of Hospitals and Emergency Departments.

PubMed

Stryckman, Benoit; Walsh, Lauren; Carr, Brendan G; Hupert, Nathaniel; Lurie, Nicole

2017-10-01

National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy's 2012 landfall in New Jersey (NJ). This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED) and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission. In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional "surge" patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%). Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events.

Emergency Visits for Prescription Opioid Poisonings

PubMed Central

Tadros, Allison; Layman, Shelley M.; Davis, Stephen M.; Davidov, Danielle M.; Cimino, Scott

2016-01-01

Background Prescription opioid abuse and overdose has steadily increased in the United States (U.S.) over the past two decades and current research has shown a dramatic increase in hospitalizations resulting from opioid poisonings. Still, much is unknown about the clinical and demographic features of patients presenting to emergency departments for poisoning from prescription drugs. Objective We sought to evaluate ED visits by adults for prescription opioids. Methods This was a retrospective cohort study utilizing 2006 – 2011 data from the Nationwide Emergency Department Sample (NEDS). Total number of admissions (weighted), disposition, gender, age, expected payer, income, geographic region, charges, and procedures performed were examined. Results From 2006 – 2010, there were 259,093 ED visits by adults for poisoning by opioids and 53.50% of these were unintentional. The overall mean age of patients was 45.5 with more visits made by females (52.37%). Patients who unintentionally overdosed were more likely to have Medicare (36.54%), whereas those who intentionally overdosed had private insurance (29.41%). The majority of patients reside in the South (40.93%) and come from lower-income neighborhoods. Approximately 108,504 patients were discharged and 140,395 were admitted. Conclusions There were over 250,000 visits to U.S. EDs from 2006 – 2011 with a primary diagnosis of poisoning by a prescription opioid. The majority of visits were made by females and over half were admitted to the hospital, resulting in over $4 billion in charges. Future studies should examine preventative measures, optimal screening and intervention programs for these patients. PMID:26409674

Does Churning in Medicaid Affect Health Care Use?

PubMed Central

Roberts, Eric T.; Pollack, Craig Evan

2017-01-01

Background Transitions into and out of Medicaid, termed churning, may disrupt access to and continuity of care. Low-income, working adults who became eligible for Medicaid under the Affordable Care Act are particularly susceptible to income and employment changes that lead to churning. Objective To compare health care use among adults who do and do not churn into and out of Medicaid. Data Longitudinal data from 6 panels of the Medical Expenditure Panel Survey. Methods We used differences-in-differences regression to compare health care use when adults reenrolled in Medicaid following a loss of coverage, to utilization in a control group of continuously enrolled adults. Outcome Measures Emergency department (ED) visits, ED visits resulting in an inpatient admission, and visits to office-based providers. Results During the study period, 264 adults churned into and out of Medicaid and 627 had continuous coverage. Churning adults had an average of approximately 0.05 Medicaid-covered office-based visits per month 4 months before reenrolling in Medicaid, significantly below the rate of approximately 0.20 visits in the control group. Visits to office-based providers did not reach the control group rate until several months after churning adults had resumed Medicaid coverage. Our comparisons found no evidence of significantly elevated ED and inpatient admission rates in the churning group following reenrollment. Conclusions Adults who lose Medicaid tend to defer their use of office-based care to periods when they are insured. Although this suggests that enrollment disruptions lead to suboptimal timing of care, we do not find evidence that adults reenroll in Medicaid with elevated acute care needs. PMID:26908088

Are the current thresholds, indicators, and time window for cold warning effective enough to protect cardiovascular health?

PubMed

Lin, Shao; Lawrence, Wayne R; Lin, Ziqiang; DiRienzo, Stephen; Lipton, Kevin; Dong, Guang-Hui; Leung, Ricky; Lauper, Ursula; Nasca, Philip; Stuart, Neil

2018-10-15

More extreme cold weather and larger weather variations have raised concerns regarding their effects on public health. Although prior studies assessed the effects of cold air temperature on health, especially mortality, limited studies evaluated wind chill temperatures on morbidity, and health effects under the current cold warning threshold. This study identified the thresholds, lag periods, and best indicators of extreme cold on cardiovascular disease (CVD) by comparing effects of wind chill temperatures and cold air temperatures on CVD emergency department (ED) visits in winter and winter transition months. Information was collected on 662,625 CVD ED visits from statewide hospital discharge dataset in New York State. Meteorological factors, including air temperature, wind speed, and barometric pressure were collected from National Oceanic and Atmospheric Administration. A case-crossover approach was used to assess the extreme cold-CVD relationship in winter (December-February) and transition months (November and March) after controlling for PM 2.5 . Conditional logistic regression models were employed to analyze the association between cold weather factors and CVD ED visits. We observed CVD effects occurred when wind chill temperatures were as high as -3.8 °C (25 °F), warmer than current wind chill warning standard (≤-28.8 °C or ≤-20 °F). Wind chill temperature was a more sensitive indicator of CVD ED visits during winter with temperatures ≤ -3.8 °C (25 °F) with delay effect (lag 6); however, air temperature was better during transition months for temperatures ≤ 7.2 °C (45 °F) at earlier lag days (1-3). Among all CVD subtypes, hypertension ED visit had the strongest negative association with both wind chill temperature and air temperature. This study recommends modifying the current cold warning temperature threshold given larger proportions of CVD cases are occurring at considerably higher temperatures than the current criteria. We also recommend issuing cold warnings in winter transitional months. Copyright © 2018 Elsevier B.V. All rights reserved.