Impact of Alcohol Intoxication on Mortality and Emergency Department Resource Use in Suicidal Patients

Lack of adequate risk adjustment methodologies has hindered the progress of emergency medicine health services research. The authors hypothesized that a consensus-derived, diagnosis-based severity classification system (SCS) would be significantly associated with actual measures of emergency department (ED) resource use and could ultimately be used to examine severity-adjusted outcomes across patient populations. A panel of subject matter experts used consensus methods to assign severity scores (1 = lowest severity to 5 = highest severity) to 3,041 ED International Classifications of Diseases (ICD), 9th revision, diagnosis codes. SCS scores were assigned to ED visits using the visit diagnosis code with the highest severity. We tested the association between the SCS scores and measures of ED resource use in three data sets: the Pediatric Emergency Care Applied Research Network Core Data Project (PCDP), the National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Connecticut state ED data set. There was a significant association between the five-level SCS and all six measures of resource use: triage category, disposition, ED resource use, Current Procedural Terminology Evaluation and Management (CPT E&M) codes, ED length of stay, and ED charges within the three ED data sets. The SCS demonstrates validity in its strong association with actual ED resource use. The use of readily available ICD-9 diagnosis codes makes the SCS useful as a risk adjustment tool for health services research.

The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ≤5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

ObjectiveA common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.MethodsWe conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.ResultsA total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.ConclusionOver 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

Few studies have evaluated the common assumption that graduate medical education is associated with increased resource use. To compare resources used in supervised vs attending-only visits in a nationally representative sample of patient visits to US emergency departments (EDs). Cross-sectional study of the National Hospital Ambulatory Medical Care Survey (2010), a probability sample of US EDs and ED visits. Supervised visits, defined as visits involving both resident and attending physicians. Three ED teaching types were defined by the proportion of sampled visits that were supervised visits: nonteaching ED, minor teaching ED (half or fewer supervised visits), and major teaching ED (more than half supervised visits). Association of supervised visits with hospital admission, advanced imaging (computed tomography, ultrasound, or magnetic resonance imaging), any blood test, and ED length of stay, adjusted for visit acuity, demographic characteristics, payer type, and geographic region. Of 29,182 ED visits to the 336 nonpediatric EDs in the sample, 3374 visits were supervised visits. Compared with the 25,808 attending-only visits, supervised visits were significantly associated with more frequent hospital admission (21% vs 14%; adjusted odds ratio [aOR], 1.42; 95% CI, 1.09-1.85), advanced imaging (28% vs 21%; aOR, 1.27; 95% CI, 1.06-1.51), and a longer median ED stay (226 vs 153 minutes; adjusted geometric mean ratio, 1.32; 95% CI, 1.19-1.45), but not with blood testing (53% vs 45%; aOR, 1.18; 95% CI, 0.96-1.46). Of visits to the sample of 121 minor teaching EDs, a weighted estimate of 9% were supervised visits, compared with 82% of visits to the 34 major teaching EDs. Supervised visits in major teaching EDs compared with attending-only visits were not associated with hospital admission (aOR, 1.15; 95% CI, 0.83-1.58), advanced imaging (aOR, 1.21; 95% CI, 0.96-1.53), or any blood test (aOR, 1.02; 95% CI, 0.79-1.33), but had longer ED stays (adjusted geometric mean ratio, 1.32; 95% CI, 1.14-1.53). In a sample of US EDs, supervised visits were associated with a greater likelihood of hospital admission and use of advanced imaging and with longer ED stays. Whether these associations are different in EDs in which more than half of visits are seen by residents requires further investigation.

Objectives: Although emergency department (ED) return visits are a significant problem universally, it has not been previously studied in our ED. The aim of this study was to determine the extent of the problem in our ED, to identify the relevant clinical predictor variables and to detect diagnostic errors.Methods: A retrospective observational study of ED return visits by patients managed by the General Internal Medicine (GIM) service was performed. The study was performed over a one year period at a tertiary hospital ED. Data are reported as relative risk (RR) and 95% confidence interval (CI).Results: There were a total of 51.210 ED visits during the study period. The total number of ED return visits within 72 hours was 1.124 (2,19%; 95% CI 2,07 to 2,32). The total number of ED patients managed by the GIM service was 9.511. The percentage of patients treated by the GIM service who returned to the ED within 72 hours was 1,48% (95% CI 1,25 to 1,74) when calculated for the whole group and 2,9 % (95% CI 2,46-3,41) for those discharged home from the ED (n=4.860). The majority (82,98%) of ED return visits by patients discharged from the GIM service were unscheduled and related to their index presenting complaint. Abdominal pain was the commonest initial presenting symptom in the patients who returned to the ED after discharge. Patients with diarrhoea as the initial initial presenting symptom had the highest relative risk of an ED return visit (RR=4.07).Conclusion: The percentage ED return visits by patients discharged from the ED by the GIM service is 1,48%. Patients presenting with diarrhoea as the initial presenting symptom have the highest relative risk of an early ED return visit. Our main practical conclusion is that patients with abdominal pain need to be re-examined carefully and instructed about potential evolution before discharge.

IntroductionIn clinical trials rifaximin-α (RFX) has been shown to reduce recurrence of episodes of overt hepatic encephalopathy (HE) and HE-related hospitalisations. UK real world data confirmed reductions in hospital admissions...

Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency. We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed. In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P < .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P < .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P < .001 and P < .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change. Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.

Caractéristiques, consommation de ressources des usagers des services d’urgences de plus de 75 ans en France: Résultats d’une enquête nationale

To describe the patterns of referral and use of resources for patients with psychiatric-related visits presenting to pediatric emergency departments (EDs) in a pediatric research network. We conducted a retrospective chart review of a random sample of patients (approximately 10 charts per month per site) who presented with psychiatric-related visits in 2002 to 4 pediatric EDs in the Pediatric Emergency Care Applied Research Network. Emergency department resource use variables evaluated included the use of consultation services, restraints, and laboratory tests as well as ED length of stay. We reviewed 462 patient visits with a psychiatric-related ED diagnosis. Mean (SD) age was 12.8 (3.7) years, 52% were male, and 49% were African American. The most common chief complaints were suicidality (47%), aggression/agitation (42%), and anxiety/depression (27%), alone or in combination. Ninety percent of patients (range across sites, 83%-94%) had a mental health consult in the ED, 5% were restrained (range, 3%-9%), and 35% had a laboratory test performed (range, 15%-63%). Mean (SD) ED length of stay was 5.1 (5.4) hours, and 52% were admitted (93% to a psychiatric bed, including transfers to separate psychiatric facilities). Children with psychiatric-related visits seem to require substantial ED resources. Interventions are needed to reduce the burden on the ED by increasing the linkage to mental health services, particularly for suicidal youths.

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer.

Ecstasy and related drug consumption and the effect on emergency department resource use

Predictors of return visits to the emergency department among different age groups of older adults.

IntroductionAlcohol intoxication is a common patient presentation to urban emergency departments (ED). There is limited data on the healthcare financial impact of caring for alcohol-intoxicated patients in the ED. In this study we examined the facility-based financial billings and collections related to ED visits for alcohol intoxication.MethodsUsing a retrospective cohort analysis of two large, urban EDs, with a combined yearly census of approximately 150,000 patient visits, we included all encounters between June 2018–December 2021 with a discharge diagnosis consistent with acute alcohol intoxication. We reviewed records of patient encounters with a final diagnosis consistent with acute alcohol intoxication who only had minimal or no interventions performed, implying the visit was solely consistent with acute alcohol intoxication. We reviewed the facility charges of these patients, along with insurance status and average payment by status to understand the financial impact.ResultsOf 495,436 patient presentations to the EDs during the study period, 13,454 met study criteria (2.7% of total patients). Patient length of stay in the ED had an average of 254 minutes and median of 240 minutes. In total, this cohort of patients occupied ED beds for 56,505 hours cumulatively, or an average of 43.2 bed hours per day for alcohol intoxication-related visits, representing 3.14% of all ED bed hours across both sites. The majority of patient encounters were billed as a level 3 facility code (76%). Facility charges for the cohort totaled $22,590,000. The estimated reimbursement based on the percentage reimbursed by payor mix was $1.7 million (7.5%), or an average of $126 per patient visit—less than one quarter of the general average visit collection.ConclusionPatients with acute alcohol intoxication and no other complaints are a minority of ED patients, yet their care results in substantial charges and ED resources. Based on the known facility collection rates per insurer, the weighted prevalence of insurers among this cohort yields an estimated collection rate of 7.5%. Opportunities to provide proven alcohol-related interventions should consider the unreimbursed costs of these visits when determining cost effectiveness.

Introduction: Recent evidence shows an increase in alcohol-related emergency department (ED) visits among youth. We sought to quantify the impact of ED visits (type and frequency, patient characteristics and resource use) related to alcohol in our centre. Methods: This was a chart review of patients aged 12-24 with alcohol-related ED visits between Sept 2013-Aug 2017. The National Ambulatory Care Reporting System (NACRS) database was searched for visits alcohol related ICD-10 codes. The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) database was also searched using the keyword alcohol. Duplicate visits were removed. Visits were excluded if patients had a history of psychosis, were held in the ED for psychiatric assessment, were homeless, were inmates from a correctional institute, if alcohol use was not mentioned and for complaints of sexual assault/intimate partner violence. Data was abstracted by two reviewers using a standard form with predetermined variables. Differences were resolved with third party adjudication. Interrater reliability of the reviewers was assessed with Kappa scores through duplicate review of 10% of randomly selected charts. A further 10% were assessed by a 3rd reviewer for extraction accuracy. Results: 3,256 ED visits were identified with 777 removed via predefined exclusion criteria. 2,479 visits were reviewed with a male predominance (54.3%). More than half of all patients (50.9%) arrived via ambulance. Assigned CTAS levels were Resuscitation: 1% Emergent: 9.9% Urgent: 48.2% Less Urgent: 35.7% Non-Urgent: 4.2% (missing 1%). The median LOS was 2.9 hrs (IQR 1.8-4.6). All visits were subclassified into mutually exclusive categories: injury (51.8%), acute intoxication (45.1%) and mental health issue (3.2%). Males were more likely to present with injury (62.4% vs 42.6%, p &lt; 0.01). Females were more likely to present with acute intoxication (53.3% vs 46.7%, p &lt;0.01) and mental health issues (59.5% vs 40.5%, P = 0.01). ED resource use was notable: 483 (19.4%) had imaging tests and 1216 (49.1%) had some medical intervention (blood test, fluids or medication). 57 (2.3%) patients were admitted and there was one death from an alcohol related MVC. Conclusion: Alcohol-related ED visits by youth are common in our centre and utilize substantial prehospital and in-hospital resources. Identification of effective harm reduction strategies should be a research priority.

Satisfaction and Emergency Department Revisits in Patients With Possible Acute Coronary Syndrome