30-day Emergency Department Revisits Research Articles

Clinical and economic impact of partnered pharmacist medication charting in the emergency department.

Introduction: Partnered pharmacist medication charting (PPMC), a process redesign hypothesised to improve medication safety and interdisciplinary collaboration, was trialed in a tertiary hospital's emergency department (ED). Objective: To evaluate the health-related impact and economic benefit of PPMC. Methods: A pragmatic, controlled study compared PPMC to usual care in the ED. PPMC included a pharmacist-documented best-possible medication history (BPMH), followed by a clinical conversation between a pharmacist and a medical officer to jointly develop a treatment plan and chart medications. Usual care included medical officer-led traditional medication charting in the ED, without a pharmacist-obtained BPMH or clinical conversation. Outcome measures, assessed after propensity score matching, were length of hospital or ED stay, relative stay index (RSI), in-hospital mortality, 30-day hospital readmissions or ED revisits, and cost. Results: A total of 309 matched pairs were analysed. The median RSI was reduced by 15.4% with PPMC (p = 0.029). There were no significant differences between the groups in the median length of ED stay (8 vs. 10h, p = 0.52), in-hospital mortality (1.3% vs. 1.3%, p > 0.99), 30-day readmission rates (21% vs. 17%; p = 0.35) and 30-day ED revisit rates (21% vs. 19%; p = 0.68). The hospital spent approximately $138.4 for the cost of PPMC care per patient to avert at least one medication error bearing high/extreme risk. PPMC saved approximately $1269 on the average cost of each admission. Conclusion: Implementing the ED-based PPMC model was associated with a significantly reduced RSI and admission costs, but did not affect clinical outcomes, noting that there was an additional focus on medication reconciliation in the usual care group relative to current practice at our study site.

An AI-Enabled Dynamic Risk Stratification for Emergency Department Patients with ECG and CXR Integration.

Emergency department (ED) triage scale determines the priority of patient care and foretells the prognosis. However, the information retrieved from the initial assessment is limited, hindering the risk identification accuracy of triage. Therefore, we sought to develop a 'dynamic' triage system as secondary screening, using artificial intelligence (AI) techniques to integrate information from initial assessment data and subsequent examinations. This retrospective cohort study included 134,112 ED visits with at least one electrocardiography (ECG) and chest X-ray (CXR) in a medical center from 2012 to 2022. Additionally, an independent community hospital provided 45,614 ED visits as an external validation set. We trained an eXtreme gradient boosting (XGB) model using initial assessment data to predict all-cause mortality in 7 days. Two deep learning models (DLMs) using ECG and CXR were trained to stratify mortality risks. The dynamic triage levels were based on output from the XGB-triage and DLMs from ECG and CXR. During the internal and external validation, the area under the receiver operating characteristic curve (AUC) of the XGB-triage model was >0.866; furthermore, the AUCs of DLMs using ECG and CXR were >0.862 and >0.886, respectively. The dynamic triage scale provided a higher C-index (0.914-0.920 vs. 0.827-0.843) than the original one and demonstrated better predictive ability for 5-year mortality, 30-day ED revisit, and 30-day discharge. The AI-based risk scale provides a more accurate and dynamic stratification of mortality risk in ED patients, particularly in identifying patients who tend to be overlooked due to atypical symptoms.

Evaluation of a transitions clinic to bridge emergency department and primary care.

Suboptimal transitions from the emergency department (ED) to ambulatory settings contribute to poor clinical outcomes and unnecessary nonurgent ED utilization. Care transition clinics (CTCs) are a potential solution by providing ED follow-up and facilitating the bridge to longer-term primary care. The objective was to evaluate the implementation of an ED transitions clinic on 30-day ED revisits and hospital readmissions. Retrospective cross-sectional study. This study included adults 18 years and older discharged from the ED and reeferred to the CTC. Appointment attendance, follow-up time, and frequencies of care type provided were computed to assess clinic utilization. Rates of 30-day ED revisit and hospital admission were compared between completed and missed appointments using logistic regression. Between March 2021 and March 2022, 373 patients were referred to the CTC totaling 405 appointments. Half (53%) of appointments were completed with a median follow-up time of 4 days (IQR = [2, 7]). The most common care types provided were wound care (44%) and clinical problem management (33%), with wound care appointments more likely to be completed compared with clinical appointments (OR = 1.7, CI = [1.1, 2.8], p = .03). Patients who completed their CTC appointment were 50% less likely to return to the ED in 30 days compared with those who did not complete their appointment (OR = 0.51, CI = [0.27, 0.98], p < .05). No effect was seen for CTC appointment completion on hospital readmission. Transition clinics are a viable method to provide timely access to follow-up for patients discharged from the ED and may help reduce excess ED use for ambulatory care needs.

Association of Geriatric Emergency Department post-discharge referral order and follow-up with healthcare utilization.

Compared with younger adults who receive care in the emergency department (ED), older patients who are discharged home have greater risk of adverse health outcomes. Connecting older adults with outpatient care following ED discharge are among the guidelines of the Geriatric Emergency Department (GED). The objective of this study was to examine the association between referral order placed during the ED visit for older adults and post-discharge follow-up to the outcomes of 72-h ED revisit, 30-day ED revisit, and 30-day all cause and unplanned hospital admission. We conducted a retrospective cohort study. Ten accredited GEDs within one midwestern health system and all ED encounters of older adults aged 65 years and older who were discharged home from the ED between July 2019 and December 2020 were included. Predictor variables included age, sex, race, ISAR©, ED Length of Stay, post-ED referral order, and follow-up. Among the older adults discharged home from the ED, 17% of older adult encounters had an outpatient referral ordered in the ED, 48.4% attended a follow-up appointment. Referrals were ordered for 69 referral order types with orthopedic, family practice, and urology referrals as the top 3. In mixed-effect regression models, compared with older adults with follow-up, those with a referral order but no follow-up had 19% higher odds of having a 30-day ED revisit (OR=1.19; 95% CI=1.07-1.31) and 11% higher odds of having 30-day unplanned hospital admission (OR=1.11; 95% CI=0.98-1.26). Older adults who had an outpatient referral ordered prior to ED discharge and followed up had lower odds of a 30-day ED revisit and 30-day subsequent unplanned hospital admission. However, less than half of patients with a referral order attended a follow-up appointment. Designing interventions for older adults aimed at improving follow-up after an ED visit is needed.

Antibiotic use and outcomes among children hospitalized with suspected pneumonia.

Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP). We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP. We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP. The exposure was the receipt of antibiotics in the emergency department (ED). Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses. Among 523 children, 66% were <5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.

The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits.

Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

Factors related to the success or failure of cardioversion in atrial fibrillation and emergency department revisit according to restoration of sinus rhythm: analysis of the URGFAICS cohort

Rhythm control in atrial fibrillation (AF) improves haemodynamic status and symptoms. However, there are few data related to revisit of patients who have undergone cardioversion in the Emergency Department (ED). The aim of the study was to compare ED revisit within 30 days according to the effectiveness of cardioversion and analyse the variables related to effective cardioversion. We undertook a multicentre, observational, cohort study with a 30-day follow-up. Older adults with AF presenting to 5 EDs in Spain and undergoing cardioversion were included. The primary endpoint was revisit to the ED within 30 days, and univariate and multivariate analyses were carried out according to the effectiveness of cardioversion. We enrolled 336 patients who underwent cardioversion in the ED. Following the index visit, 7.4% revisited the ED within 30 days, with no differences with respect to the effectiveness of cardioversion (hazard ratio: 0.87; 95%confidence interval (CI) 0.31–2.43). In the multivariate study, AF lasting &lt;48 hours was related to more effective cardioversion (adjusted odds ratio (aOR): 2.14; 95% CI 1.16–3.59) while the use of amiodarone (aOR: 0.52; 95% CI 0.27–0.99) and digoxin in ED (aOR: 0.28; 95% CI 0.13–0.66) was related to less effective cardioversion. In patients with AF undergoing a rhythm control strategy in the ED, the absence of restoration of sinus rhythm was not associated with a greater frequency of 30-day ED revisit.

Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial.

Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30days following discharge. We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72h postdischarge and one to three phone calls over 28days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. Participant characteristics (N=1,756) were similar across groups: meanage 72.4±8.6years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR]=0.97, 95% confidence interval [CI]=0.72 to 1.30) or medication adherence (AOR=0.89, 95% CI=0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR=1.24, 95% CI=1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR=1.34 95% CI=1.05 to 1.71). The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Outcomes Associated With High- Versus Low-Frequency Laboratory Testing Among Hospitalized Children.

Previous pediatric studies have revealed substantial variation in laboratory testing for specific conditions, but clinical outcomes associated with high- versus low-frequency testing are unclear. We hypothesized that hospitals with high- versus low-testing frequency would have worse clinical outcomes. We conducted a multicenter retrospective cohort study of patients 0 to 18 years old with low-acuity hospitalizations in the years 2018-2019 for 1 of 10 common All Patient Refined Diagnosis Related Groups. We identified hospitals with high-, moderate-, and low-frequency testing for 3 common groups of laboratory tests: complete blood cell count, basic chemistry studies, and inflammatory markers. Outcomes included length of stay, 7- and 30-day emergency department revisit and readmission rates, and hospital costs, comparing hospitals with high- versus low-frequency testing. We identified 132 391 study encounters across 44 hospitals. Laboratory testing frequency varied by hospital and condition. We identified hospitals with high- (13), moderate- (20), and low-frequency (11) laboratory testing. When we compared hospitals with high- versus low-frequency testing, there were no differences in adjusted hospital costs (rate ratio 0.89; 95% confidence interval 0.71-1.12), length of stay (rate ratio 0.98; 95% confidence interval 0.91-1.06), 7-day (odds ratio 0.99; 95% confidence interval 0.81-1.21) or 30-day (odds ratio 1.01; 95% confidence interval 0.82-1.25) emergency department revisit rates, or 7-day (odds ratio 0.84; 95% confidence interval 0.65-1.25) or 30-day (odds ratio 0.91; 95% confidence interval 0.76-1.09) readmission rates. In a multicenter study of children hospitalized for common low-acuity conditions, laboratory testing frequency varied widely across hospitals, without substantial differences in outcomes. Our results suggest opportunities to reduce laboratory overuse across conditions and children's hospitals.

Prevalence and risk factors of hypertonic dehydration among older patients admitted to the emergency department: A prospective cross-sectional study.

The prevalence of hypertonic dehydration (HD) among community-dwelling and hospitalized populations has been evaluated. However, to our knowledge, no study had previously focused on older patients admitted to the emergency department (ED). The present study aimed to evaluate the prevalence, risk factors and short-term outcomes of HD among Thai older patients admitted to the ED. This was a prospective cross-sectional study at one urban ED in Thailand. Patients aged ≥65 years who were admitted to the ED were enrolled into the study. Data including clinical hydration status, Charlson Comorbidity Index (CCI) score, activities of daily living score, current use of medications, laboratory examination results and serum osmolarity level were collected. HD was defined as a serum osmolarity level of >300 mOsm/kg. The short-term outcomes were a 30-day ED revisit, hospital readmission and mortality rates. In total, 80 (21.6%) of 370 patients presented with HD. A CCI score of ≥5 was found associated with HD among older patients (adjusted odds ratio: 1.82; 95% confidence interval: 1.03-3.21). The ED revisit rates were 18.1% in the dehydrated group and 10.9% in the non-dehydrated group. The hospital readmission rates were 8.3% in the dehydrated group and 10.6% in the non-dehydrated group. Furthermore, the 30-day mortality rates were 6.9% and 5.3% in the dehydrated and non-dehydrated groups, respectively. One-fifth of older patients admitted to the ED presented with HD. A CCI score of ≥5 was considered a risk factor of HD. Moreover, further studies should focus on the long-term outcomes of HD and risk reduction. Geriatr Gerontol Int 2021; 21: 485-491.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal.

PurposeAcute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.MethodsWe conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.ResultsThe AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43–4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11–3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362–6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.ConclusionThe current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.

Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience.

Emergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature. To analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment. This was a retrospective cohort study of LT patients at our ED (2015-2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death. For 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n=152, 30.1%). Infection was the most common ED diagnosis (n=101, 20.0%). Many patients were sent home from the ED (n=235, 46.5%), and 31.3% (n=158) returned to the ED within 30days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90mm Hg were significantly associated with ICU admission or death. Infection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.

The Golden Letter: Innovation Collaboration to Reduce Avoidable Hospital Admissions.

Emergency Department (ED) overutilization and avoidable hospital admissions have been identified as areas of improvement. Studies have shown that ensuring adequate primary care follow-up after discharge from ED is an area that can be targeted to help decrease hospitalizations. Between April 2017 and December 2018, any family medicine patient presented by the ED for admission who was determined to be a candidate for rapid primary care follow-up, was offered a "Golden Letter." This letter guaranteed that the patient would be evaluated within 48 hours of discharge at the patient's primary care clinic. We studied the impact on reducing hospital admissions, 30-day ED revisits, and 30-day hospitalizations. Our data analysis included gender, age, and insurance status. A total of 191 ED encounters that may have been admitted to the hospital were instead given a golden letter after shared decision making. A total of 104 (54.5%) completed a follow-up appointment within 48 hours. The 30-day ED revisit rate was 34% (65 encounters) with 33 (31.7%) of these patients having completed a follow-up visit and 32 (36.8%) did not follow up. There were 35 (18.3%) hospital admissions within 30 days of the ED visit. Of the patients admitted, 12 (11.5%) completed a follow-up visit and 23 (26.4%) did not complete a follow-up visit. This initiative effectively reduced the number of low-acuity admissions and 30-day hospitalizations. This concept can provide a significant reduction of health care resource utilization and cost by ensuring safe ED discharge and rapid outpatient follow-up for low-acuity patients.

Comparison of 30-day readmission and emergency department revisit rates among homeless patients at teaching versus non-teaching hospitals

Providing quality healthcare for homeless patients is a major public health challenge, and some hospitals may be better at treating homeless patients than others. However, whether the quality of care that homeless patients receive differs by the teaching status of hospitals remains unclear. Using statewide databases that include all hospital admissions and emergency department (ED) visits in four states (Florida, Massachusetts, Maryland, and New York) in 2014, we compared 30-day readmission and ED revisit rates for homeless and non-homeless patients discharged from teaching hospitals versus non-teaching hospitals, after adjusting for patient and hospital characteristics. Among 3,438,538 patients (median age [IQR]: 63 [49-77] years) analyzed, 132,025 (4%) were homeless patients. Overall, homeless patients had a higher readmission rate (28.3% vs. 17.7%; average marginal effects [AME], 10.5%; 95% confidence interval [CI], 8.2%-12.9%; p<0.001) and a higher ED revisit rate (37.6% vs. 23.9%; AME, 13.7%; 95%CI, 10.9%-16.6%; p<0.001) than non-homeless patients. Patients from teaching hospitals had similar readmission rate (18.2% vs. 18.3%; AME, -0.1%; 95%CI, -0.8%-0.5%; p=0.69) and slightly lower ED revisit rate than those from non-teaching hospitals (24.1% vs. 25.2%; AME, -1.1%; 95%CI, -1.9% to -0.3%; p<0.01). When we focus on joint effects of homelessness and hospital teaching status, we found that homeless patients treated at teaching hospitals had lower rates of 30-day readmission (AME, -5.8%; 95%CI, -9.7% to -1.8%; p<0.01) and ED revisit (AME, -9.3%; 95%CI, -13.1% to -5.5%; p<0.001) compared to those treated at non-teaching hospitals. For non-homeless patients, in contrast, we found no evidence that rates of hospital readmission (AME, 0%, 95%CI, -0.1%-0.1%; p=0.94) or ED revisit (AME, -0.9%; 95%CI, -1.7% to -0.1%; p=0.02) differ between teaching and non-teaching hospitals. These findings suggest the healthcare settings in which homeless patients receive care have important implications for their patient outcomes.

Improving transitions from acute care to home among complex older adults using the LACE Index and care coordination

BackgroundImproving transitions in care is a major focus of healthcare planning. The objective of this study was to determine the improvement in transitions from an intervention identifying complex older adult...

Variation in Proportion of Blood Cultures Obtained for Children With Skin and Soft Tissue Infections.

To identify variation in the proportion of blood cultures obtained for pediatric skin and soft tissue infections (SSTIs) among children's hospitals. We conducted a retrospective cohort study using the Pediatric Health Information System database, which we queried for emergency department (ED)-only and hospital encounters between 2012 and 2017 for children aged 2 months to 18 years with diagnosis codes for SSTI. The primary outcome was proportion of SSTI encounters during which blood cultures were obtained. Encounters with and without blood cultures were compared for length of stay, costs, and 30-day ED revisit and readmission rates, adjusted for patient factors and hospital clustering. We also identified encounters with bacteremia using billing codes for septicemia and bacteremia. We identified 239 954 ED-only and 49 291 hospital SSTI encounters among 38 hospitals. Median proportions of ED-only and hospital encounters with blood cultures were 3.2% (range: 1%- 11%) and 51.6% (range: 25%-81%), respectively. Adjusted ED-only encounters with versus without blood culture had higher costs ($1266 vs $460, P < .001), higher ED revisit rates (3.6% vs 2.9%, P < .001), and higher admission rates (2.0% vs 0.9%, P < .001). Hospital encounters with blood culture had longer length of stay (2.3 vs 2.0 days, P < .001), higher costs ($5254 vs $4425, P < .001), and higher readmission rates (0.8% vs 0.7%, P = .027). The overall proportion of encounters with bacteremia was 0.6% for ED-only encounters and 1.0% for hospital encounters. Despite multiple studies in which low clinical value was demonstrated and current Infectious Diseases Society of America guidelines arguing against the practice, blood cultures were obtained frequently for children hospitalized with SSTIs, with substantial variation across institutions. Few bacteremic encounters were identified.

A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation.

Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical-first and electrical-first strategies have been advocated, there are no comparative effectiveness data to guide clinicians. At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS2 score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length-of-stay (LOS); prespecified ED-based adverse events; and 30-day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL). Eighty-four patients were analyzed: 41 in the chemical-first group and 43 in the electrical-first group. Groups were balanced in terms of age, sex, vital signs, and CHADS2 scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical-first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical-first group (p=0.001). In the chemical-first group, the median ED LOS was 5.1 hours (interquartile range [IQR]= 3.5 to 5.9 hours) compared to 3.5 hours (IQR= 2.4 to 4.6 hours) in the electrical-first group, for a median difference of 1.2 hours (95% confidence interval= 0.4 to 2.0 hours, p<0.001). No patients experienced stroke or death. All other outcomes, including adverse events, ED revisits, and QoL, were similar. In uncomplicated ED AF patients managed with rhythm control, chemical-first and electrical-first strategies both appear to be successful and well tolerated; however, an electrical-first strategy results in a significantly shorter ED LOS.

Analysis of How Emergency Physicians’ Decisions to Hospitalize or Discharge Patients With Acute Heart Failure Match the Clinical Risk Categories of the MEESSI-AHF Scale

The Multiple Estimation of Risk Based on the Emergency Department Spanish Score in Patients With Acute Heart Failure (MEESSI-AHF) is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure patients. The objective of this study is to compare the distribution of risk categories between hospitalized and discharged ED patients with acute heart failure. We included consecutive acute heart failure patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI-AHF risk categories. We calculated the odds of hospitalization (versus direct discharge from the ED) across MEESSI-AHF risk categories. Next, we assessed the following 30-day postdischarge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low- and increased-risk categories. We included 7,930 patients (80.5 years [SD 10.1 years]; women 54.7%; hospitalized 75.3%). Compared with that for low-risk MEESSI-AHF patients, odds ratios for hospitalization of patients in intermediate-, high-, and very-high-risk categories were 1.83 (95% confidence interval [CI] 1.64 to 2.05), 3.05 (95% CI 2.48 to 3.76), and 3.98 (95% CI 3.13 to 5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as being at increased risk by MEESSI-AHF, and 19.0% of all the increased-risk patients were discharged from the ED. Among the low-risk MEESSI-AHF patients, the 30-day postdischarge mortality did not differ by ED disposition (hazard ratio [HR] for discharged patients with respect to hospitalized ones 0.65; 95% CI 0.70 to 1.11), nor did it differ in the increased-risk group (HR 0.88; 95% CI 0.63 to 1.23). The discharged low-risk MEESSI-AHF patients had higher risks of 30-day ED revisit and hospitalization (HR 1.86, 95% CI 1.57 to 2.20; and HR 1.92, 95% CI 1.54 to 2.40, respectively) compared with the admitted patients, as did the discharged patients in the increased-risk group (HR 1.62, 95% CI 1.39 to 1.89; and HR 1.40, 95% CI 1.16 to 1.68, respectively), with similar results for the combined endpoint. The disposition decisions made in current clinical practice for ED acute heart failure patients calibrate with MEESSI-AHF risk categories, but nearly half of the patients currently discharged from the ED fall into increased-risk MEESSI-AHF categories.

Racial/Ethnic Variation in Emergency Department Care for Children With Asthma.

To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients. This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED. The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01). In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.

Comparative Analysis of Short-Term Outcomes of Patients With Heart Failure With a Mid-Range Ejection Fraction After Acute Decompensation

To determine short-term outcomes after an episode of acute heart failure in patients with mid-range ejection fraction (40%-49%; HFmrEF) compared with patients with reduced (<40%) and preserved (>49%) ejection fractions (HFrEF and HFpEF, respectively) and according to their final destination after emergency department (ED) care. This is an exploratory, secondary analysis of the Epidemiology of Acute Heart Failure in the Emergency departments Registry, which includes consecutive acute heart failure patients diagnosed in 41 Spanish EDs. Patients with echocardiography data were included and divided into HFrEF, HFmrEF, and HFpEF. The primary outcome was 30-day all-cause mortality, and secondary outcomes were in-hospital all-cause mortality, hospital length of stay >10 days, and 30-day postdischarge ED revisit due to AHF and combined end point (ED revisit and/or death). We included 6,856 patients (age 79 [10]; 52.1% women): 21.6% had HFrEF, 14.3% HFmrEF, and 64.1% HFpEF. The main destinations for the 982 HFmrEF patients after ED management were internal medicine (293, 29.8%), cardiology (194, 19.9%) and not hospitalized (241, 24.5%), whereas the remaining 254 patients were admitted to other departments, including geriatric wards, short-stay units and intensive care units. Outcomes for HFmrEF did not differ compared with either HFrEF or HFpEF. Compared with HFmrEF admitted to cardiology, internal medicine admission or direct ED discharge increased the 30-day postdischarge ED revisit (hazard ratio [HR] 1.713, 95% confidence interval [CI] 1.042 to 2.816; and HR 1.683, 95% CI 1.046 to 2.708, respectively) and the 30-day postdischarge combined end point (HR 1.732, 95% CI 1.070 to 2.803; and HR 1.727, 95% CI 1.083 to 2.756, respectively). In conclusion, patients in the newly created HFmrEF category suffering from an acute decompensation have similar short-term outcomes as those in the classical HFrEF and HFpEF categories; nonetheless, HFmrEF patients handled in cardiology wards during decompensation obtain better outcomes, and reasons for these differences have to be unmasked and corrected.