Massachusetts Emergency Departments Research Articles

Disparities in Psychiatric Emergency Department Boarding of Children and Adolescents.

Since the COVID-19 pandemic, emergency department boarding of youth with mental health concerns has increased. To summarize characteristics (including gender, age, race, ethnicity, insurance, diagnosis, and barriers to placement) of youth who boarded in emergency departments while awaiting inpatient psychiatric care and to test for racial, ethnic, and gender disparities in boarding lengths and inpatient admission rates after boarding. Secondarily, to assess whether statewide demand for inpatient psychiatric care correlated with individual outcomes. This cross-sectional analysis included administrative data collected from May 2020 to June 2022 and represented a statewide study of Massachusetts. All youth aged 5 to 17 years who boarded in Massachusetts emergency departments for 3 or more midnights while awaiting inpatient psychiatric care were included. Boarding for 3 or more midnights while awaiting inpatient psychiatric care. Emergency department boarding length (number of midnights) and whether inpatient care was received after boarding. Statistical analyses performed included logistic and gamma regressions; assessed gender, racial, and ethnic disparities; and correlations between statewide demand for psychiatric care and boarding outcomes. A total of 4942 boarding episodes were identified: 2648 (54%) for cisgender females, 1958 (40%) for cisgender males, and 336 (7%) for transgender or nonbinary youth. A total of 1337 youth (27%) were younger than 13 years. Depression was the most common diagnosis (2138 [43%]). A total of 2748 episodes (56%) resulted in inpatient admission, and 171 transgender and nonbinary youth (51%) received inpatient care compared with 1558 cisgender females (59%; adjusted difference: -9.1 percentage points; 95% CI, -14.7 to -3.6 percentage points). Transgender or nonbinary youth boarded for a mean (SD) of 10.4 (8.3) midnights compared with 8.6 (6.9) midnights for cisgender females (adjusted difference: 2.2 midnights; 95% CI, 1.2-3.2 midnights). Fewer Black youth were admitted than White youth (382 [51%] and 1231 [56%], respectively; adjusted difference: -4.3 percentage points; 95% CI, -8.4 to -0.2 percentage points). For every additional 100 youth boarding statewide on the day of assessment, the percentage of youth admitted was 19.4 percentage points lower (95% CI, -23.6% to -15.2%) and boarding times were 3.0 midnights longer (95% CI, 2.4-3.7 midnights). In this cross-sectional study, almost one-half of 3 or more midnight boarding episodes did not result in admission, highlighting a need to understand the effects of boarding without admission. Gender and racial disparities were identified, suggesting the need for targeted resources to reduce boarding and promote equitable access to care.

Disparities in Psychiatric Emergency Department Boarding of Children and Adolescents

Since the COVID-19 pandemic, emergency department boarding of youth with mental health concerns has increased. To summarize characteristics (including gender, age, race, ethnicity, insurance, diagnosis, and barriers to placement) of youth who boarded in emergency departments while awaiting inpatient psychiatric care and to test for racial, ethnic, and gender disparities in boarding lengths and inpatient admission rates after boarding. Secondarily, to assess whether statewide demand for inpatient psychiatric care correlated with individual outcomes. This cross-sectional analysis included administrative data collected from May 2020 to June 2022 and represented a statewide study of Massachusetts. All youth aged 5 to 17 years who boarded in Massachusetts emergency departments for 3 or more midnights while awaiting inpatient psychiatric care were included. Boarding for 3 or more midnights while awaiting inpatient psychiatric care. Emergency department boarding length (number of midnights) and whether inpatient care was received after boarding. Statistical analyses performed included logistic and gamma regressions; assessed gender, racial, and ethnic disparities; and correlations between statewide demand for psychiatric care and boarding outcomes. A total of 4942 boarding episodes were identified: 2648 (54%) for cisgender females, 1958 (40%) for cisgender males, and 336 (7%) for transgender or nonbinary youth. A total of 1337 youth (27%) were younger than 13 years. Depression was the most common diagnosis (2138 [43%]). A total of 2748 episodes (56%) resulted in inpatient admission, and 171 transgender and nonbinary youth (51%) received inpatient care compared with 1558 cisgender females (59%; adjusted difference: -9.1 percentage points; 95% CI, -14.7 to -3.6 percentage points). Transgender or nonbinary youth boarded for a mean (SD) of 10.4 (8.3) midnights compared with 8.6 (6.9) midnights for cisgender females (adjusted difference: 2.2 midnights; 95% CI, 1.2-3.2 midnights). Fewer Black youth were admitted than White youth (382 [51%] and 1231 [56%], respectively; adjusted difference: -4.3 percentage points; 95% CI, -8.4 to -0.2 percentage points). For every additional 100 youth boarding statewide on the day of assessment, the percentage of youth admitted was 19.4 percentage points lower (95% CI, -23.6% to -15.2%) and boarding times were 3.0 midnights longer (95% CI, 2.4-3.7 midnights). In this cross-sectional study, almost one-half of 3 or more midnight boarding episodes did not result in admission, highlighting a need to understand the effects of boarding without admission. Gender and racial disparities were identified, suggesting the need for targeted resources to reduce boarding and promote equitable access to care.

Dissecting patterns and predictors of interhospital transfers for patients with brain metastasis.

Interhospital transfers in the acute setting may contribute to high cost, patient inconvenience, and delayed treatment. The authors sought to understand patterns and predictors in the transfer of brain metastasis patients after emergency department (ED) encounter. The authors analyzed 3037 patients with brain metastasis who presented to the ED in Massachusetts and were included in the Healthcare Cost and Utilization Project State Inpatient Database and State Emergency Department Database in 2018 and 2019. The authors found that 6.9% of brain metastasis patients who presented to the ED were transferred to another facility, either directly or indirectly after admission. The sending EDs were more likely to be nonteaching hospitals without neurosurgery and radiation oncology services (p < 0.01). Transferred patients were more likely to present with neurological symptoms compared to those admitted or discharged (p < 0.01). Among those transferred, approximately 30% did not undergo a significant procedure after transfer and approximately 10% were discharged within 3 days, in addition to not undergoing significant interventions. In total, 74% of transferred patients were sent to a facility significantly farther (> 3 miles) than the nearest facility with neurosurgery and radiation oncology services. Further distance transfers were not associated with improvements in 30-day readmission rate (OR [95% CI] 0.64 [0.30-1.34] for 15-30 miles; OR [95% CI] 0.73 [0.37-1.46] for > 30 miles), 90-day readmission rate (OR [95% CI] 0.50 [0.18-1.28] for 15-30 miles; OR [95% CI] 0.53 [0.18-1.51] for > 30 miles), and length of stay (OR [95% CI] 1.21 days [0.94-1.29] for both 15-30 miles and > 30 miles) compared to close-distance transfers. The authors identified a notable proportion of transfers without subsequent significant intervention or appreciable medical management. This may reflect ED physician discomfort with the neurological symptoms of brain metastasis. Many patients were also transferred to hospitals distant from their point of origin and demonstrated no differences in readmission rates and length of stay.

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators.

Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care. We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California. PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%). ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.

Community Validation of an Approach to Detect Delayed Diagnosis of Appendicitis in Big Databases.

Detection of delayed diagnosis using administrative databases may illuminate the healthcare settings at highest risk. A method for detection of delays in claims has been validated in children's hospitals. We sought to further validate the method in community emergency departments (EDs). We studied patients <21 years old diagnosed with appendicitis from 2008 to 2019 in 8 eastern Massachusetts EDs. Eligible patients had 2 ED encounters within 7 days, the second with an appendicitis diagnosis. Delayed diagnosis was evaluated in medical records by trained reviewers. A previously validated trigger tool was applied to participants' electronic medical record data. The tool used data elements included in administrative data, including initial encounter diagnoses, time between encounters, presence of medical complexity, and ultimate length of stay. The tool assigned a probability of delayed diagnosis for each patient. Test characteristics at 4 confidence thresholds were determined, and the area under the receiver operating curve was calculated. We analyzed 68 children with 2 encounters leading to a diagnosis of appendicitis (i.e., possible delay). When assigning a delayed diagnosis prediction to patients at 4 thresholds of confidence (>0%, >50%, >75%, and >90% confident), the positive predictive values were respectively 74%, 89%, 92%, and 89%; the negative predictive values were respectively 100%, 57%, 50%, and 33%. The area under the receiver operating curve was 0.837 (95% confidence interval 0.719-0.954). A trigger tool that identifies delays in diagnosis using only administrative data in community EDs has a high positive predictive value for true delay. The tool may be applied in community EDs.

Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity.

Metabolic syndrome (MetS) is associated with increased risk of severe COVID-19. MetS inflammatory biomarkers share similarities with those of COVID-19, yet this association is poorly explored. Biomarkers of COVID-19 patients with and without MetS, the combination of diabetes, hypertension, obesity, and/or dyslipidemia, were analyzed to identify biological predictors of COVID-19 severity. In this prospective observational study, at a large academic emergency department in Boston, Massachusetts, clinical and proteomics data were analyzed from March 24 to April 30, 2020. Patients age ≥18 with a clinical concern for COVID-19 upon arrival and acute respiratory distress were included. The main outcome was severe COVID-19 as defined using World Health Organization COVID-19 outcomes scores ≤4, which describes patients who died, required invasive mechanical ventilation, or required supplemental oxygen. Among 155 COVID-19 patients, 90 (58.1%) met the definition of MetS and 65 (41.9%) were identified as Control. The MetS cohort was more likely to have severe COVID-19 compared with the Control cohort (OR 2.67 [CI 1.09-6.55]). Biomarkers, including CXCL10 (OR 1.94 [CI 1.38-2.73]), CXCL9 (OR 1.79 [CI 1.09-2.93]), HGF (OR 3.30 [CI 1.65-6.58]), and IL6 (OR 2.09 [CI 1.49-2.94]) were associated with severe COVID-19. However, when stratified by MetS, only CXCL10 (OR 2.39 [CI 1.38-4.14]) and IL6 (OR 3.14 [CI 1.53-6.45]) were significantly associated with severe COVID-19. MetS-associated severe COVID-19 is characterized by an immune signature of elevated levels of CXCL10 and IL6. Clinical trials targeting CXCL10 or IL6 antagonism in this population may be warranted.

Likelihood of Bacterial Infection in Patients Treated With Broad-Spectrum IV Antibiotics in the Emergency Department.

Best practice guidelines and quality metrics recommend immediate antibiotic treatment for all patients with suspected sepsis. However, little is known about how many patients given IV antibiotics in the emergency department are ultimately confirmed to have bacterial infection. We performed a retrospective study of adult patients who presented to four Massachusetts emergency departments between June 2015 and June 2018 with suspected serious bacterial infection, defined as blood cultures drawn and broad-spectrum IV antibiotics administered. Structured medical record reviews were performed on a random sample of 300 cases to determine the post hoc likelihood of bacterial infection, categorized as definite, likely, unlikely, or definitely none. None. Among the 300 patients with suspected serious bacterial infections, mean age was 68 years (sd 18), median hospital length of stay was 5 days (interquartile range, 3-8 d), 45 (15%) were admitted directly to ICU, and 14 (5%) died in hospital. Overall, 196 (65%) had definite (n = 115; 38%) or likely (n = 81; 27%) bacterial infection, whereas 104 (35%) were unlikely (n = 55; 18%) or definitely not infected (n = 49; 16%). Antibiotic treatment durations differed by likelihood of infection (median 15 days for definite, 9 for likely, 7 for unlikely, and 3 for definitely not infected). The most frequent post hoc diagnoses in patients with unlikely or definitely no bacterial infection included viral infections (28%), volume overload or cardiac disease (9%), drug effects (9%), and hypovolemia (7%). The likelihoods of infection were similar in the subset of 96 cases in whom emergency department providers explicitly documented possible or suspected sepsis and in the 45 patients admitted from the emergency department to the ICU. One third of patients empirically treated with broad-spectrum antibiotics in the emergency department are ultimately diagnosed with noninfectious or viral conditions. These findings underscore the difficulty diagnosing serious infections in the emergency department and have important implications for guidelines and quality measures that compel immediate empiric antibiotics for all patients with possible sepsis.

Decreased hospital admissions through emergency departments during the COVID-19 pandemic.

Study objectiveEmergency Department (ED) visits decreased significantly in the United States during the COVID-19 pandemic. A troubling proportion of this decrease was among patients who typically would have been admitted to the hospital, suggesting substantial deferment of care. We sought to describe and characterize the impact of COVID-19 on hospital admissions through EDs, with a specific focus on diagnosis group, age, gender, and insurance coverage.MethodsWe conducted a retrospective, observational study of aggregated third-party, anonymized ED patient data. This data included 501,369 patient visits from twelve EDs in Massachusetts from 1/1/2019–9/9/2019, and 1/1/2020–9/8/2020. We analyzed the total arrivals and hospital admissions and calculated confidence intervals for the change in admissions for each characteristic. We then developed a Poisson regression model to estimate the relative contribution of each characteristic to the decrease in admissions after the statewide lockdown, corresponding to weeks 11 through 36 (3/11/2020–9/8/2020).ResultsWe observed a 32% decrease in admissions during weeks 11 to 36 in 2020, with significant decreases in admissions for chronic respiratory conditions and non-orthopedic needs. Decreases were particularly acute among women and children, as well as patients with Medicare or without insurance. The most common diagnosis during this time was SARS-CoV-2.ConclusionOur findings demonstrate decreased hospital admissions through EDs during the pandemic and suggest that several patient populations may have deferred necessary care. Further research is needed to determine the clinical and operational consequences of this delay.

Electronic Health Record Documentation of Psychiatric Assessments in Massachusetts Emergency Department and Outpatient Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic

This cohort study investigates the documentation of psychiatric symptoms in narrative clinical notes as coronavirus disease 2019 (COVID-19) prevalence increased in eastern Massachusetts.

Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic

Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients' likelihood of a subsequent urologic intervention could inform decision-making in this population. To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. A total of 66 218 unique index visits by 55 314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60 367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P < .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P < .001) compared with patients with all other insurance types. In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients.

One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose

Despite the increased availability of naloxone, death rates from opioid overdose continue to increase. The goal of this study is to determine the 1-year mortality of patients who were treated for a nonfatal opioid overdose in Massachusetts emergency departments (EDs). This was a retrospective observational study of patients from 3 linked statewide Massachusetts data sets: a master demographics list, an acute care hospital case-mix database, and death records. Patients discharged from the ED with a final diagnosis ofopioid overdose were included. The primary outcome measure was death from any cause within 1 year of overdose treatment. During the study period, 17,241 patients were treated for opioid overdose. Of the 11,557 patients who met study criteria, 635 (5.5%) died within 1 year, 130 (1.1%) died within 1 month, and 29 (0.25%) died within 2 days. Of the 635 deaths at 1 year, 130 (20.5%) occurred within 1 month and 29 (4.6%) occurred within 2 days. The short-term and 1-year mortality of patients treated in the ED for nonfatal opioid overdose is high. The first month, and particularly the first 2 days after overdose, is the highest-risk period. Patients who survive opioid overdose should be considered high risk and receive interventions such as being offered buprenorphine, counseling, and referral to treatment before ED discharge.

Emergency Department and Primary Care Use in Massachusetts 5 Years After Health Reform.

Conceptually, access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions. We sought to identify characteristics of insured Massachusetts residents associated with PCS ED use, and compare such use for public versus private insurees. People under age 65 in the Massachusetts All-Payer Claims Data, 2011-2012. Retrospective, observational analysis of PCS ED use with nonurgent, urgent/primary care treatable, and urgent/potentially avoidable visits being considered PCS. We predicted utilization in 2012 using multivariable regression models and data available in 2011 administrative records. Among 2,269,475 nonelderly Massachusetts residents, 40% had public insurance. Among public insurees, PCS ED use was higher than for private (mean, 36.5 vs. 9.0 per 100 persons; adjusted risk ratio, 2.53; 95% confidence limits, 2.49-2.56), while having any primary care visit was less common (70% vs. 83%), as was having any visit to one's own (attributed) primary care provider (38% vs. 44%). Public insurance was associated with less access to primary care and more PCS ED use; statewide labor shortages and low reimbursement rates from public insurance may have provided inadequate access to care that might otherwise have helped reduce PCS ED use.

Applying Computer Adaptive Testing Methods to Suicide Risk Screening in the Emergency Department.

Combine test theory with technology to develop brief, reliable suicide risk measures in the emergency department. A computer adaptive test for suicide risk was built using the Beck Scale for Suicide Ideation and tested among the emergency department population. Data were analyzed from a sample of 1,350 patients in several Massachusetts emergency departments. The test was built as outlined by the National Institutes of Health Patient-Reported Outcomes Measurement Information System. Of 1,350 patients, 74 (5%) scored above the cutoff of BSS>2. Item 2, "Wish to die", was the most informative item. When using only Item 2, 20% (n=15/74) of at-risk patients and 3% (n=40/1,276) of not-at-risk patients were misclassified. Patients were classified after four items with computer adaptive testing trait estimates highly comparable to those of the full scale. The precision rule model did not reduce the scale. This study models the creation of a computer adaptive test for suicide ideation and marks the start of the development of computer adaptive tests as a novel suicide risk screening tool in the emergency department. Computer adaptive tests hold promise for revolutionizing behavioral health screening by addressing barriers including time and knowledge deficits.

Age Legislation and Off-Road Vehicle Injuries in Children.

In 2010, the Massachusetts Legislature passed a comprehensive law that restricted off-road vehicle (ORV) use by children <14 years old and regulated ORV use by children up to the age of 18 years. We aimed to examine the impact of the 2010 Massachusetts law on the rates of ORV-related injuries. A retrospective analysis was performed of Massachusetts emergency department (ED) and inpatient discharges between 2002 and 2013 as found in the Center for Health Information and Analysis database by using external causes of injury codes specific to ORV-related injuries. Yearly population-based rates were compared before and after the implementation of the law (2002-2010 vs 2011-2013) by using Poisson regression analysis and segmented regression. There were 3638 ED discharges and 481 inpatient discharges for ORV-related injuries in children across the 12-year study period. After the implementation of the law, the rate of ED discharges declined by 33% in 0- to 9-year-olds, 50% in 10- to 13-year-olds, and 39% in 14 to 17-year-olds (P < .0001). There was no significant decline in ED discharges for 25- to 34-year-olds. Inpatient hospital discharges were also reduced by 41% in 0- to 17-year-olds after implementation (P < .001). As compared with adults (ages 25-34 years), the population-based ORV-related injury rate of residents <18 years old significantly declined after the passage of legislation that imposed age restrictions and other safeguards for youth riders.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study

We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality. Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals.

Analysis of Emergency Department Length of Stay for Mental Health Patients at Ten Massachusetts Emergency Departments

Prolonged boarding times in the emergency department (ED) disproportionately affect mental health patients, resulting in patient and provider dissatisfaction and increased patient morbidity and mortality. Our objective is to quantify the burden of mental health boarding and to elucidate the effect of insurance together with demographic, social, and comorbid factors on length of stay. We conducted a cross-sectional observational study of 871 consecutive patients requiring an ED mental health evaluation at one of 10 unaffiliated Massachusetts hospitals. Demographics; insurance; length of stay; medical, psychiatric, and social history; and disposition data were collected. We evaluated the effect of these characteristics on boarding time. ED median length of stay varied greatly by disposition, driven primarily by ED boarding time. Admitted and transferred patients had longer delays than discharged patients (5.63, 9.32, and 1.23 hours, respectively). Medical clearance time (1.40 hours) composed only 10.5% of total ED length of stay and varied little by insurance. In our multivariate analyses, patients with Medicaid and the uninsured had significantly longer total lengths of stay and were more than twice as likely to remain in the ED for 24 hours or greater compared with privately insured patients. Mental health patients in Massachusetts have lengthy ED visits, particularly those requiring inpatient admission. Boarding time accounts for the majority of total ED length of stay and varies by insurance, even when other factors known to affect ED length of stay are controlled. Efforts to improve timeliness of care for mental health emergencies should focus on reducing ED boarding and eliminating disparities in care by insurance status.

Decline in Consultant Availability in Massachusetts Emergency Departments: 2005 to 2014

Emergency department (ED) consultation is a common practice. There are few data on consultant availability or changes in availability over time, which may hinder resource planning and allocation. We conduct serial surveys of Massachusetts EDs to investigate these trends. We surveyed ED directors in Massachusetts in 2006 (n=61 EDs), 2009 (n=63), and 2015 (n=63) about ED characteristics in the previous year, including specialty-specific consultant availability in person (yes/no) and continuous consultant availability (yes/no). We tested trends in consultant availability (P for trend) and used multivariable logistic regression to calculate odds of continuous availability in 2014 versus2005. Response rates were greater than 80% each year. From 2005 to 2014, there was an increase in the median number of annual ED visits from 32,025 (interquartile range [IQR] 23,000 to 50,000) to 42,000 (IQR 26,000 to 59,300), number of full-time attending physicians from 11 (IQR 8 to 16) to 12 (IQR 8 to 22), and number of full-time ED nurses from 27 (IQR 17 to 54) to 42 (IQR 25 to 65). In adjusted models, there was a significantly reduced odds of consultant availability in 2014 versus 2005 for general surgery (odds ratio [OR] 0.05; 95% confidence interval [CI] 0.01 to 0.35), neurology (OR 0.39; 95% CI 0.17 to 0.86), obstetrics/gynecology (OR 0.40; 95% CI 0.16 to 0.97), orthopedics (OR 0.34; 95% CI 0.13 to 0.89), pediatrics (OR 0.19; 95% CI 0.06 to 0.54), plastic surgery (OR 0.10; 95% CI 0.03 to 0.32), and psychiatry (OR 0.25; 95% CI 0.12 to 0.52). In Massachusetts EDs between 2005 and 2014, ED consultant availability significantly declined despite accounting for other ED characteristics.

Savings in acute care costs if all older adults treated for fall-related injuries completed matter of balance.

BackgroundFalls among older adults are a common and serious public health problem. Evidence-based fall prevention programs delivered in community settings and targeting older adults living independently are increasingly deployed throughout the nation. These programs tend to be offered by public and private organizations that serve older adults, and recruitment usually occurs through direct marketing to the target population, rather than through referrals from healthcare providers. Matter of Balance, a program developed to reduce fear of falling and associated activity restriction in community-dwelling older adults, is currently being delivered in 38 of the 50 United States. In this study, we estimate the one-year medical care cost savings if older adults treated at Massachusetts hospitals for fall-related injuries were referred by healthcare providers to participate in Matter of Balance.MethodsData from several sources were used for this study. We estimated annual cost savings in older adult falls recidivism for a hypothetical 100 patients presenting at an emergency department for a fall-related injury, assuming that all were referred to, and 50 % completed, Matter of Balance. This cost-saving estimate was subsequently expanded based on the actual number (43,931) of older adult patients presenting at, and discharged from Massachusetts emergency departments for all fall-related injuries in 2012. Cost savings were calculated for two additional participation rates: 25 % and 75 %. The return on investment (ROI), was calculated based on the percentage of return per each dollar invested.ResultsThe calculated ROI for Matter of Balance was 144 %. Statewide savings ranged from $2.79 million assuming a 25 % participation rate to $8.37 million, assuming a 75 % participation rate.ConclusionsReferral to evidence-based falls prevention programs of older adult patients presenting at EDs with a fall-related injury could reduce subsequent falls and associated treatment costs.

Variation and Trends in Charges for Pediatric Care in Massachusetts Emergency Departments, 2000–2011

Emergency department (ED) utilization by children is common and growing more expensive. Tracking trends and variability in ED charges is essential for policymakers who strive to improve the efficiency of the health care system and for payers who prepare health care budget forecasts. Our objective was to examine trends and variability in ED charges for pediatric patients across Massachusetts. This was a comprehensive analysis of the statewide database containing all the visits of children aged 0 to 18 years evaluated in any of the state's EDs from 2000 to 2011, excluding patients with chronic medical conditions and those whose visits resulted in hospital admission. A validated system designed to specifically classify pediatric emergency patients into major diagnostic groups was used. Mean charges as well as interhospital variability of charges over time were examined for the most common diagnostic groups. Seventy-six hospitals provided emergency care in Massachusetts during the study period, with 6,249,923 pediatric patients treated and discharged. Statewide charges significantly increased from 2000 until 2007/2008, before plateauing or decreasing through 2011. There was no evidence that interhospital variability changed over time. With the exception of academic teaching status, no hospital-level factors emerged as consistent predictors of charges. Charges for common pediatric emergency conditions varied widely across Massachusetts EDs, and hospital-level factors by and large could not consistently explain the variability. Although a plateau (and in some cases decrease) of statewide pediatric emergency health care charges was observed after 2007, no evidence was found that interhospital variability decreased. These data may be useful in the ongoing effort to reform the economics of health care delivery systems.

319 Variability in Patient Care Process Measures Across 7 Massachusetts Academic Emergency Departments

Study Objectives: To identify areas of variability and consistency in clinical operations and practice parameters across academic emergency departments (EDs). Methods: A retrospective cross-sectional descriptive review of Massachusetts EDs where emergency medicine residents spend 1 month of required training time. Of the 13 eligible, 7 became participants by identifying a site PI, obtaining local institutional review board approval, and collecting the requested data. Seven domains of data were collected for 2011 including: patients, care space and disposition; clinical staffing; triage type; lab and radiology testing; process improvement trials; documentation and billing; acute coronary syndrome and congestive heart failure clinical practice. We have reported averages and 1 standard of deviation to describe central tendency and variability. Results: Average ED daily volume (177 +/− 79) and space (3.4 +/− 1.4 patients per sq ft per yr) are quite variable across facilities. Attending physician staffing has low variability (2.5 +/− 0.5 hrs per day) while nursing staffing is more variable (1.9 +/−0.8 nursing hrs per patients seen). When PAs and NPs are included with residents as physician extenders, affiliate site attending physicians with their extenders see fewer patients per hour than those at primary residency sites (0.8 patients per hr +/− 0.2 versus 1.5 +/− 0.4). However, affiliate site EDs bill a higher percentage of level 5 APC charts (36%) compared to the primary sites (24%), which are also the higher volume receiving centers for high acuity patients. Most EDs use some degree of RN triage (87%), but 43% have a combination model using some degree of direct to room or physician triage. EDs with observation units did not have shorter ED length of stay (LOS) for admitted patients as compared to those without (6.5 +/−0.8 hrs versus 5.0, +/−0.5hrs). ED LOS for discharged patients demonstrates relatively low variability (3.9 +/− 0.5 hrs). In the past 10 years, 85.7% of EDs have worked on patient flow, triage and inpt admission processes. 71.4% have addressed care-space use, fast track areas, lab testing services, and consultations. Only 57.1% have worked on radiology testing services. The greatest variability in payer mix occurs amongst private insurance (28.9%, +/−25.6) and self-pay patients (25.5%, +/−22.3), with much less variability amongst Medicare (24.2% +/−11.7) and Medicaid (21.5% +/−12.0) patients. All EDs use either a Troponin T or an ultrasensitive Troponin I. The average interval for 2 troponin assays as part of an acute coronary syndrome evaluation was 6hrs. All discharged a maximum of 10% of patients with a primary diagnosis of congestive heart failure from the ED. Conclusion: As academic EDs cope with increasing volume and patient complexity, a variety of innovative approaches have been taken to improve throughput and care quality. However, throughput to discharge seems relatively homogeneous. Larger EDs are managing with fewer resources and a poorer income generation scenario. The area of least process improvement innovation was radiology testing. Regarding cardiovascular care, there is potential practice and throughput improvement for patients being evaluated for acute coronary syndrome with a more evidence-based use of cardiac enzymes by using intervals shorter than 6 hours, and with congestive heart failure patients where less than 10% are discharged.