Rates Of Emergency Department Research Articles

488 National Trends and Outcomes of Irritable Bowel Syndrome Presenting to Emergency Departments: Results From the Nationwide Emergency Department Sample (NEDS) Database

INTRODUCTION: Irritable bowel syndrome (IBS) is a chronically relapsing disease that causes gastrointestinal discomfort with diarrhea and/or constipation in a large group of Americans. Estimates of IBS disease burden in emergency departments (ED) are lacking. We sought to investigate IBS emergency department visits nationally, patient demographics and hospitalization trends from 2009-2014 using Nationwide Emergency Department Sample (NEDS) database. METHODS: The Nationwide Emergency Department Sample database was used to extract data from 2009 to 2014 for patients who visited the ED with a primary diagnosis of irritable bowel syndrome. International Classification of Diseases (ICD-9-CM) were used to identify patients; Irritable bowel syndrome (ICD-9-CM: 564.1). The 2009-2014 NEDS data was used to study the incidence of ED visits, patient/hospital factors, inpatient charges, length of hospitalization and discharge from hospital to home. RESULTS: There were 189,210 (0.02%) ED visits identified with a diagnosis of IBS among a total of 795,980,104 ED visits between 2009-2014 in the NEDS database. Most patients were female (n = 143247.6, 75.8%) with a mean age of 42.4 years. The rate of ED visits decreased from 10.2 per 100,000 in 2009, to 9.4 per 100,000 in 2014 (decrease of 8%; z = -1.691, P = 0.091). The majority of patients had private insurance (n = 68687, 36.3%) followed by Medicare (n = 43272, 22.9%) and Medicaid (n = 41737, 22.1%). Uninsured patients presenting with IBS to the ED constituted 15% (n = 28392) of the study population. Patients presented with IBS in far greater numbers to urban EDs (n = 150148, 79.4%) compared to rural EDs (n = 39062, 20.6%). Most were discharged from the ED (n = 134616.9, 71.1%) while 28.9% (n = 54593.5) patients were admitted. Hospitalized patients had a decrease in mean length of stay from 3.64 days in 2009 to 3.53 days in 2014; however, the mean inpatient charges increased from $20,823 in 2009 to $27,649 in 2014 (increase of 32.8%). CONCLUSION: Irritable bowel syndrome emergency department visits remained relatively constant between 2009 and 2014 while nearly 30% of patients were admitted. Despite unchanged hospital length of stay, hospitalization costs appear to be increasing. Better outpatient management of irritable bowel syndrome is needed to avoid emergency department visits and rising inpatient costs.

Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016

BackgroundTotal knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system. MethodsUsing data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information. ResultsLOS decreased significantly over the study period (P < .0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit. ConclusionsWe identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.

Trends in United States emergency department visits and associated charges from 2010 to 2016

BackgroundDemographic shifts and care delivery system evolution affect the number of Emergency Department (ED) visits and associated costs. Recent aggregate trends in ED visit rates and charges between 2010 and 2016 have not been evaluated. MethodsData from the National Emergency Department Sample, comprising approximately 30 million annual patient visits, were used to estimate the ED visit rate and charges per visit from 2010 to 2016. ED visits were grouped into 144 mutually exclusive clinical categories. Visit rates, compound annual growth rates (CAGRs), and per visit charges were estimated. ResultsFrom 2010 to 2016, the number of ED visits increased from 128.97 million to 144.82 million; the cumulative growth was 12.29% and the CAGR was 1.95%, while the population grew at a CAGR of 0.73%. Expressed as a population rate, ED visits per 1000 persons increased from 416.92 in 2010 to 448.19 in 2016 (p value <0.001). The mean charges per visit increased from $2061 (standard deviation $2962) in 2010 to $3516 (standard deviation $2962) in 2016; the CAGR was 9.31% (p value <0.001). Of 144 clinical categories, 140 categories had a CAGR for mean charges per visit of at least 5%. ConclusionThe rate of ED visits per 1000 persons and the mean charge per ED visit increased significantly between 2010 and 2016. Mean charges increased for both high- and low-acuity clinical categories. Visits for the 5 most common clinical categories comprise about 30% of ED visits, and may represent focus areas for increasing the value of ED care.

Emergency department visits and hospitalizations among hemodialysis patients by day of the week and dialysis schedule in the United States.

Background and objectivePrevious reports indicated that patients on thrice-weekly hemodialysis (HD) had higher mortality rates after the 3-day interdialytic interval. However, day-of-the-week patterns of emergency department (ED) visits and hospitalizations remain under-investigated.MethodsWe conducted a retrospective cohort study of HD patients on thrice-weekly dialysis, using 2013 data from the United States Renal Data System (USRDS). We estimated crude incidence rates of ED visits and hospitalizations by day of the week and dialysis schedule (Monday, Wednesday, Friday or Tuesday, Thursday, Saturday). Using Poisson regression, we estimated case-mix adjusted rate ratios of all-cause ED visits and hospitalizations, and adjusted rates of cause-specific ED visits and hospitalizations.ResultsWe identified 241,093 eligible HD patients in 2013, who had 514,773 ED visits and 301,674 hospitalizations that year. Three distinct but related patterns of outcome events were observed. Crude and adjusted incidence rates of all-cause, cardiovascular, and infection-related ED visits and hospitalizations, but not vascular-access-related events, were higher on all three HD treatment days (“dialysis-day effect”). Rates for ED visits and hospitalizations were lower on weekends than weekdays, rising appreciably from Sunday to Monday for both dialysis schedules (“post-weekend effect”); and rates were highest after the long 3-day interval between dialysis sessions for both dialysis schedules (“interdialytic-gap effect”). In contrast, rates of hospitalizations not preceded by an ED visit were nearly the same Monday through Friday and lower on weekends for both dialysis schedules.ConclusionsHigher rates of ED visits and hospitalizations on the days of HD sessions and early in the week are a public-health concern that should stimulate research to explain these patterns and reduce the excessive morbidity and associated costs among patients on thrice-weekly HD, while improving quality of care and patient experience with dialysis.

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations. DesignRetrospective cohort study. Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes. MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access. ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access. Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.

Association of an Emergency Department–Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions

Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes. To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission. This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019. Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs. The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission. A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217). Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

Resource Utilization in Non-Academic Emergency Departments with Advanced Practice Providers.

IntroductionAdvanced practice providers (APP), including physicians’ assistants and nurse practitioners, have been increasingly incorporated into emergency department (ED) staffing over the past decade. There is scant literature examining resource utilization and the cost benefit of having APPs in the ED. The objectives of this study were to compare resource utilization in EDs that use APPs in their staffing model with those that do not and to estimate costs associated with the utilized resources.MethodsIn this five-year retrospective secondary data analysis of the Emergency Department Benchmarking Alliance (EDBA), we compared resource utilization rates in EDs with and without APPs in non-academic EDs. Primary outcomes were hospital admission and use of computed tomography (CT), radiography, ultrasound, and magnetic resonance imaging (MRI). Costs were estimated using the 2014 physician fee schedule and inpatient payments from the Centers for Medicare and Medicaid Services. We measured outcomes as rates per 100 visits. Data were analyzed using a mixed linear model with repeated measures, adjusted for annual volume, patient acuity, and attending hours. We used the adjusted net difference to project utilization costs between the two groups per 1000 visits.ResultsOf the 1054 EDs included in this study, 79% employed APPs. Relative to EDs without APPs, EDs staffing APPs had higher resource utilization rates (use per 100 visits): 3.0 more admissions (95% confidence interval [CI], 2.0–4.1), 1.7 more CTs (95% CI, 0.2–3.1), 4.5 more radiographs (95% CI, 2.2–6.9), and 1.0 more ultrasound (95% CI, 0.3–1.7) but comparable MRI use 0.1 (95% CI, −0.2–0.3). Projected costs of these differences varied among the resource utilized. Compared to EDs without APPs, EDs with APPs were estimated to have 30.4 more admissions per 1000 visits, which could accrue $414,717 in utilization costs.ConclusionEDs staffing APPs were associated with modest increases in resource utilization as measured by admissions and imaging studies.

THE ASSOCIATION BETWEEN ELEVATED EMERGENCY DEPARTMENT SYSTOLIC BLOOD PRESSURE AND IN HOSPITAL MORTALITY AMONG HYPERTENSIVE PATIENTS

Objective: Blood pressure (BP) is severely elevated at 16.3% and moderately elevated at 27.2% of hospital emergency department (ED) visits. Among ED patients with elevated BP, 50% to 70% have chronic hypertension. The aim of our study was to determine whether elevated systolic blood pressure (SBP) in the ED is associated with increased in-hospital mortality among hypertensive patients. Design and method: We retrospectively retrieved records of adult hypertensive patients who were hospitalized in one medical center during a five-year period (1/2013 – 12/2017). Patients were grouped according to initial ED SBP measurements; <90, 90 – 109, 110 – 139, 140 – 159, 160 – 179, 180 – 199, 200 – 219 and >220, mmHg. We examined the association between SBP measurements in the ED and in-hospital mortality rate, adjusted for the following ED features: demographics, mode of arrival, chief complaint, heart rate, known co-morbidities, laboratory results and type of hospitalization ward. Results: Overall, 198,784 hospitalizations were retrieved. Of those, 71,562 (36%) had a prior history of HTN. Among hospitalized hypertensive patients, adjusted in-hospital mortality rates versus initial ED SBP showed a “J” shape curve. Adjusted mortality rates were: 14.6%, 7.7%, 5.3%, 4.2%, 3.8%, 3.8%, 3.9% and 4.1% for SBP values of <90, 90 – 109, 110 – 139, 140 – 159, 160 – 179, 180 – 199, 200 – 219 and >220, mmHg, respectively. Conclusions: SBP measurements in the range of 140 – 200 mmHg were not associated with increased mortality in hospitalized hypertensive patients. Thus, elevated SBP in these ranges should not be an indication for hospitalization.

Characteristics and outcomes of older patients attending the emergency department at an academic university hospital

Objective: Because older populations have been increased significantly over the last decades globally, emergency departments (ED) have become a vital place in the care of older patients. Characterizing the usage of the ED by older patients will facilitate the qualifying planning activities in emergency care delivery. Method: The retrospective data were extracted from a database and included all patients, aged 65 years or over, admitted to the ED between 1 January 2017- 31 December 2017. Results: The rate of ED visits accounted for 16.1%. A large majority of the ED visits were during the day shift (49.6 %), and in summer months (June-August 28.7 %). The most common diagnoses (18.4%) were cardiovascular conditions. A large majority (67.8%) of ED visits involved diagnostic imaging and nearly half (46.7%) of them received consultation services. Nearly one-third (31.3%) of older patients were admitted to hospital following their ED visit. Hospital admission, length of stay in ED, having consulting service, involving some kind of diagnostic imaging and being triaged as urgent/emergent are more likely to be increased with age group. Conclusions: ED visits increase with age and also the resource use intensity of the ED, including the length of stay, diagnostic imaging, consultation and admission to the hospital after an ED visit appears to increase with ageing. Patterns of the ED usage were described in this study may be helpful in resource planning, or may provide an approach for the future the investigation involving improved or alternative care options for the older patient.

Emergency department (ED) visits and hospitalizations in survivors of childhood cancer in the Childhood Cancer Survivor Study.

10056 Background: Chronic health conditions are frequent among childhood cancer survivors and lead to increased health care resource utilization. We compared rates of ED visits and hospitalizations between survivors and siblings. Methods: Analyses included 10,762 ≥5-year survivors and 2,069 siblings who completed a questionnaire from 2014-2016. We calculated ED visits and non-obstetric hospitalizations in the last 12 months per 1,000 person-years (PY) and evaluated cause-specific hospitalization rates using ICD-10 categories. Multivariable Poisson regression models evaluated predictors of survivor visits. Results: Median age in survivors and siblings was 35.3 years (interquartile range [IQR] 29.0-43.1) and 42.9 years (IQR 35.6-50.2), respectively; time from cancer diagnosis was 27.8 years (IQR 21.7-34.1). 24.2% of survivors and 16.2% of siblings had ≥1 ED visit (p &lt; 0.001); rates were 521/1,000 PY for survivors and 246/1,000 PY for siblings (age/sex-adjusted relative rate [RR] 2.0; 95% confidence interval [CI] 1.7 - 2.3). Factors associated with increased survivor ED visits were black race (RR 1.6, CI 1.2-2.0), being obese (RR 1.4, CI 1.2-1.7) or underweight (RR 1.9, CI 1.2-3.0), female sex (RR 1.3, CI 1.1-1.5), younger age (p = 0.02) or abdomen/pelvis (RR 1.2, CI 1.1-1.4) or brain irradiation (RR 1.2, CI 1.0-1.4). 13.3% of survivors and 8.3% of siblings had ≥1 hospitalization (p &lt; 0.001); rates were 219/1,000 PY for survivors and 130/1,000 PY for siblings (RR 1.9; CI 1.3 - 2.9). Factors associated with increased survivor hospitalizations were female sex (RR 1.3, 1.1-1.5), younger age (p &lt; 0.0001), being obese (RR 1.3, CI 1.0-1.6) or underweight (RR 1.5, 95% CI 1.1-2.2) or platinum chemotherapy exposure (RR 1.6, CI 1.3-2.0). The most common indications for hospitalization were diseases of the digestive (21.9/1,000 PY; CI 18.7 - 25.7) and circulatory (20.9/1,000 PY; CI 17.8 – 24.4) systems. Leukemia survivors had the highest ED visit and hospitalization rates. Conclusions: Childhood cancer survivors had a 2-fold increased likelihood of an ED visit or hospitalization compared with their siblings. This increases the economic burden on survivors and the health care system.

Ambulatory care-sensitive emergency department cases: a mixed methods approach to systemize and analyze cases in Germany.

BackgroundInternationally, emergency departments (ED) are treating increasing numbers of patients with conditions that could have been managed appropriately in ambulatory care (AC) settings. The aim of our study was to develop the first consensus-based list of AC-sensitive conditions commonly seen in German EDs and explore predictors of these visits.MethodsOur study used a Delphi survey of 30 physicians to compile a list of conditions they agreed were amenable to AC treatment. The group identified reasons why patients visit EDs instead of AC. We used the results to inform spatial regression models analysing the association of patient characteristics and attributes of AC with AC-sensitive ED visits based on 2015 district-level data.ResultsOur study provides a list of AC-sensitive conditions based on the German ED context. Results suggest that, up to the age of 70 years, the older the patients, the less likely they seek EDs for these conditions. Results of our regression analyses suggest that AC-sensitive ED rates were significantly higher in districts with lower physician density. Patients’ urgency perception and preferences were identified as main drivers of AC-sensitive ED visits.ConclusionFuture policy measures should aim to help guide patients through the healthcare system so that they receive the best care in place that is most appropriate in terms of quality, safety and continuity of care. A list of AC-sensitive ED conditions can be used as a monitoring instrument and for further analyses of routine data to inform policy makers seeking to improve resource use and allocation.

Tabletop Simulation Exercise of Critically Ill Patient Evacuation from a Hospital Fire

Introduction:Recent hospital fire incidents in South Korea have heightened the importance of patient evacuation. Moving patients from an intensive care unit (ICU) or emergency department (ED) setting is a challenge due to the complexity of moving acutely unwell patients who are reliant on invasive monitoring and organ support. Despite the importance of patient evacuation, the readiness of ICU and ED for urgent evacuation has not been assessed.Aim:To enhance the readiness and competencies of workers from ICU and ED in the evacuation of patients during a simulated tabletop fire exercise.Methods:A tabletop simulation exercise was developed by the Center for Disaster Relief, Training, and Research referencing the fire evacuation manual developed by the hospital’s ICU and ED. The scenario consisted of evacuating patients horizontally and vertically from each department. The participants’ actions were assessed using a checklist. A debriefing was completed after the exercise to discuss the gaps observed. A post-survey questionnaire was used to evaluate the exercise and assess the perception changes of the participants. All pre-to-post differences within subjects were analyzed with paired t-tests.Results:A total of 22 and 29 people participated in the exercise from ICU and ED, respectively. Knowledge and confidence improved post-exercise for both ICU and ED scenarios (p&lt;0.05). Course satisfaction was 7.9 and 8.7, respectively for ICU and ED exercise. Correct performance rates for ICU and ED were 59% and 58%, respectively. Common gaps noted for both ICU and ED were wearing protective masks, patient hand-over communication, and preparation for resources.Discussion:There need to be exercises to recognize system gaps in place for hospital fire evacuation preparedness. Tabletop simulation exercises are ideal tools for this purpose. Although this was a short 90-minute exercise, this increased familiarity with the evacuation plan, tested the plan, and allowed for identification of gaps.

Changes in the acute response of respiratory diseases to PM2.5 in New York State from 2005 to 2016

Prior studies reported that exposure to increased concentrations of fine particulate matter (PM2.5) were associated with increased rates of hospitalization and emergency department (ED) visits for asthma and chronic obstructive pulmonary disease (COPD). In this study, rates were examined from 2005 to 2016 using a case-crossover design to ascertain if there have been changes in the rates per unit mass exposure given substantial reductions in PM2.5 concentration and changes in its composition. PM2.5 concentrations were reduced through a combination of policies designed to improve air quality and economic drivers, including the 2008 economic recession and shifts in the relative costs of coal and natural gas. The study period was split into three periods reflecting that much of the emissions changes occurred between 2008 and 2013. Thus, the three periods were defined as: BEFORE (2005 to 2007), DURING (2008–2013), and AFTER (2014–2016). In general, the number of hospitalizations and ED visits declined with the decreased concentration of PM2.5. However, the rate of COPD hospitalizations and asthma ED visits associated with each interquartile range increase in ambient PM2.5 concentration was larger in the AFTER period than the DURING and BEFORE periods. For example, each 6.8 μg/m3 increase in PM2.5 on the same day was associated with 0.4% (0.0%, 0.8%), 0.3% (−0.2%, 0.7%), and 2.7% (1.9%, 3.5) increases in the rate of asthma emergency department visits in the BEFORE, DURING, and AFTER periods, respectively, suggesting the same mass concentration of PM2.5 was more toxic in the AFTER period.

Tranexamic Acid for the Treatment of Epistaxis.

Epistaxis is a common reason for patients to present to the emergency department (ED), reflecting one of every 200 ED visits in the United States.1 While many cases of epistaxis are self-limiting, those requiring medical treatment can be associated with significant time and health care costs.2 Additionally, nasal packing and hemostatic matrices can be painful and require the patient to return for at least one follow-up visit. Therefore, identifying an effective and inexpensive treatment is of particular importance. Tranexamic acid is an anti-fibrinolytic agent that has been proposed as one potential modality for this. The Cochrane Review discussed here included randomized controlled trials comparing tranexamic acid (TXA) in any formulation (e.g., delivered orally, intravenously, or topically) with usual care versus usual care with placebo, usual care with any other hemostatic agent, or usual care alone.3 The primary outcome was the proportion of patients with rebleeding within 10 days and significant adverse events (i.e., seizures, thromboembolic events). Among the six trials (n = 692 patients), two studies used oral TXA,4, 5 while the remaining four used topical TXA.6-9 For the primary outcome (n = 225 patients), TXA was associated with lower rates of rebleeding at 10 days (47% vs. 67%; relative risk [RR] = 0.71, 95% confidence interval = 0.56 to 0.90; absolute risk difference = 20%; number needed to treat = 5; moderate-quality evidence) compared to placebo. There were no significant differences between groups for adverse events, although only five of the trials reported adverse events.4, 5, 7-9 The included trials did not report outcomes requiring further intervention (e.g. repacking, surgery, embolization). Another recent systematic review of topical TXA in epistaxis identified faster discharge rates, reduced rebleeding at 24 hours, and greater patient satisfaction with TXA, but no difference in rebleeding at 30 minutes.10 While the studies utilized different search strategies, both were informed by similar studies in their reviews. The current review further supports the potential value of this intervention.10 Interpreting the results of the systematic review and meta-analysis discussed here warrants some caution. First, there was significant clinical heterogeneity in the study populations, with differences in the routes of administration (i.e., oral vs. topical), comparator groups (placebo vs. anterior nasal packing), and primary outcomes. Additionally, only three studies assessed the primary outcome of rebleeding at 10 days, while several other trials had different individual study outcomes (e.g., bleeding control within 30 minutes). Moreover, there was poor reporting of adverse events in the included studies. However, no significant adverse events were reported and most events were considered minor in nature (e.g., nausea, vomiting). Further, while rebleeding at 10 days is a clinically significant outcome, there were limited data on other ED-relevant outcomes (e.g., time to bleeding cessation, time to discharge, return to ED rates). Anterior epistaxis might also respond differently to treatment than posterior epistaxis. Only three of the included trials assessed the location of bleeding and only enrolled patients with anterior epistaxis. Other trials did not specify the location of bleeding. Another important limitation is that a large number of patients in some of the trials were on antiplatelet agents (i.e., aspirin, clopidogrel, or both); this could have affected the outcomes and contributed to the clinical heterogeneity in response to treatment. Future studies should identify what subgroup of patients (e.g., anterior vs. posterior epistaxis, antiplatelets use) are most likely to benefit from TXA, which delivery route is most effective, and how to better assess differences in adverse events. The existing evidence supports the efficacy of TXA to reduce the risk of rebleeding at 10 days among adult patients. Despite inconsistent reporting of adverse events, the occurrence of such events appears to be unlikely, particularly with topical use. Therefore, we have assigned a color recommendation of green (benefit > harm) to the use of TXA for epistaxis. Editor's Note: Brass Tacks are concise reviews of published evidence. This series is a result of collaboration between Academic Emergency Medicine and the evidence-based medicine website, www.TheNNT.com. For inquiries please contact the section editor, Shahriar Zehtabchi, MD ([email protected]).

Evaluation of Antibiotic Utilization in an Emergency Department After Implementation of an Antimicrobial Stewardship Pharmacist Culture Review Service.

Background: Antimicrobial stewardship programs (ASP) have been widely implemented in hospitals to improve antimicrobial use and prevent resistance. However, the role of ASP in the emergency department (ED) setting is not well defined. Objective: The objective of this study is to evaluate the impact of an ASP pharmacist culture review service in an ED. Methods: This was a retrospective, quasi-experimental study of all patients discharged from the ED with a positive culture. Patients discharged from the ED from February 1, 2015 to October 31, 2015 were managed by ED providers (pre-ASP), and those discharged from February 1, 2016 to October 31, 2016 were managed by a pharmacist-driven ASP (post-ASP implementation). The primary outcome was median time to change of antibiotic(s) in patients with inadequate antimicrobial therapy based on culture results. Secondary outcomes included time to culture evaluation, appropriateness of antimicrobials, and 30-day readmissions. Results: A total of 790 patients were included in the analysis (398 in pre-ASP group vs 392 in post-ASP implementation group). Median time to modification of inadequate antibiotic therapy decreased from 6.79 days in the pre-ASP group to 1.99 days in the post-ASP implementation group (P < .0001). Median time to culture review decreased in the post-ASP implementation group from 9.83 to 0.32 days (P < .0001). Appropriateness of culture-guided therapy increased in the post-ASP implementation group from 85.7 to 91.8% (P = .047). The rate of combined ED revisits and hospital readmissions was similar between groups (P = .367). Conclusion: ASP pharmacist evaluation of positive cultures in the ED was associated with a significant decrease in the time to appropriate therapy in patients discharged with inadequate therapy and higher rates of appropriate antimicrobial therapy.

The association between alcohol access and alcohol-attributable emergency department visits in Ontario, Canada.

The availability of alcohol through retail outlets is associated with alcohol-related harms, but few studies have demonstrated a causal relationship. We investigated the association between alcohol availability and alcohol-attributable emergency department (ED) visits in the province of Ontario during a period of deregulation of controls on the number of alcohol outlets. Cross-sectional and pre-post design SETTING AND PARTICIPANTS: The study used data from two time-periods: pre-deregulation (2013-14) and post-deregulation (2016-17), to compare rates of ED visits for 513 defined geographic regions in Ontario Canada, called Forward Sortation Areas (FSAs). The primary outcome was the age-standardized rates of alcohol-attributable ED visits. We compiled a list of all alcohol retail outlets in Ontario during 2014 and 2017 and matched them to their corresponding FSA. We fitted mixed-effects Poisson regression models to assess: (a) the cross-sectional association between number of outlets and hours of operation and ED visits; and (b) the impact of deregulation on ED visits using a difference-in-difference approach. Alcohol-attributed ED visits increased 17.8% over the study period: more than twice the rate of increase for all ED visits. Increased hours of operation and numbers of alcohol outlets within an FSA were positively associated with higher rates of alcohol-attributable ED visits. The increase in ED visits attributable to alcohol was 6% (incident rate ratio =1.06; 95% confidence interval=1.04-1.08) greater in FSAs that introduced alcohol sales in grocery stores following deregulation compared with FSAs that did not. Deregulation of alcohol sales in Ontario, Canada in 2015 was associated with increased emergency department visits attributable to alcohol.

Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?

Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers. To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs. A retrospective cohort study with a propensity-matched analysis. 143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center. Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience. At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses. After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed.

Depression in Emergency Department Patients and Association With Health Care Utilization.

Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations. This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes. Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR]=1.61, 95% confidence interval [CI]= 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR=1.49, 95% CI= 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR=1.10, 95% CI= 1.04 to 1.16) and hospitalizations (IRR=1.10, 95% CI= 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates. Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.

Health services use among children diagnosed with medium-chain acyl-CoA dehydrogenase deficiency through newborn screening: a cohort study in Ontario, Canada

BackgroundWe describe early health services utilization for children diagnosed with medium-chain acyl-CoA dehydrogenase (MCAD) deficiency through newborn screening in Ontario, Canada, relative to a screen negative comparison cohort.MethodsEligible children were identified via newborn screening between April 1, 2006 and March 31, 2010. Age-stratified rates of physician encounters, emergency department (ED) visits and inpatient hospitalizations to March 31, 2012 were compared using incidence rate ratios (IRR) and incidence rate differences (IRD). We used negative binomial regression to adjust IRRs for sex, gestational age, birth weight, socioeconomic status and rural/urban residence.ResultsThroughout the first few years of life, children with MCAD deficiency (n = 40) experienced statistically significantly higher rates of physician encounters, ED visits, and hospital stays compared with the screen negative cohort. The highest rates of ED visits and hospitalizations in the MCAD deficiency cohort occurred from 6 months to 2 years of age (ED use: 2.1–2.5 visits per child per year; hospitalization: 0.5–0.6 visits per child per year), after which rates gradually declined.ConclusionsThis study confirms that young children with MCAD deficiency use health services more frequently than the general population throughout the first few years of life. Rates of service use in this population gradually diminish after 24 months of age.

Using Lean to Improve Patient Safety and Resource Utilization After Pediatric Adenotonsillectomy.

The objective of this quality improvement project was to decrease the rate of nonemergent use of emergency department (ED) resources in children undergoing adenotonsillectomy by 50% and/or reach a future state of 5% or less overall ED visits among all postoperative patients within 1 year. A secondary objective was to standardize the preoperative, intraoperative, and postoperative management of these patients. The study was a quality improvement project using Lean. The target population was children younger than 18 years undergoing tonsillectomy with or without adenoidectomy. A retrospective review of adenotonsillectomy was performed for a 12-month period. Lean tools including A3 Thinking, Ishikawa "fishbone" diagram, and value stream mapping were used to analyze the problem and identify interventions. Postintervention data were collected for a 10-month period. Compared with the baseline period, the ED visit rate after adenotonsillectomy decreased from 36.2% to 15.5% (P = 0.0095). The rate of ED visits for nonbleeding complaints decreased from 30.4% to 12.1% (P = 0.01748). There was no significant change in rate of ED visits for bleeding (decreased from 5.8% to 3.5% [P = 0.6873]). There was no significant change in the use of intraoperative dexamethasone and acetaminophen. Postadenotonsillectomy patients often use emergency resources better reserved for other patients. Addressing this problem with Lean principles significantly decreased postoperative ED visit rates by more than 50%. To our knowledge, this is the first reported use of Lean principles to decrease utilization of emergency resources in the postoperative period. Lean can be applied to other processes in our field to eliminate waste and add value to improve patient outcomes. NA.