Emergency Department Revisits Research Articles

Evaluation of COPD Chronic Care Management Collaborative to Reduce Emergency Department and Hospital Revisits Across U.S. Hospitals.

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of early readmissions. The Centers for Medicare and Medicaid instituted a financial penalty for excessive COPD readmissions galvanizing hospitals to implement effective strategies to reduce readmissions. We evaluated a 6-month COPD Chronic Care Management Collaborative to support hospitals to reduce preventable COPD-related revisits. Sites were recruited among nearly 300 Vizient, Inc., members. The Collaborative used performance improvement initiatives to assist with implementation of effective strategies. Participants submitted performance data for 2 outcome measures: emergency department (ED) and hospital revisits. Forty-seven members enrolled (Part I+II: n=33; Part I: n=3; Part II: n=11) of which 23 submitted data (n=23/47). The majority (n=19/23, 83%) reduced rates of COPD-related ED and/or hospital revisits. Among all 23 sites, the change in ED visits went from 11.05% to 10.87%; among 7 sites with reductions in ED visits, the reduction was 12.7% to 9%. Among all 23 sites, there were not reductions in hospital readmissions (18.53% to 18.64%); among 7 sites with reductions, the readmission rate went from 20.1% to 15.6%. The mean reach across 17 hospitals reporting reach for their most successful measure at baseline was 35.2% (SD=26.7%) and for the other 6, reporting reach at follow-up was 73.8%% (SD=18.3%); of note, only 3 sites submitted both baseline and follow-up data. The Collaborative successfully supported the majority of sites in reducing COPD-related ED and/or hospital revisits using subject matter experts and coaching strategies to support hospitals' implementation of COPD quality improvement interventions.

Evaluation of COPD Chronic Care Management Collaborative to Reduce Emergency Department and Hospital Revisits Across U.S. Hospitals

Evaluation of COPD Chronic Care Management Collaborative to Reduce Emergency Department and Hospital Revisits Across U.S. Hospitals

A comparative evaluation of the strengths of association between different emergency department crowding metrics and repeat visits within 72hours.

We sought to compare strengths of association among multiple emergency department (ED) input, throughput and output metrics and the outcome of 72-h ED re-visits. This database analysis used healthcare administrative data from three urban, university-affiliated EDs in Calgary, Canada, calendar years 2010-2014. We used data from all patients presenting to participating EDs during the study period, and the primary analysis was performed on patients discharged from the ED. Regression models quantified the association between input, throughput and output metrics and the risk of return ED visit within 72h of discharge from the index ED encounter. Strength of association between the crowding metrics and 72-h ED re-visits was compared using Akaike's Information Criterion. The findings of this study are based on data from 845,588 patient encounters ending in discharge. The input metric with the strongest association with 72-h re-visits was median ED waiting time. The throughput metric with the strongest association with 72-h re-visits was the ED occupancy. The output metric with the strongest association with 72-h re-visits was the median inpatient boarding time. Input, throughput and output metrics are all associated with 72-h re-visits. Delays in any of these operational phases have detrimental effects on patient outcomes. ED waiting time, ED occupancy, and boarding times are the most meaningful input, throughput and output metrics. These should be the preferred metrics for quantifying ED crowding in research and quality improvement efforts, and for clinicians to monitor ED crowding in real time.

Predicting Unscheduled Emergency Department Revisits Leading to Acute Hospital Admissions Among Older Adults

Background: Unscheduled emergency department (ED) revisits leading to acute hospital admission (RVA) are tantamount to a failed discharge, associated with physician error, mis-prognosis, and inadequate care planning. Previous research has shown RVA to be associated with adverse outcomes such as ICU admissions, long hospitalizations and mortality. Given the limited impact of pre-existing screening tools for older adults, we developed and validated a machine learning model to predict individual patient risk of RVA within 72 hours and 9 days of index ED visits. Method: A machine learning model was applied to retrospective electronic health record (EHR) data of patients presenting to 2 geographically and demographically divergent urban EDs in 2019. 478 clinically meaningful EHR data variables were included: socio-demographics, ED and comorbidity diagnoses, therapeutics, laboratory test orders and test results, diagnostic imaging test orders, vital signs, and utilization and operational data. Multiple machine learning algorithms were constructed; models were compared against a pre-existing adult ED-RVA risk score as a baseline. Results: A total of 62,154 patients were included in the analysis, with 508 (0.82%) and 889 (1.4%) having 72-hour and 9-day RVA. The best-performing model, combining deep significance clustering (DICE) and regularized logistic regression, achieved AUC of 0.86 and 0.79 for 72-hour and 9-day ED-RVA for older adult patients, respectively, outperforming the pre-existing RVA risk score (0.704 and 0.694). Discussion: Machine learning models to screen for and predict older adults at high-risk for ED-RVA may be useful in directing interventions to reduce adverse events in older adults discharged from the ED.

The Effect of an Automated Mobile Patient Engagement Application on Emergency Department Revisits: Prospective Observational Study

BackgroundRevisits within 30 days to an emergency department (ED), observation care unit, or inpatient setting following patient discharge continue to be a challenge, especially in urban settings. In addition to the consequences for the patient, these revisits have a negative impact on a health system’s finances in a value-based care or global budget environment. LifeBridge Health, a community health system in Maryland, United States, implemented an automated mobile patient engagement application as part of our enterprise-wide digital health strategy to improve patient engagement and reduce revisits to the ED.ObjectiveThe aim of this paper was to evaluate the effectiveness of a customized automated digital patient engagement application (GetWell Loop) to reduce 30-day revisits after home discharge from an ED.MethodsThe LifeBridge Health Innovation Department and ED staff from 2 participating health system hospitals collaborated with GetWellNetwork to customize their patient engagement application with automated check-in questions and other on-demand resources (eg, streaming content explaining aspects of self-care during COVID-19). An application link was emailed to adult patients discharged home from the ED. A study of ED visits for patients treated for general medicine and cardiology conditions between August 1, 2018, and July 31, 2019, was conducted using CRISP (Chesapeake Regional Information System for our Patients), Maryland’s state-designated health information exchange. We also used data within GetWell Loop (GetWellNetwork) to track patient activation and engagement. The primary outcome was the number of ED patients who experienced a 30-day revisit and who did or did not activate their GetWell Loop account. Secondary outcomes included the overall activation rate and the rate of engagement as measured by the number of logins, alerts, and comments generated by patients through the application. Bivariate analysis comparing outcomes among patients who activated the GetWell Loop application to patients who did not was conducted using the Fisher exact test. Multivariate logistic regression modeling with elastic net regularization was also performed to account for potential confounders and potential collinearity of covariates.ResultsDuring this 1-year study, 1062 (27.4%) of 3866 of all emergency patients treated for general medicine or cardiology conditions, who received an invite to use the digital application, activated their account. The patients discharged from the ED, who were treated for general medicine conditions (n=2087) and who activated their GetWell Loop account, experienced a 30-day revisit rate of 17.3% (n=101) compared with 24.6% (n=369) for those who did not activate their account (P<.001). Of the patients treated for cardiology conditions (n=1779), 12.8% (n=61) of those who activated their GetWell account experienced a 30-day revisit compared with 17.7% (n=231) of those who did not activate their account (P=.01). The significance of these findings persisted after adjustment for confounding variables including age, race, sex, and payor in logistic regression modeling (adjusted odds ratio 0.75, 95% CI 0.62-0.92; P=.006).ConclusionsOur results suggest that a significant percentage of patients are willing to utilize a digital application following ED discharge to better engage in their own care, and that usage of such digital applications may significantly reduce 30-day revisit rates. LifeBridge Health’s experience demonstrates that health care systems can leverage automated mobile apps to improve patient engagement and successfully impact clinical outcomes at scale.

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

236 PREDICTORS OF ADVERSE OUTCOMES IN OLDER PATIENTS DISCHARGED DIRECTLY FROM THE EMERGENCY DEPARTMENT

Abstract Background Over 40% of older patients are discharged directly from the Emergency Department (ED) and this cohort is at increased risk of adverse outcomes. The purpose of this study was to explore the factors that predict future adverse outcomes in this cohort to inform practice, resource planning and policy. Methods A secondary analysis of the OPTIMEND, a single-centre, randomized-controlled trial was completed. OPTIMEND examined the effectiveness of an intervention by a team of Health and Social Care Professionals along with usual care and compared this to standard ED care alone (Dec 2018-May 2019). The inclusion criteria were adults aged 65 years and over presenting to the ED at a University Teaching Hospital with medical complaints and a Manchester Triage System category 2–5. Results 220 patients were included (median age 79 years; 62% female). Median length of stay in ED was 5.5 hrs. 70 patients re-attended the ED within 6 months with 43 re-hospitalised within 6 months. 9 patients died within six months of discharge. Multivariant logistic regression was completed. Age was the only independent predictor of mortality within six months of discharge {Odds Ratio (OR) 1.15, p = 0.044}. Past hospitalisation (&amp;lt;6 months) was associated with a lower likelihood of ED re-attendance, and rehospitalization within six months of discharge (OR: 0.452 p = 0.022; OR:0.442, p = 0.046; respectively). Clinical Frailty Score was associated with a significantly higher likelihood of rehospitalization (OR:1.48, p = 0.031) but not with ED revisits (OR: 1.235, p = 0.165). Conclusion Older people have a high ED re-attendance rate of 33% after an index visit with 20% hospitalized subsequently. Frailty is a significant predictor of rehospitalisation. Rapid and targeted intervention for frail patients who reattend the ED should be a priority for the integrated care program to enhance admission avoidance.

Implementation of a Physician Incentivized QI Strategy to Address Time to Parenteral Analgesia in Patients with Voe in the Pediatric Emergency Department

IntroductionVaso-occlusive episodes (VOE) are the most common cause of pediatric Emergency Department (ED) visits and hospitalizations in Sickle Cell Disease (SCD). The National Heart Lung and Blood Institute published an Expert Panel Report regarding the management of SCD and VOE. Their consensus statement recommends initiating analgesic therapy within 30 minutes of triage or within 60 minutes of registration in the Emergency Department. Previous studies have demonstrated that earlier maximum opioid has been associated with shorter length of hospitalization and improved time to ED disposition decision.Despite the overwhelming evidence for timely administration of parenteral analgesic, significant delays still exist in delivery of pain medication in the pediatric SCD population. Barriers to timely administration include rapid triage of SCD patients, provider ordering of pain medication, and peripheral intravenous access. Therefore, a standardized approach to pain management may improve ED management of SCD crises.In order to address timely administration of opiates to SCD patients with VOE episodes in our pediatric ED a SCD pain order set was developed. This order set implemented the use of intranasal (IN) fentanyl as a first line analgesic for SCD patients who presents to the ED with VOE. The purpose of this study was addressing barriers to decrease time to parenteral opioid administration in the pediatric ED.MethodsThis Quality Improvement (QI) measure was performed at a free-standing, urban pediatric ED. Patients were included if they had a diagnosis of SCD and presented with a pain score >5 and without fever.A PDSA cycle was utilized for designing and evaluating the proposed changes. This cycle consisted of three intervention phases: (1) electronic medical record (EMR) order set development in October 2019, (2) provider incentive for order set use in January 2020, and (3) nursing/patient & family education in April 2020. Baseline data was collected pre-intervention from April-September 2019.The outcomes measures were mean time to 1 st analgesic, mean time from triage to disposition, Hospital Length of Stay, and overall admission rates. Our balancing measure included 48 hour ED re-visits after discharge.ResultsThere were 67 ED visits from April-September 2019 (pre-intervention) and 104 ED visits in the post-intervention data from October-June 2020. There was no significant difference in age or initial pain score in the pre- and post- intervention groups. Improvements were seen in: mean time to first analgesic (58 to 26 minutes), time to disposition (271 to 213 minutes). Hospital length of stay was found to increase with the introduction of IN fentanyl: pre-intervention (120 hours), phase 1 (148 hours), phase 2 (152 hours), phase 3 (218 hours). However, the overall admission rate decreased (55% to 44%). The number of 48-hour ED re-visits remained stable.ConclusionBy using QI methods to address key barriers in the pediatric ED, we demonstrated that timely administration of parenteral analgesic can be achieved for SCD patients with VOE. Utilizing the EMR order set allowed for more stream-lined care, both by physicians and nursing staff, resulting in more rapid ordering of medication therefore decreasing time to ED disposition. Additional interventions such as provider incentivization to meet the goal of parenteral opioids within 30 minutes of patient arrival led to further improvement. One of the greatest barriers to our QI intervention was hesitancy both by patients and their caregivers regarding the efficacy of IN fentanyl in decreasing pain compared to IV opioid. Further education was needed both for families and medical staff regarding the efficacy of IN fentanyl as a first line analgesic.It is unclear why overall hospital length of stay was not shown to be decreased with these interventions but this can be offset by an overall decrease in hospital admissions seen with our interventions. This data may be limited by the SARS-CoV-2 pandemic and how psychosocial stressors can impact patients with chronic medical conditions. Length of stay is also confounded by other factors during the hospitalization and acquisition of other diagnoses such as acute chest. Future research is needed to determine if the demonstrated trend of admission rates and hospital length of stay can be replicated in other pediatric EDs and whether earlier opioid administration affects the outcome of VOEs beyond the ED. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

17 Medical and Social Resources at Emergency Department Discharges: A Prospective Analysis of the Impact of a Volunteer Patient Discharge Initiative on Emergency Department Revisits

The objective of this study was to examine the rates of emergency department (ED) revisits of patients receiving the Patient Discharge Initiative (PDI) intervention of medical and social community resources upon discharge from the ED. A quasi-randomized controlled trial was conducted to evaluate the PDI intervention, which consisted of volunteers approaching patients prior to discharge and providing community resources, including connections to social and medical support such as transportation, low-cost dental services, and housing support. The study took place at a public, urban hospital in Houston with over 80,000 ED visits annually. Patients were assigned to control versus intervention groups based on the final digits of their medical record number. Patients in the control group were provided with food and housing assistance information only if the patient asked. At 7 and 30 days after the initial ED visit, all patients were given post-visit follow-up telephone calls. Patients below 18 years of age or with missing medical record number or ED visit date were excluded from analysis. We used the health system’s electronic health record system to gather demographic, health status, and utilization data. Primary outcomes measured included frequency of ED revisits at 30 and 90 days after initial ED visits. A total of 491 patients were included in the study. The median patient age was 46 years old (interquartile range = 22). The majority of patients were female (54%), Hispanic/Latino (53%), and did not have public or private insurance (76%). Over one third (35%) of all patients self-reported as primarily Spanish-speaking. The most frequent chief complaint was abdominal pain (19%). Comparing patients in the intervention and control groups, a higher proportion of those in the intervention group were experiencing homelessness (p = 0.026), uninsurance (p < 0.001), and were enrolled in Harris County Financial Assistance Program (p < 0.001). Patients receiving the PDI intervention had a significantly lower odds of an ED revisit within 30 days of ED discharge compared to the control group (OR = 0.58 (95% CI 0.34 – 0.99); p = 0.047). We also observed a lower average number of ED revisits in the intervention group within 30- and 90-days post-discharge (ANOVA comparison of means p = 0.013 and p = 0.033, respectively). Multivariable analyses accounting for homelessness and the presence of an ED revisit in the 90 days preceding the intervention showed that the intervention group had significantly lower odds of ED revisits within 90 days when compared to the control group (adjusted OR 0.53 (95% CI 0.31 – 0.92); p = 0.024). The Patient Discharge Initiative is an ED discharge intervention embedded in ED workflow that provides patients with medical and social resources, showing potential to decrease future ED visits.

191 Comparing Cost, Risk Factors, and Rates of Return in Immediate versus Delayed Cholecystectomy for Emergency Department Patients with Biliary Colic Using Statewide Linked Datasets

Approximately 700,000 patients present annually with biliary colic to United States emergency departments (EDs) and providers must decide whether patients should be admitted for immediate cholecystectomy or can be discharged for outpatient management. Despite the prevalence of biliary colic, the timing of surgery varies greatly and this decision is based on factors such as cost, the risk of ED re-visits (EDRs) and clinical prognosis that are not well-defined. The primary objective of this study was to compare the patient characteristics, the costs and the risks of EDRs in ED patients with biliary colic who are allocated to different treatment options including immediate cholecystectomy, delayed cholecystectomy or no cholecystectomy. Patients who presented to an ED in the state of Maryland were identified in the State ED Database (SEDD) using the ICD-10 code for cholelithiasis (K80) and then followed for one year using unique identifiers in the SEDD, the State Ambulatory Surgery Database (SASD), and the State Inpatient Database (SID) for 2016-18. Hospital admissions, outpatient surgeries, and EDRs were identified for each patient. Patients that died on their index ED visit or from a cause unrelated to cholelithiasis were excluded from the analysis, and only charts that contained a K80 diagnosis were included. Following index visit, ED patients were analyzed based on the following categories: (1) Admit and immediate cholecystectomy, (2) Discharge and delayed cholecystectomy as an outpatient, (3) No cholecystectomy, and (4) Discharge and repeat ED visit for return immediate cholecystectomy. Costs were estimated using Medicare Relative Value Units (RVUs) and Healthcare Cost and Utilization Project Cost-Charge Ratio files, and a multivariate logistic regression analysis was performed on the four clinical pathways. Of the 4069 patients identified and followed for a year, 67% underwent immediate surgery, 6% delayed surgery, 27% no surgery, and 1% return immediate surgery. Patients who received immediate surgery had fewer EDRs (0.01 vs 0.05, p<10-9) and was associated with higher average costs compared to all discharged patients ($11,100 vs $7500, p<10-36). Of all patients initially discharged from the ED, 81% did not undergo cholecystectomy within one year. Biliary colic described as “inflammatory” was significantly associated with cholecystectomy, while increased age and ischemic heart disease were strongly associated with both discharge and no surgery after discharge (Table 1). Race, sex, and insurance status were not associated with differences in cholecystectomy allocation. The majority of patients who present to the ED undergo immediate cholecystectomy (67%) which is associated with lower EDRs (0.01 vs 0.05) but higher cost ($11,100 vs $7500). For patients discharged from the ED, 81% never receive a cholecystectomy within one year. Inflammatory biliary colic was associated with increased likelihood of both immediate and delayed surgery, while increasing age was associated with a decreased likelihood of both immediate and delayed surgery. More research is needed to understand how to balance the increased cost of immediate cholecystectomy with the increased risk ED returns from a delayed approach.

"Could we have predicted this?" The association of a future mental health need in young people with a non-specific complaint and frequent emergency department visits.

ObjectiveMental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non‐specific condition and emergency department (ED) revisits have increased mental health needs.MethodsRetrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010–2014) of young people (11–24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of “Symptoms, signs, and ill‐defined conditions” (Non‐Specific); “Diseases of the respiratory system” (Respiratory) and “Unintentional injury” (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit.ResultsPatients in the Non‐Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17–1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non‐Specific index visit and 1, 2, and 3 or more revisits with non‐specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29–1.47; OR 1.70; 95% CI 1.46–1.98; OR 2.20; 95% CI 1.70–2.87, respectively.)ConclusionsYoung people who go to the ED for non‐specific conditions and revisits may benefit from targeted ED mental health screening.

Early intravenous nitroglycerin use in prehospital setting and in the emergency department to treat patients with acute heart failure: Insights from the EAHFE Spanish registry

Background and objectiveAlthough recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In the current analysis, we have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients. MethodsWe analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group. ResultsWe included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459–1.114), 30-day (HR = 0.818, 0.576–1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643–0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936–1.448; 30-day: HR = 0.980, 0.819–1.174; 365-day: HR = 0.929, 0.830–1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780–0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings. ConclusionsEarly prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.

PD03-01 RACIAL AND ETHNIC DISPARITIES IN EMERGENCY CARE AMONG PATIENTS WITH URINARY STONE DISEASE

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making I (PD03)1 Sep 2021PD03-01 RACIAL AND ETHNIC DISPARITIES IN EMERGENCY CARE AMONG PATIENTS WITH URINARY STONE DISEASE Joshua Hayden, Hui-Jie Lee, and Charles Scales Joshua HaydenJoshua Hayden More articles by this author , Hui-Jie LeeHui-Jie Lee More articles by this author , and Charles ScalesCharles Scales More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001967.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Symptomatic urinary stone disease is a common cause for emergency department (ED) visits; for some patients, ED revisits often occur before cessation of a stone episode. Little is known regarding how non-clinical factors such as patient race, ethnicity, or insurance status contribute to ED revisit for stone disease. We sought to identify associations between ED revisit and patient race/ethnicity. METHODS: This was a retrospective cohort study of patients in Florida, Georgia, and Maryland who had initial ED treat-and-release visits for urinary stone disease utilizing the state-specific Healthcare Cost and Utilization Project (HCUP) databases between 2016-2017. A repeat ED visit for urinary stones within 30 days of an initial ED encounter was the primary outcome. A generalized estimating equation with a logit link that accounted for hospital-level clustering was employed, using race/ethnicity as the primary predictor and adjusting for other covariates such as age, sex, and primary payer. Race and ethnicity were reported as a single variable by HCUP, with ethnicity taking precedence over race in the assignment; categories were White, Hispanic, Black, and Other/Unknown. RESULTS: Of the 209,309 patients who had an initial treat-and-release ED visit for symptomatic urinary stones, 14,853 (7.1%) had at least one additional ED encounter for symptomatic stones within 30 days of their initial ED visit. Revisit percentages differed among racial/ethnic groups (White 7.5%, Hispanic 6.8%, Black 5.7%, p < 0.001). Black (adjusted odds ratio (aOR) 0.72, 95% confidence interval (CI) 0.67 to 0.76) and Hispanic (aOR 0.88, 95% CI 0.82 to 0.94) individuals were less likely to revisit than White individuals. Primary insurance coverage with Medicaid compared to private insurance (aOR 1.49, 95% CI 1.41 to 1.57), and rural residence compared to large metropolitan (aOR 1.13, 95% CI 1.02 to 1.25) were associated with increased odds of revisit. CONCLUSIONS: In this cohort, repeat emergency care for symptomatic urinary stones affects 7.1% of patients after initial stone management in the ED setting. Race/ethnicity was associated with stone-related ED revisit. To understand the revisit discrepancies, further investigation into potential explanations of observed race/ethnicity-associated care patterns following initial ED encounters for urinary stones is warranted. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e43-e43 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Hayden More articles by this author Hui-Jie Lee More articles by this author Charles Scales More articles by this author Expand All Advertisement Loading ...

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.

Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study.

IntroductionEmergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database.MethodsThis was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit.ResultsOf the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172).ConclusionPatients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

Comparing Pain Intensity Using the Numeric Rating Scale and Defense and Veterans Pain Rating Scale in Patients Revisiting the Emergency Department.

Objective To determine the relationship between Numeric Rating Scale (NRS) and Defense and Veterans Pain Rating Scale (DVPRS) as pain intensity measures, we compared pain scores to sociodemographic and treatment data in patients revisiting the emergency department (ED).Methods After Institutional Review Board approval, 389 adults presenting within 30 days of an index visit were enrolled. Pain scores were classified as follows: 0-3 (mild), 4-7 (moderate), and 8-10 (high). Data were analyzed using descriptive analysis. Wilcoxon rank-sum test measured the association of pain score with gender. Pain scales were correlated using Spearman correlation coefficient. Pain scale association with opioid treatment was tested via ordinal logistic regression controlling for gender, home opioid use, and if ED revisit was for pain.Results Average patient age was 49. Most patients were African American (68.4%), male (51.2%), and returned for pain (67.0%). As continuous measures, both scales were positively correlated with each other (p<0.0001). Pain score severity categories were distributed differently between the two scales (p=0.0085), decreasing by 8% in patients reporting high pain severity when using DVPRS. For both scales, the proportion of patients (1) administered opioids (p=0.0009 and p≤0.0001, respectively) and (2) discharged with opioids (p=0.0103 and p=0.0417, respectively) increased with pain severity. Discharge NRS (p=0.0001) (OR=3.2, 1.780-5.988) and DVPRS pain score categories (p<0.0001) (OR=2.7, 95% CI=1.63-4.473) were associated with revisits for pain. ConclusionsOur findings demonstrate a link between NRS and administration of opioid medications and suggest that DVPRS may better differentiate between moderate and high levels of pain in the ED setting.

Association of limited English proficiency and increased pediatric emergency department revisits.

Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits. This was a retrospective, cross-sectional study of patients 0 to 21years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted. There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference= 0.97, 95% confidence interval [CI]= 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR]= 1.15, 95% CI= 1.01 to 1.30) and in hospitalization (OR= 1.28, 95% CI= 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results. These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes.

IntroductionThere is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits.MethodsThis was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition.ResultsAmong 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22–24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%).ConclusionIn a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.

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.

Eliminating Lumbar Puncture for Low-Risk Febrile Infants: A Quality Improvement Initiative.

Bacterial meningitis in low-risk febrile young infants (FYIs) aged >28 days has become increasingly rare. Routine performance of lumbar puncture (LP) in these infants is associated with adverse consequences and may be unnecessary. We modified our clinical practice guideline (CPG) to reduce the number of FYIs 29 to 56 days old who receive LP. This quality improvement project sought to modify a preexisting CPG to diagnose and manage FYIs 0 to 56 days old that eliminated routine performance of LP in children 29 to 56 days old who were considered low-risk for serious bacterial infection. The change was implemented by making adjustments to the online CPG. A statistical process control chart was used to assess the affect of the initiative on our primary outcome of LP rate in this population of FYIs. Postimplementation of the CPG initiative, 71% of FYIs 29 to 56 days old did not receive LP, compared with 42% preimplementation. This practice change was also associated with fewer hospitalizations, lower median emergency department (ED) length of stay, and fewer 72-hour ED revisits. Over 3 years of sustained practice, 1/713 (0.1%; 95% confidence interval, 0%-0.8%) low-risk FYI returned within 72 hours and was subsequently treated for probable bacterial meningitis, although cerebrospinal fluid culture was negative for bacterial growth. A change in CPG reduced the number of LPs performed in febrile infants 29 to 56 days old. This change resulted in fewer LPs, hospitalizations, ED revisits, and a lower ED length of stay for FYIs 29 to 56 days old.