Emergency Department Readmission Research Articles

RESPECT: Reducing 30-day Emergency Department Visits and Readmissions of Bariatric Surgical Patients Effectively through Cultural Competency Training of Nurses

RESPECT: Reducing 30-day Emergency Department Visits and Readmissions of Bariatric Surgical Patients Effectively through Cultural Competency Training of Nurses

Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases.

Acute abdominal pain (AAP) accounts for 7-10% of all Emergency Department (ED) visits. Nevertheless, the epidemiology of AAP in the ED is scarcely known. The aim of this study was to investigate the epidemiology and the outcomes of AAP in an adult population admitted to an urban ED. We made a retrospective analysis of all records of ED visits for AAP during the year 2014. All the patients with repeated ED admissions for AAP within 5 and 30 days were scrutinized. Five thousand three hundred and forty cases of AAP were analyzed. The mean age was 49 years. The most frequent causes were nonspecific abdominal pain (NSAP) (31.46%), and renal colic (31.18%). Biliary colic/cholecystitis, and diverticulitis were more prevalent in patients aged >65 years (13.17% vs. 5.95%, and 7.28% vs. 2.47%, respectively). Appendicitis (i.e., 4.54% vs. 1.47%) and renal colic (34.48% vs. 20.84%) were more frequent in patients aged <65 years. NSAP was the most common cause in both age classes. Renal colic was the most frequent cause of ED admission in men, whereas NSAP was more prevalent in women. Urinary tract infection was higher in women. Overall, 885 patients (16.57%) were hospitalized. Four hundred and eighty-five patients had repeated ED visits throughout the study period. Among these, 302 patients (6.46%) were readmitted within 30 days, whereas 187 patients (3.82%) were readmitted within 5 days. Renal colic was the first cause for ED readmission, followed by NSAP. In 13 cases readmitted to the ED within 5 days, and in 16 cases readmitted between 5-30 days the diagnosis was changed. Our study showed that AAP represented 5.76% of total ED visits. Two conditions (i.e., NSAP and renal colic) represented >60% of all causes. A large use of active clinical observations during ED stay (52% of our patients) lead to a negligible percentage of changing diagnosis at the second visit.

276 Will Scheduled Clinic Visits Prevent Emergency Department Re-Admission in Chest Pain Patient?

276 Will Scheduled Clinic Visits Prevent Emergency Department Re-Admission in Chest Pain Patient?

Safely Discharging Infants with Bronchiolitis from an Emergency Department: A Five Step Guide for Pediatricians.

Recent publications have established the pulse oxygen saturation (SpO2) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO2 above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO2 ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO2 < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO2 level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0–14.0) vs. 3.0 hours (IQR 2.0–6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0–11.7) vs. 14.6 hours (IQR 7.6–22.2), P = 0.037]. Based on the present study’s results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.

Dedicated Pediatricians in Emergency Department: Shorter Waiting Times and Lower Costs.

BackgroundDedicated pediatricians in emergency departments (EDs) may be beneficial, though no previous studies have assessed the related costs and benefits/harms. We aimed to evaluate the net benefits and costs of dedicated emergency pediatricians in a pediatric ED.MethodsCost-consequences analysis of visits to a pediatric ED of a tertiary hospital. Two pediatric ED Medical Teams (MT) were compared: MT-A (May–September 2012), with general pediatrics physicians only; and MT-B (May–September 2013), with emergency dedicated pediatricians. The main outcomes analyzed were relevant clinical outcomes, patient throughput time and costs.ResultsWe included 8,694 children in MT-A and 9,417 in MT-B. Medication use in the ED increased from 42.3% of the children in MT-A to 49.6% in MT-B; diagnostic tests decreased from 24.2% in MT-A to 14.3% in MT-B. Hospitalization increased from 1.3% in MT-A to 3.0% in MT-B; however, there was no significant difference in diagnosis-related group relative weight of hospitalized children in MT-A and MT-B (MT-A, 0.979; MT-B, 1.075). No differences were observed in ED readmissions or in patients leaving without being seen by a physician. The patient throughput time was significantly shorter in MT-B, with faster times to first medical observation. Within the cost domains analyzed, the total expenditures per children observed in the ED were 16% lower in MT-B: 37.87 euros in MT-A; 31.97 euros in MT-B.ConclusionThe presence of dedicated emergency pediatricians in a pediatric ED was associated with significantly lower waiting times in the ED, reduced costs, and similar clinical outcomes.

Incidence, Risk Factors, and Costs for Hospital Returns After Total Joint Arthroplasties

BackgroundUnplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA. MethodsWe retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode. ResultsOf the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654. ConclusionUnplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs.

Emergency Department-Based Care Transitions for Pediatric Patients: A Systematic Review.

Successful care transitions between emergency departments (EDs) and outpatient settings have implications for quality, safety, and cost of care. To investigate the effectiveness of ED-based care transition interventions in achieving outpatient follow-up among pediatric patients. Medline, Embase, CINAHL, Cochrane Library, trial registers, and reference lists of relevant articles. Eligible studies included randomized controlled trials of ED-based care transition interventions involving pediatric patients (aged ≤18 years). Study selection, data extraction, and risk of bias assessment were performed in duplicate and independent manner. Study results were pooled for meta-analysis by using a random effects model. Sixteen randomized controlled trials, comprising 3760 patients, were included in the study. Most interventions were single-site (n = 14), multicomponent (n = 12), and focused on patients with asthma (n = 8). Pooling data from 10 studies (n = 1965 patients) found moderate-quality evidence for a relative increase of 29% in outpatient follow-up with interventions compared with routine care (odds ratio, 1.58 [95% confidence interval, 1.08-2.31]). Successful interventions included structured telephone reminders, educational counseling on follow-up, and appointment scheduling assistance. There was low-quality evidence when pooling data from 5 studies (n = 1609 participants) that exhibited little or no beneficial effect of interventions on ED readmissions (risk ratio, 1.02 [95% confidence interval, 0.91-1.15]). All studies were conducted in urban US hospitals which makes generalization of the results to rural settings and other countries difficult. ED-based care transition interventions are effective in increasing follow-up but do not seem to reduce ED readmissions. Further research is required to investigate the mechanisms that affect the success of these interventions.

Abstract C09: Socioeconomic disparities in hospital admission patterns following cancer-related ED visits in the United States

Abstract Background: Emergency departments (EDs) evaluate and manage cancer patients with a variety of conditions (e.g., cancer-related symptoms, treatment complications). EDs provide appropriate care for acute management but utilization may reflect problems in cancer care and does not represent the optimal care setting for cancer patients. Insurance status has been shown to impact ED presentation. Yet, little is known about the impact of socioeconomic factors on hospital admission of cancer patients presenting to EDs. Identifying factors associated with admission of cancer patients from the ED may provide insight into methods to improve cancer care and reduce ED utilization. Methods: A retrospective study of cancer-related ED visits in the US in 2012 was conducted using the Nationwide Emergency Department Sample. Cancer-related ED visits among adults over age 18 were identified by cancer-specific Clinical Classification Software codes (11-45) in the first five diagnostic positions. Care acuity was defined by Current Procedural Terminology codes for physician level of service (low=99281-99282, moderate=99283-99284, high=99285, 99291). Patients who were transferred, died in the ED, or discharged to an unknown destination (total &amp;lt;3%) were excluded. Weighted multivariate logistic regression was performed to analyze the association between insurance status, income quartile, location and hospital admission. Results: There were 3,019,119 cancer-related ED visits in the US in 2012 (3% of all adult ED visits). Patients with cancer-related ED visits were 69% publicly insured (57% Medicare [MC], 12% Medicaid [MA]), 23% privately insured (PI), and 5% uninsured (UN). Breast (15%), lung (14%), prostate (10%), and colon (8%) cancers were most common. Reasons for ED visits included respiratory (36%), gastrointestinal (36%), genitourinary (28%), and fluid or electrolyte (20%) problems, pain (15%), and fatigue, fever, neutropenia, and sepsis (3-5% each). Fewer UN (15%), MA (17%), and PI (18%) patients were coded as high acuity, compared to MC (21%; p&amp;lt;.001). 50% of cancer-related ED visits resulted in admission to the same hospital, compared to 17% of all adult ED visits (p&amp;lt;.001). In multivariate analysis adjusted for age, gender, cancer type, presenting conditions, acuity, location of patient's residence, admission timing (weekday/weekend), hospital region, and teaching status, the odds of admission following ED presentation were lower for UN (odds ratio [OR]=0.67; 95% confidence interval [CI]=0.48-0.93) and MA (OR=0.87; 95%CI=0.77-0.98) and higher for PI (OR=1.16; 95%CI=1.06-1.26) patients, compared to MC patients. The odds of admission were also lower for residents of non-large metro areas (OR=0.31; 95%CI=0.21-0.44), compared to large metro, and in Midwest (OR=0.14; 95%CI=0.09-0.21) and West (OR=0.15; 95%CI=0.09-0.24) region hospitals, compared to South, and higher with older age (OR=1.22; 95%CI=1.16-1.27) and for patients with metastatic disease (OR=6.89; 95%CI=5.98-7.94), neutropenia (OR=7.93; 95%CI=6.22-10.12), or fluid or electrolyte problems (OR=5.97; 95%CI=5.46-6.53). There was no difference in admission odds by income quartile. Conclusion: Lower odds of admission following cancer-related ED visits were associated with non-clinical factors (UN/MA patients, non-large metro location, Midwest/West region). Clinical elements (older age, metastases, neutropenia, fluid or electrolyte problems) were important correlates of admission but only partly explained differences by insurance, location, and region. Additional research will seek to identify potential causes of decreased admission among UN and MA patients, including the roles of source of care, different acuity levels, and undesirable financial liability associated with inpatient management, to evaluate the rate of ED readmission after discharge, and to determine factors contributing to lower admission rates in the Midwest and West regions. Citation Format: Marc Kowalkowski, Derek Raghavan, Michael Runyon, Mellisa Wheeler, Michael Gibbs, Andrea Bouronich, Carol Farhangfar. Socioeconomic disparities in hospital admission patterns following cancer-related ED visits in the United States. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C09.

First lifetime psychiatric admission in the postpartum period: A population-based comparison to women with prior psychiatric admission.

To better understand women with a first lifetime psychiatric hospitalization in the postpartum period. We included all 1071 postpartum women in Ontario, Canada, with a psychiatric admission in the 1-year postpartum (2007-2012). We compared women with their first lifetime psychiatric admission to those with any prior psychiatric admission on demographic and clinical characteristics and on mental health physician visits, psychiatric emergency department (ED) revisits and psychiatric readmission within 1-year postdischarge. Compared to women with prior admission, women with a first lifetime admission (n=537, 59%) were less likely to have psychotic disorders (14% vs. 25%) and had shorter lengths of stay (13.6+/-12.7 vs. 18.9+/-27.8days). Women with prior admission were at higher risk for ED revisits (44% vs. 32%, odds ratio=1.63, 95% confidence interval=1.26-2.09) and readmissions (32% vs. 24%, odds ratio=1.82, 95% confidence interval=1.39-2.38) by 1-year postdischarge versus women with first lifetime admission; differences were explained by clinical factors. Although women with a first lifetime psychiatric admission postpartum have a favorable clinical course up to 1year after index admission versus women with any prior admission, 25% are readmitted with 1-year postdischarge, underscoring need for attention to this group.

Eliminating unnecessary routine head CT scanning in neurologically intact mild traumatic brain injury patients: implementation and evaluation of a new protocol.

OBJECTIVE The utility of routine repeat head CT (HCT) scans in the management of minimal head injury (MHI) patients with an intracranial hemorrhage (ICH) has been questioned in multiple studies. All these studies analyzed this by obtaining a repeat HCT study, and none examined the effects of eliminating these routine HCT studies in neurologically intact patients. The authors' institution implemented a new "Neurologic Observation without Repeat HCT" (NORH) protocol with no repeat HCT scanning for patients admitted for MHI and ICH whose neurological status was maintained or improved to a Glasgow Coma Scale score of 15 at 24 hours after admission. This purpose of this study was to assess the outcomes and safety of this novel protocol. METHODS Records of patients who sustained blunt trauma MHI and an ICH and/or skull fracture on initial HCT between January 1, 2009, and December 31, 2012, were retrieved from the trauma registry of a Level I trauma center. The authors analyzed 95 patients in whom the NORH protocol was followed. Outcome measures included death, emergency department readmission, neurosurgical intervention, delayed repeat HCT, and length of stay. RESULTS The NORH protocol was followed for 95 patients; 83% of the patients were male, the average age was 38 ± 16.0 years old, and the most common cause of trauma was assault (35%). Of the 95 patients in whom the NORH protocol was followed, 8 (8%) had a delayed repeat HCT study (> 24 hours) after admission, but none resulted in neurosurgical intervention because of progression of ICH. The average length of stay was 4 ± 7.2 days. None of the patients were readmitted to the hospital. CONCLUSIONS Implementation of the NORH protocol (eliminating routine follow-up HCT) resulted in very low rates of delayed neurological deterioration, no late neurosurgical interventions resulting from ICH progression, very few emergency department revisits, and no readmissions. For a select group of MHI patients with ICH, the NORH protocol is safe and effective, and can reduce radiation exposure and costs.

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations

BackgroundPerforming root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions. ObjectivesTo describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers. DesignSNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial. ParticipantsSixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers. InterventionsSNFs received education and technical assistance in INTERACT implementation. MeasuresData were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. ResultsA total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers. ConclusionSummarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.

Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure

Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes. To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression. Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non-VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users. Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.

Selective Early Hospital Discharge Does Not Increase Readmission but Unnecessary Return to the Emergency Department Is Excessive Across Groups After Primary Total Knee Arthroplasty

BackgroundThere has been much attention paid to the ability to optimize outcomes, limit complications, and reduce costs within the episode of care after total joint arthroplasty. Limiting the duration of postoperative hospitalization as well as reducing emergency department (ED) visits and readmissions are additional considerations in the paradigm of cost containment. Our purpose was to evaluate the safety of early hospital discharge after primary total knee arthroplasty (TKA) and to identify the diagnoses responsible for ED visits and readmissions in the postoperative period. MethodsWe investigated risk factors for readmission in 995 patients undergoing primary TKA. We compared 2 groups: length of hospital stay (LOS) ≤2 or ≥3 days. Analysis included LOS, Charlson score, history of DVT, discharge disposition, and postdischarge ED visits. ResultsPatients who stayed ≤2 postoperative days had a significantly lower mean Charlson score and more likely discharged home. Charlson score and history of DVT were predictive of return events. Patients discharged to home were less likely to have return events. More than half of the patients evaluated in the ED were not readmitted. ConclusionAmong patients undergoing primary TKA, it is the health of the patient, and not their resultant LOS, that correlates to return events. The ED is overused for complaints that may otherwise be managed as effectively and more cost efficiently in outpatient settings. Cost containment must include unnecessary utilization of the ED.

Opioid Prescription Practices at Discharge and 30-Day Returns in Children with Sickle Cell Disease and Pain

Background: Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. Lack of evidence-based guidelines contributes to variability in the management of children with SCD after hospitalization for acute pain. However, the impact of treatment variability on readmissions in this population has not been well studied. We examined prescription practices at time of discharge in children with SCD and acute pain to determine their impact on incidence of 30-day Emergency Department (ED) revisits and readmissions. We hypothesize that prescription of scheduled opioids after discharge for acute pain episodes is associated with lower 30-day ED revisits and readmissions when compared to the prescription of as needed or no opioids.Methods: We performed a single-institution, retrospective study of all patients with SCD aged 7 to 21 who were hospitalized or discharged from the ED with a diagnosis of acute pain episode from June 2009 to May 2014. Patients with ≥ 8 hospitalizations in a single year were excluded from the analysis. We reviewed demographic, treatment and discharge data from each encounter along with 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Between-groups comparisons for continuous variables were performed using the Mann-Whitney U test and categorical variables using the Chi-Square or Fisher's Exact test where appropriate. Independent predictors of 30-day returns were evaluated using multivariable logistic regression (IBM, SPSS v22).Results: We reviewed a total of 290 encounters (n=110, ED discharge; n=180, hospital discharge) in 97 patients (51% male, median 11.9 years old) during the 5-year period. Patients had hemoglobin SS or S/ß0 thalassemia in 209/290 (72%) encounters and were on hydroxyurea in 104/290 (36%). For hospitalizations (median length of stay 4 days), patients were treated with parenteral opioids in 159/180 (88%) encounters, most commonly by patient-controlled analgesia. Patients were prescribed opioids at the time of discharge in 259/290 (89%) encounters, more commonly at discharge from the hospital versus ED (96 vs. 79%, p < 0.01). The remaining patients were either prescribed non-steroidal anti-inflammatory drugs (NSAIDs) or a prescription was not given. Compared to as needed or no therapy, scheduled opioids were more frequently prescribed when discharged from the hospital versus ED (61 vs. 19%, p < 0.01). In total, 56/290 (19%) encounters resulted in 30-day ED revisits or readmissions after discharge from the hospital or ED. Compared to hospital discharges, discharge from the ED for acute pain was associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI 1.5, 4.8], p < 0.01). Median number of days to return was also shorter for patients discharged from the ED versus hospital (4 vs. 11.5 days, p < 0.01). In general, we found no association between prescribed opioid frequency and incidence of 30-day returns. Prescription of scheduled opioids was similar between encounters that did or did not result in a 30-day ED revisit or readmission (46 vs. 48%, p = 0.8). Using multivariable logistic regression, we examined if other factors were associated with an increased incidence of 30-day returns. After discharge from the ED, the prescription of NSAIDs only, without opioids, was independently associated with a higher incidence of 30-day ED revisits but not readmissions. Neither 30-day ED revisits nor readmissions was affected by age, sex, genotype, or hydroxyurea use. After discharge from the hospital, none of these factors, including hospital length of stay or use of patient-controlled analgesia, were independently associated with 30-day ED revisits or readmissions.Conclusions: Variability exists in opioid prescription practices after discharge from the ED or hospital in children with SCD and acute pain episodes. Prescribed opioid frequency did not impact overall 30-day returns after discharge from the ED or hospital. After discharge from the ED, however, prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence 30-day returns in children with SCD and acute pain are needed. Standardized approaches to outpatient opioid management after discharge and their impact on 30-day returns are also warranted in this population. DisclosuresNo relevant conflicts of interest to declare.

Characteristics of older adults admitted to the emergency department (ED) and their risk factors for ED readmission based on comprehensive geriatric assessment: a prospective cohort study.

BackgroundPatients aged 75 years and older represent 12% of the overall emergency department (ED) population, and this proportion will increase over the next decades. Many of the discharged patients suffer an unplanned readmission in the immediate and midterm post-discharge period, suggesting under recognition of psychosocial, cognitive and medical problems. The aim of this study was to compare the characteristics of older patients admitted and discharged from the ED and to determine independent predictors for ED readmission 1 month and 3 months after ED discharge based on comprehensive geriatric assessment (CGA).MethodsCohort study in a Belgian university hospital. A CGA, including demographic and medical data (e.g. reason for admission, comorbidity, number of medications), functional (e.g. activities of daily living, falls), mental (i.e. cognition, dementia, delirium), and nutritional status, and pain, was performed in 442 ED patients aged 75 years or older.ResultsPatients discharged from the ED (n = 117, 26.5%) were significantly less dependent for ADL, mobility, shopping and finances compared with hospitalised patients. Hospitalised patients (n = 325, 73.5%) were significantly more at risk for having nutritional problems, had a higher comorbidity index, and a lower cognitive status compared with those discharged. Ninety-seven patients (82.9%) were discharged home from the ED. Of the latter, 18 (18.6%) and 28 patients (28.9%) suffered an ED readmission within 1 and 3 months, respectively. At one month post-discharge, nursing care at home, meals on wheels, and risk for depression; and at 3 months post-discharge previous hospitalisation in the last 3 months, physiotherapy and meals on wheels were found to be independent predictors for ED readmission, respectively.ConclusionsThis study observed a geriatric risk profile in older adults at the ED and a high readmission rate of those discharged, and suggests the potential value of CGA in identifying older patients at high risk for ED readmission.

Hospital readmission after emergency room visit for cholelithiasis

BackgroundFor patients presenting with symptomatic cholelithiasis, cholecystectomy is the definitive treatment modality. Our goal was to evaluate the surgical follow-up and outcomes in patients seen in the emergency department (ED) for an episode of symptomatic cholelithiasis and discharged home for elective follow-up. MethodsWe performed a retrospective review of consecutive patients seen in the ED for cholelithiasis and discharged without hospital admission between August 2009 and May 2014. All patients were followed for 2 y from the date of the initial ED visit. We evaluated outpatient surgeon visits, elective and emergent cholecystectomy rates, and additional ED visits. Cumulative incidence and Kaplan–Meier curves were used to examine the time from the initial ED visit to outpatient surgeon evaluation and the time from the initial ED visit to ED readmission. ResultsSeventy-one patients were discharged from the ED with a diagnosis of symptomatic gallstones. Patients who had an elective cholecystectomy in the 2 y after the initial visit were 12.6%. In this group, the mean time from the initial ED visit to outpatient surgeon follow-up was 7.7 d, and all elective cholecystectomies occurred within 1 mo of the initial visit. Of the 62 patients who did not have an elective cholecystectomy, only 14.5% of patients in this group had outpatient surgeon follow-up at mean time of 137 d from the initial ED visit for symptomatic gallstones. In addition, 37.1% of patients in this group had additional ED visits for gallstone-related symptoms, with 17.7% of patients having two or more additional ED visits, and 12.9% required emergent and/or urgent cholecystectomy. Additional ED visits (43.5%) occurred within 1 mo and 60.9% within 3 mo of their initial ED visit. In patients with additional ED visits for symptomatic cholelithiasis, 60.9% had more than one abdominal ultrasound or computed tomography scan during the course of multiple visits. ConclusionsFailure to achieve a timely surgical follow-up leads to multiple ED readmissions and emergent gallstone-related hospitalizations, including emergency cholecystectomy. System-level interventions to ensure outpatient surgical follow-up within 1–2 wk of the initial ED visit has the potential to improve outcomes for patients with symptomatic biliary colic.

The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department.

This study sought to determine the prevalence, test characteristics, and severity of illness of pediatric patients with systemic inflammatory response syndrome (SIRS) vital signs among pediatric emergency department (ED) visits. This was a retrospective descriptive cohort study of all visits to the ED of a tertiary academic free-standing pediatric hospital over 1 year. Visits were included if the patient was <18 years of age and did not leave before full evaluation or against medical advice. Exclusion criteria were trauma diagnoses or missing documentation of vital signs. Data were electronically extracted from the medical record. The primary predictor was presence of vital signs meeting pediatric SIRS definitions. Specific vital sign pairs comprising SIRS were evaluated as predictors (temperature-heart rate, temperature-respiratory rate, and temperature-corrected heart rate, in which a formula was used to correct heart rate for degree of temperature elevation). The primary outcome measure was requirement for critical care (receipt of a vasoactive agent or intubation) within 24 hours of ED arrival. There were 56,210 visits during the study period; 40,356 met inclusion criteria. Of these, 6,596 (16.3%) visits had fever >38.5°C, and 6,122 (15.2% of included visits) met SIRS vital sign criteria. Among included visits, those with SIRS vital signs accounted for 92.8% of all visits with fever >38.5°C. Among patients with SIRS vital signs, 4993 (81.6%) were discharged from the ED without intravenous (IV) therapy and without 72-hour readmission. Critical care within the first 24 hours was present in 99 (0.25%) patients: 23 patients with and 76 without SIRS vital signs. Intensive care unit (ICU) admission was present in 126 (2.06%) with SIRS vital signs and 487 (1.42%) without SIRS vital signs. SIRS vital signs were associated with increased risk of critical care within 24 hours (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.06 to 2.70), ICU admission (RR = 1.45, 95% CI = 1.19 to 1.76), ED laboratory tests (RR = 1.41, 95% CI = 1.37 to 1.45), ED IV medication/fluid administration (RR = 2.54, 95% CI = 2.29 to 2.82), hospital admission (RR = 1.52, 95% CI = 1.42 to 1.63), and 72-hour readmission (RR = 1.31, 95% CI = 1.01 to 1.69). SIRS vital signs were not associated with 30-day in-hospital mortality (RR = 0.37, 95% CI = 0.05 to 2.82). SIRS vital signs had a low sensitivity for critical care requirement (23.2%, 95% CI = 15.3% to 32.8%). The pair of SIRS vital signs with the strongest association with critical care requirement was temperature and corrected heart rate (positive likelihood ratio = 2.74, 95% CI = 1.87 to 4.01). Systemic inflammatory response syndrome vital signs are common among medical pediatric patients presenting to an ED, and critical illness is rare. The majority of patients with SIRS vital signs were discharged without IV therapy and without readmission. Patients with SIRS vital signs had a statistically significant increased risk of critical care requirement, ED IV treatment, ED laboratory tests, admission, and readmission. However, SIRS vital sign criteria did not identify the majority of patients with mortality or need for critical care. SIRS vital signs had low sensitivity for critical illness, making it poorly suited for use in isolation in this setting as a test to detect children requiring sepsis resuscitation.

Transforming Hospital Emergency Department Workflow and Patient Care

When we encounter an unexpected critical health problem, a hospital’s emergency department (ED) becomes our vital medical resource. Improving an ED’s timeliness of care, quality of care, and operational efficiency while reducing avoidable readmissions, is fraught with difficulties, which arise from complexity and uncertainty. In this paper, we describe an ED decision support system that couples machine learning, simulation, and optimization to address these improvement goals. The system allows healthcare administrators to globally optimize workflow, taking into account the uncertainties of incoming patient injuries and diseases and their associated care, thereby significantly reducing patient length of stay. This is achieved without changing physical layout, focusing instead on process consolidation, operations tracking, and staffing. First implemented at Grady Memorial Hospital in Atlanta, Georgia, the system helped reduce length of stay at Grady by roughly 33 percent. By repurposing existing resources, the hospital established a clinical decision unit that resulted in a 28 percent reduction in ED readmissions. Insights gained from the implementation also led to an investment in a walk-in center that eliminated more than 32 percent of the nonurgent-care cases from the ED. As a result of these improvements, the hospital enhanced its financial standing and achieved its target goal of an average ED length of stay of close to seven hours. ED and trauma efficiencies improved throughput by over 16 percent and reduced the number of patients who left without being seen by more than 30 percent. The annual revenue realized plus savings generated are approximately $190 million, a large amount relative to the hospital’s $1.5 billion annual economic impact. The underlying model, which we generalized, has been tested and implemented successfully at 10 other EDs and in other hospital units. The system offers significant advantages in that it permits a comprehensive analysis of the entire patient flow from registration to discharge, enables a decision maker to understand the complexities and interdependencies of individual steps in the process sequence, and ultimately allows the users to perform system optimization.

Changes to hospice attending physician rules

Performing root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions.To describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers.SNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period.SNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial.Sixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers.SNFs received education and technical assistance in INTERACT implementation.Data were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.A total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers.Summarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.

Characterizing types of readmission after acute coronary syndrome hospitalization: implications for quality reporting.

BackgroundThirty‐day readmission rates have been tied to hospital reimbursement in the United States, but remain controversial as measures of healthcare quality. We profile the timing, main diagnoses, and survival outcomes of inpatient and emergency department readmissions after acute coronary syndrome (ACS), based on a large regional database.Methods and ResultsPatients enrolled in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry with an ACS hospitalization between April 2008 and March 2010 (n=3411) were included. Primary outcomes were inpatient and emergency department–only readmissions, at 30 days and 1 year. Predictors of 30‐day readmission were identified, and the association between 30‐day readmission status and mortality was evaluated. A total of 1170 (34.3%) patients had ≥1 hospital readmission within 30 days, reaching 2106 (61.7%) within 1 year of ACS discharge. Of first readmissions, 45% were emergency department only and 53% were for cardiovascular or possibly related diagnoses. Renal disease and diabetes predicted all‐cause readmissions at 30 days and 1 year, but there were no robust predictors of cardiovascular readmissions. Thirty‐day inpatient, but not emergency department, readmissions were associated with increased mortality.ConclusionsHospital readmissions within 30 days after discharge for ACS are common, and associated with increased mortality. However, our findings underline that readmissions are quite heterogeneous in nature, and that many readmissions are unrelated to index stay and thus not easily predicted with common clinical variables. All‐cause 30‐day readmission rates may be too simplistic, and perhaps even misleading, as a hospital performance metric.