Emergency Department Recidivism Research Articles

272 Advanced nurse practitioner -supported nursing home liaison service

Abstract Background Nursing Home Residents (NHR) are the frailest group of older people in society and require a gerontologically attuned approach to address multiple challenges presented to the practitioner. In 2018 we commenced an advanced nurse practitioner (ANP) specialist liaison service with bespoke comprehensive geriatric assessment (CGA) to support NHR admitted to a tertiary referral university teaching hospital. Given the impact of COVID-19 on NHR in particular, in 2020 this service was expanded to include a consultant physician and specialist registrar in geriatric medicine, when full care of NHRs came under geriatric medicine services. This includes a two-week post-discharge virtual clinic with the Nursing Home director of nursing and/or GP. Methods Information on all NHRs attending a tertiary referral university teaching hospital was collected from 2018–2023. Data on demographics, presenting complaints, CGA, and outcomes of Length of Stay (LoS), emergency department (ED) recidivism, and mortality were collected. Impact on clinical outcomes of liaison versus full geriatric medicine care are presented in this abstract. Results In 2018 there were 353 NHRs admitted from ED who represented 4,170 total hospital bed days. In 2019 there were 329 NHRs admitted with 3,991 total bed days. In 2021, 251 NHRs were admitted representing 2,582 total bed days. As result of the enhanced care model, where full inpatient governance came under the geriatric medicine services, we observed: (1) Readmission rate 37% (2018) vs 12.7% (2021), (2) Reduction in LoS from 2018–2021 from 11.8 to 10.0 days, (3) Halved the overall bed-usage days from 2018–2021. Conclusion The high complexity of this cohort of patients requires a timely, comprehensive gerontological approach in order to provide holistic care. Better care with CGA embedded also translates to better use of acute hospital resource.

Behavioral Health Decision Support Systems and User Interface Design in the Emergency Department.

The objective of this qualitative study is to gauge physician sentiment about an emergency department (ED) clinical decision support (CDS) system implemented in multiple adult EDs within a university hospital system. This CDS system focuses on predicting patients' likelihood of ED recidivism and/or adverse opioid-related events. The study was conducted among adult emergency physicians working in three EDs of a single academic health system in Rhode Island. Qualitative, semistructured interviews were conducted with ED physicians. Interviews assessed physicians' prior experience with predictive analytics, thoughts on the alert's placement, design, and content, the alert's overall impact, and potential areas for improvement. Responses were aggregated and common themes identified. Twenty-three interviews were conducted (11 preimplementation and 12 postimplementation). Themes were identified regarding each physician familiarity with predictive analytics, alert rollout, alert appearance and content, and on alert sentiments. Most physicians viewed these alerts as a neutral or positive EHR addition, with responses ranging from neutral to positive. The alert placement was noted to be largely intuitive and nonintrusive. The design of the alert was generally viewed positively. The alert's content was believed to be accurate, although the decision to respond to the alert's call-to-action was physician dependent. Those who tended to ignore the alert did so for a few reasons, including already knowing the information the alert contains, the alert offering information that is not relevant to this particular patient, and the alert not containing enough information to be useful. Ultimately, this alert appears to have a marginally positive effect on ED physician workflow. At its most beneficial, the alert reminded physicians to deeply consider the care provided to high-risk populations and to potentially adjust their care and referrals. At its least beneficial, the alert did not affect physician decision-making but was not intrusive to the point of negatively impacting workflow.

Prevalence of Adverse Childhood Experiences in a Pediatric Emergency Department: Support for Trauma-Informed Pediatric Emergency Care.

Data from the 2019 National Survey of Children's Health revealed that 39.8% of children in the United States have been exposed to adverse childhood experiences (ACEs), which are risk factors for long-term negative health outcomes. This study aimed to determine the prevalence of ACE exposure in a pediatric emergency department (ED) patients and describe the association between ACE exposure and ED recidivism. Five hundred children aged 0 to 17 years were evaluated for ACE exposure in an academic, urban, tertiary-care, pediatric ED via convenience sampling. The 2019 National Survey of Children's Health section on ACEs was administered to define ACE exposure. A prospective chart review was conducted on all children enrolled in the study to collect data on ED utilization for 1-year postsurvey. The relationship between ACE exposure and ED recidivism was examined by calculating relative risk. We found that 40.2% (confidence interval [CI], 36.5%-45.3%) of respondents had ACE exposure. The most frequently reported ACEs were poverty (20.8%; CI, 17.3%-24.6%), divorce/separation (18.2%; CI, 14.9%-21.9%), and mental illness within the household (7.2%; CI, 5.1%-9.8%). Adverse childhood experience exposure in this pediatric ED was similar to the national prevalence. There was no significant relationship between ACE exposure and high ED recidivism as an adverse outcome. Adverse childhood experience exposure in this population matched the prevalence reported in the national population. Our results suggest that this group is particularly important when mitigating these risk factors for long-term adverse health outcomes. Adverse childhood experience exposure did not appear to impact recidivism in a period of unprecedented low ED volumes during the coronavirus disease pandemic.

Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline.

Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio=1.49, 95% confidence interval [CI]=0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio=3.17, 95% CI=1.14 to 8.85, very low certainty). We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.

Empowering patients: simplifying discharge instructions

Patients who do not have enough information about their discharge plans have decreased treatment compliance, decreased patient safety, increased emergency department (ED) recidivism, and poor satisfaction. This project aimed to...

Identifying homeless population needs in the Emergency Department using Community-Based Participatory Research

BackgroundAnnually 1.5 million Americans face housing insecurity, and compared to their domiciled counterparts are three times more likely to utilize the Emergency Department (ED). Community Based Participatory Research (CBPR) methods have been employed in underserved populations, but use in the ED has been limited. We employed CBPR in an urban American hospital with a primary goal of improved linkage to care, reduced ED recidivism, and improved homeless health care.MethodsA needs analysis was performed using semi-structured individual interviews with participants experiencing homelessness as well as with stakeholders. Results were analyzed using principles of grounded theory. At the end of the interviews, respondents were invited to join the “CBPR team”. At CBPR team meetings, results from interviews were expounded upon and discussions on intervention development were conducted.ResultsTwenty-five stakeholders were interviewed including people experiencing housing insecurity, ED staff, inpatient staff, and community shelters and services. Three themes emerged from the interviews. First, the homeless population lack access to basic needs, thus management of medical needs must be managed alongside social ones. Second, specific challenges to address homeless needs in the ED include episodic care, inability to recognize housing insecurity, timely involvement of ancillary staff, and provider attitudes towards homeless patients affecting quality of care. Lastly, improved discharge planning and communication with outside resources is essential to improving homeless health and decreasing ED overutilization. A limitation of results is difficulty for participants experiencing homelessness to commit to regular CBPR meetings, as well as possible bias towards social networks influencing included stakeholders.ConclusionCBPR is a promising approach to address gaps in homeless health care as it provides a comprehensive view incorporating various critical perspectives. Key ED-based interventions addressing recidivism include improved identification of housing insecurity, reinforced relationships between ED and community resources, and better discharge planning.

Dedicated area within the emergency department versus an outside dedicated area for evaluation and management of suspected coronavirus disease 2019.

BackgroundThe circumstances of the coronavirus disease 2019 pandemic necessitated an alternate operations strategy for efficient patient management. Alternate care sites were a viable option for managing emergency department (ED) surge in previous epidemics and disasters.ObjectiveThis study describes the development of an alternate care site and evaluates efficiency by comparing key performance indicators between an ad hoc nested respiratory evaluation unit (NRU) within the ED and an alternate care site outside the ED.MethodsThis was a cohort study of 2 care models in the same ED during 2 different time periods. As coronavirus disease 2019 surged in March 2020, potential treat‐and‐release patients with fever or respiratory symptoms were triaged to a dedicated ED area (NRU). As ED volume grew, these low‐acuity patients were triaged to an ACS. We compared ED length of stay, elopement, and left without being evaluated rates and ED recidivism between the 2 care models: NRU patients presented to the ED from March 16, 2020, to March 31, 2020, and ACS patients presented from April 1, 2020, to April 15, 2020. Continuous variables were compared using independent t test or Mann‐Whitney test. Categorical variables were compared using χ2 test.ResultsThere were 414 NRU patients and 146 alternate care site patients with no significant differences in sex or age. The mean ED length of stay was shorter for alternate care site patients: 155 versus 45 minutes (P < 0.01). Elopement and left without being evaluated rates were higher in the NRU. There was no significant difference in ED recidivism between groups: 10% versus 6% (P = 0.15).ConclusionsAn alternate care site provided an efficient resource for the evaluation of patients with fever or respiratory symptoms during the coronavirus disease 2019 pandemic.

Care Coordination Program for Children With Complex Chronic Conditions Discharged From a Rural Tertiary-Care Academic Medical Center.

Hospital discharge offers an opportunity to initiate coordination of follow-up care, preventing readmissions or emergency department (ED) recidivism. We evaluated how revisits and costs of care varied in a 12-month period between children in a care coordination program at our center (enrolled after hospital discharge with a tracheostomy or on a ventilator) and children with complex chronic condition discharges who were not enrolled. Children ages 1 to 17 years were retrospectively included if they had a hospital discharge in 2017 with an International Classification of Diseases, 10th Revision code meeting complex chronic condition criteria or if they were in active follow-up with the care coordination program. Revisits and total costs of care were compared over 2018 for included patients. Seventy patients in the program were compared with 56 patients in the control group. On bivariate analysis, the median combined number of hospitalizations and ED visits in 2018 was lower among program participants (0 vs 1; P = .033), and program participation was associated with lower median total costs of care in 2018 ($700 vs $3200; P = .024). On multivariable analysis, care coordination program participation was associated with 59% fewer hospitalizations in 2018 (incidence rate ratio: 0.41; 95% confidence interval: 0.23 to 0.75; P = .004) but was not significantly associated with reduced ED visits or costs. The care coordination program is a robust service spanning the continuum of patient care. We found program participation to be associated with reduced rehospitalization, which is an important driver of costs for children with medical complexity.

Methamphetamine, Amphetamine, and MDMA Use and Emergency Department Recidivism.

Emergency department (ED) recidivism and the use of amphetamine and associated derivatives such as methamphetamine and MDMA (MAE), are intersecting public health concerns. This study aims to determine the frequency of ED recidivism of patients who use MAE and associated factors. The study was a retrospective 6-year electronic medical record review of patients with MAE-positive toxicology screens and single and multiple ED visits in the span of 12months. There were 7844 ED visits by 5568 MAE-positive patients. Average age was 42±13years. The majority were male (65%), white (46%), tobacco smokers (55%), and in the psychiatric discharge diagnostic-related group (41%), followed by blunt trauma (20%). Admission rate was 35%, with another 17% transferred to inpatient psychiatric treatment facilities. Occasional (2-5 visits/year), heavy (6-11 visits/year), and super users (≥12 visits/year) altogether accounted for 20% of patients and 43% of visits. Heavy and super users combined represented 2% of patients and 10% of visits, with significant differences for race/ethnicity, health insurance, tobacco smoking, and psychiatric/cardiovascular/trauma discharge diagnostic-related groups. Heavy and super users were less likely to be admitted and more likely to be discharged to an inpatient psychiatric treatment facility. Regression analysis revealed racial/ethnic differences, female gender, and tobacco smoking to be associated with super and heavy use. Heavy users were more likely to have cardiovascular-related discharge diagnoses. The prevalence of ED recidivism in patients who use MAE is similar to published ranges for general ED users. Significant differences in demographics, discharge diagnoses, insurance, smoking, and disposition exist between nonfrequent and frequent ED users.

Post-discharge Health Services Use for Patients with Serious Mental Illness Treated at an Emergency Department Versus a Dedicated Community Mental Health Center.

Emergency Medical Service (EMS) alternative destination programs may lead toimproved care qualityamong those experiencing mental health crises butthe association with cost and emergency department (ED) recidivism remains unexamined. We compare rates of post-discharge health services use and Medicaid spending among patients transported to an ED or community mental health center (CMHC) finding higher ED recidivism for patient treated in the ED, compared to those treated in a CMHC (68% vs 34%, p < 0.001). There were no differences in Medicaid spending or health services use post-discharge suggesting EMS-operated alternative destination programs may be cost-neutral for Medicaid programs.

Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study.

The 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes. We conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations. A total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4-1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2-1.6), future hospitalization (OR = 1.1; 95% CI = 1.05-1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04-1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3-11.4). Our findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.

Risk Factors Associated with Emergency Department Recidivism in the Older Adult.

Our objective was to review risk factors predictive of older adult recidivism in the emergency department. Certain risk factors and themes commonly occurred in the literature. These recurring factors included increasing age, male gender, certain diagnoses (abdominal pain, traumatic injuries, and respiratory complaints), psychosocial factors (depression, anxiety, poor social support, and limited health literacy), and poor general health (cognitive health and physical functioning). Many of the identified risk factors are not easily modifiable posing a significant challenge in the quest to develop and implement effective intervention strategies.

296 Social Determinants of Health Associated With Emergency Department Recidivism in Patients With Diabetes

296 Social Determinants of Health Associated With Emergency Department Recidivism in Patients With Diabetes

210EMF Four-Week Text Messaging Follow-Up of Subjects With Low-Risk Chest Pain Associated With Anxiety

Approximately 40% of patients presenting to the emergency department (ED) with low-risk chest pain have anxiety as a significant contributor to their symptoms. Often unaddressed in this population, anxiety is associated with multiple psychological comorbidities, impaired quality of life, and significantly higher ED recidivism. Although evidence points to persistent anxiety symptom elevation at six-weeks, traditional methods of follow-up assessment in this population are prone to recall bias given the unpredictable nature of anxiety symptomatology. One method of overcoming this propensity for recall bias is through frequent repeated measures known as ecological momentary assessment (EMA). Short message service (SMS) messaging or text-messaging is a readily accessible and cheap EMA method. Our objective is to determine the feasibility of using an automated weekly SMS text message protocol to assess the prevalence and rate of persistent anxiety symptoms, chest pain recurrence, and ED utilization among a cohort of ED subjects with low-risk chest pain. This is a single academic center, two hospital, prospective observational cohort study of ED subjects with low risk chest pain. Eligible subjects between 18 and 70 years old with no history of acute coronary syndrome (ACS) and a physician-reported HEART score < 4, are eligible for enrollment. The Generalized Anxiety Disorder 7 item scale (GAD-7) is used to stratify participants by anxiety symptom severity: (none ≤4, mild 5-9, moderate 10-14, and severe ≥15). Subjects are followed for a total of 12 weeks receiving automated SMS conversations from our Research Electronic Data Capture (REDCap) software facilitated by third-party partner Twilio. These 9-item SMS conversations assess anxiety symptoms, chest pain recurrence and ED utilization in weeks 1-5 and 7-11. This is an interim analysis using descriptive statistics of this cohort through 4 weeks of follow-up. To date, 117 of the 200 planned subjects have been enrolled and their baseline characteristics are shown in Table 1.The prevalence of abnormal levels of anxiety (moderate or severe) at enrollment was 44% (n=51). GAD-7 scores ≥15 (severe) were found in 30 subjects (26%). The overall study response rate to SMS prompts is 76%. Two and four-week follow-up SMS response rates are 74% and 72% respectively. At 2 weeks, of the 41 responding subjects with abnormal anxiety at enrollment, 26 (64%) had persistently abnormal scores. Additionally, of the subjects with severe anxiety at enrollment, 77% remained abnormal compared with 40% of those with moderate scores at 2 weeks. For subjects with severe anxiety at enrollment, the rate of persistently abnormal anxiety was 72% at 4 weeks. In this interim analysis investigating the feasibility of using automated SMS conversations for follow-up of low risk chest patients, our rate of SMS response is >75%, which is currently higher than our a priori feasibility threshold of 70%. Additionally, >70% of those with severe anxiety symptoms at enrollment had persistently abnormal anxiety scores at 2- and 4-week SMS follow-up.Tabled 1Baseline cohort demographicsGAD-7 ≤9 (n=66)GAD-7 ≥10 (n=51)Age43.743.8Female Sex39 (59%)33 (65%)Race/EthnicityBlack28 (42%)37 (73%)White34 (52%)12 (24%)Hispanic3 (5%)4 (8%) Open table in a new tab

109. Identifying Adolescents With Elevated Social Risk In The Pediatric Emergency Department

Addressing social determinants of health (SDH) is a mandate of Healthy People 2020 and the American Academy of Pediatrics. The emergency department (ED), often serving as a safety net for vulnerable populations, may be a strategic venue for this activity as evidence supports the impact SDH can have on health outcomes. The objective of this analysis was to identify characteristics of adolescent ED patients who may benefit from proactive intervention during an ED visit to address and mitigate elevated social risk. We hypothesized that adolescents with one or more of the following characteristics would have a higher number of reported social risks than adolescents without them: 1) any of nine (9) chief complaints (animal bites, psychiatric complaints, intoxication, ingestion, reproductive or sexual health issues, peer assault, physical abuse, sexual assault/abuse or any complaint triaged at the least acute level), 2) a body mass index (BMI) > 95th percentile, 3) three or more non-urgent visits in the preceding 12 months, OR 4) poor asthma control. This is a secondary analysis of an ongoing randomized trial designed to measure the impact of an ED-based social navigation system on ED recidivism. Adolescents ( ≥13 years of age) seeking care in a large, urban pediatric ED completed a tablet-based survey comprised of questions regarding 13 social domains: literacy, housing, food security, education, access to primary care, mental health, substance abuse, sexual health and behaviors, intimate partner violence (IPV), immigration, human trafficking and legal issues. Items in each domain were derived from previously validated measures when available. The total number of reported social risks was calculated. The Mann Whitney U test was used to compare the median number of social risks between participants identified as high risk (as defined above) and those who did not. Statistical analysis was completed using SAS. In this ongoing study, 226 adolescents have been approached with 92 completed surveys. The mean age is 16.5 (SD 2.0) years and the majority identified as black (75.8%) and female (69.2%). 95.6% of adolescents reported at least one social risk factor; 46.1% reported at least 3 risk factors. The most frequently identified social risk factors were mental health issues (69.6%), safety issues (41.3%), sexual health issues (34.8%), and poor access to primary care (27.7%). The median number of social risk factors was 3 (95% CI 2-5) in patients with a high risk chief complaint, BMI > 95th percentile, more than 3 nonurgent visits in the preceding 12 months or poor asthma control versus 2 (95% CI 1-3) in patients without any of these characteristics (p=0.0014). Many adolescents seeking care in the pediatric ED report high rates of social risk. High risk adolescents had significantly greater numbers of social issues than non-high risk adolescents. Studies assessing optimal implementation of SDH screening and intervention in the pediatric ED are warranted.

Anxiety Screening in the Emergency Department

Background and Hypothesis: &#x0D; Preliminary research completed in the Indiana University Health Methodist Emergency Department (ED) determined that the prevalence of undetected or unaddressed abnormal anxiety levels in patients with low-risk chest pain was greater than 45%. This subset was noted to have abnormal anxiety symptoms that persisted following visits and increased ED recidivism. We hypothesize that the prevalence of abnormal anxiety in the general ED population will be similar to the subset of patients with low-risk chest pain shown previously. &#x0D; Methods: &#x0D; We enrolled a convenience sample of adult patients with non-psychiatric chief complaints who presented to IUH Methodist and Eskenazi Emergency Departments. Participants were assessed for abnormal anxiety levels using the Generalized Anxiety Disorder 7-item Scale (GAD-7) and the Hospital Anxiety Depression Scale (HADS). Subjects will also complete these assessment tools at 30-days post-enrollment via phone or REDCap survey. Data regarding ED disposition, discharge diagnosis, and ED utilization over the previous 12 months and the 30 days post-enrollment will be collected from the electronic medical record (EMR). &#x0D; Results: &#x0D; Over four weeks, 108 patients were screened and 37 gave informed consent and were enrolled. Preliminary analysis shows that 21 subjects (56%) had a GAD-7 score ≥10, indicating abnormal anxiety levels. Full data analysis including comparison of HADS and GAD-7 scores will take place after 50 subjects have been enrolled, completed their 30-day follow-up surveys, and EMR review has taken place. &#x0D; Conclusion: &#x0D; Given data regarding ED visits in patients with low-risk chest pain, identification of anxiety and referral may reduce ED utilization.

Discharging Asthma Patients on 3-Hour β-Agonist Treatments: A Quality Improvement Project.

Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of hospital protocols and national guidelines, little guidance is available regarding appropriate short-acting β-agonist (SABA) frequency discharge criteria. Our aim was to reduce the median length of stay (LOS) for children hospitalized with asthma exacerbations by 4 hours by changing the discharge requirement SABA frequency. Multiple plan-do-study-act cycles based on findings in our key driver diagram were used to decrease LOS. Our primary intervention was reducing the SABA administration frequency discharge requirement from every 4 hours to every 3 hours. After a feasibility pilot, this change was implemented throughout the hospital. Our intervention bundle included updating our evidence-based guidelines, electronic health record order sets and note templates, house-wide education, and a new process for respiratory therapists to notify physicians of discharge readiness. Our primary metric was LOS, with 3-, 7-, and 14-day same-cause emergency department (ED) revisits and hospital readmissions as balancing metrics. Statistical process control charts and nonparametric testing were performed for data analysis. Median hospital LOS was significantly lower in the postintervention period compared with the preintervention period (30.18 vs 36.14 hours respectively; P < .001). Statistical process control charts indicated special cause variation was achieved. No significant differences were observed in rates of ED revisits or hospital readmissions. Reducing the discharge requirement of SABA frequency from every 4 hours to every 3 hours resulted in a reduction in LOS, with no increase in ED recidivism or hospital readmission rates.

Reduced Impact of Diabetes Clinic Referral on High-Frequency Emergency Department Users

The patterns of emergency department (ED) visits in patients with diabetes are not well understood. The Emergency Department Diabetes Rapid-referral Program (EDRP) allows direct booking of ED patients presenting with urgent diabetes needs into a diabetes specialty clinic within 1 day of ED discharge. The objective of this secondary analysis was to examine characteristics of patients with diabetes who have frequent ED visits and determine reasons for revisits. A single-center analysis was conducted comparing patients referred to the EDRP (n = 420) to historical unexposed controls (n = 791). The primary outcome was the proportion of patients in each frequency group of ED revisits (none, 1 to 3 [infrequent], 4 to 10 [frequent], or >10 [superfrequent]) in the year after the ED index visit. Secondary outcomes were hospitalization rates and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses at ED revisits. Superfrequent users, responsible for >20% of total ED visits, made up small but not significantly different proportions of EDRP and control populations, 3.6% and 5.2%, respectively. Superfrequent groups had lower hospital admission rates at ED revisits compared to frequent groups. Mental health disorders (including substance abuse) were the primary, secondary, or tertiary ICD-9 codes in 30.6% (95% confidence interval [CI], 27.7% to 33.5%) and 6.6% (95% CI, 5.1% to 8.2%) in the superfrequent and infrequent groups, respectively. Direct access to diabetes specialty care from the ED is effective in reducing ED recidivism but not amongst a small subgroup of superfrequent ED users. This group was more likely to have mental health disorders recorded at ED revisits, suggesting that more comprehensive approaches are needed for this population. EDRP = Emergency Department Diabetes Rapid-referral Program; ED = emergency department; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases-Ninth Revision.

Real-Time Emergency Department Electronic Notifications Regarding High-Risk Patients: A Systematic Review.

Background: To systematically review evidence on the feasibility and efficacy of real-time electronic notifications about patients at high risk of emergency department (ED) recidivism. Methods: Eight electronic databases were searched for empirical studies of real-time ED-based electronic tools, identifying adult patients at high risk of frequent utilization. Study selection and data extraction were performed independently by two reviewers. Qualitative data synthesis and assessment of strength of evidence were conducted through consensus discussion. Results: Of 2,256 records found through the search, 210 were duplicates, 2,004 were excluded based on abstract review, and 31 were excluded after full text review. The final sample consisted of 10 studies described in 11 articles describing the effect of real-time ED-based electronic notifications for high-risk patients. Three were randomized controlled trials (RCTs). All notifications were based on prespecified markers of risk. Seven studies integrated complex care plans into the electronic health record. Effect on ED use and length of stay (LOS) was mixed: nine studies reported decreased ED use, although results were statistically significant in only three studies; for LOS, one study reported a statistically significant reduction. Impact on cost and financial metrics was promising, with three (of three studies reporting this metric) showing improved organizational financial metrics. Three RCTs reported a reduction in opioid prescriptions. Conclusions: Real-time electronic notifications of ED providers regarding patients at high risk of ED recidivism are feasible. They may help reduce resource utilization and costs. Large knowledge gaps remain regarding patient- and provider-centered outcomes.

Furthering the Value of the Emergency Department Beyond Its Walls: Transitions to the Medical Home for Pediatric Emergency Patients

Transitions of care between providers occur frequently in the emergency department (ED), inviting opportunity for error. The evidence base for improving transitions within the hospital is growing, yet the vast majority of children seen in EDs are discharged home to complete outpatient evaluation and management. The transition of care to the caregiver at home, primary care physician, and specialists that will assume management of the patient offers a critical opportunity to generate value for stakeholders and ensure that their needs are addressed. When reviewing in-hospital transitions, many best practices are identified that may apply to both healthy children and those with complex conditions discharged from the ED. The barriers to performing and the enablers that facilitate strong transitions to the community suggest that there is opportunity to create tools and processes including evolving digital platforms to complete efficient, effective transitions that may reduce ED recidivism.