Emergency Department Resource Utilization Research Articles

Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan.

BackgroundChest pain is one of the most frequent causes of emergency department (ED) visits in high-income countries. Little is known about chest pain patients presenting to EDs of low- and middle-income countries (LMICs). The objective of this study was to describe the characteristics of chest pain patients presenting to emergency departments (EDs) of Pakistan and to determine the utilization of ED resources in the management of chest pain patients and their outcomes.MethodsThis study used pilot active surveillance data from seven major EDs in Pakistan. Data were collected on all patients presenting to the EDs of the participating sites to seek emergency care for chest pain.ResultsA total of 20,435 patients were admitted to the EDs with chest pain. The majority were males (M 60%, F 40%) and the mean age was 42 years (SD+/- 14). The great majority (97%, n = 19,164) of patients were admitted to the EDs of public hospitals compared to private hospitals and only 3% arrived by ambulance. Electrocardiograms (ECGs) were used in more than half of all chest pain patients (55%, n = 10,890) while cardiac enzymes were performed in less than 5% of cases. Chest X-rays were the most frequently performed radiological procedure (21%, n = 4,135); more than half of the admitted chest pain patients were discharged from the EDs and less than 1% died in the ED.ConclusionChest pain is a common presenting complaint in EDs in Pakistan. The majority received an ECG and the use of diagnostic testing, such as cardiac enzymes, is quite uncommon.

Trends in Pediatric Emergency Department Utilization for Mental Health-Related Visits

To describe trends in utilization of pediatric emergency department (PED) resources by patients with mental health concerns over the past 11 [corrected] years at a tertiary care hospital. We conducted a retrospective cohort study of tertiary PED visits from 2002 [corrected] to 2012. All visits with chief complaint or discharge diagnosis related to mental health were included. Variables analyzed included number and acuity of mental health-related visits, length of stay, waiting time, admission rate, and return visits, relative to non-mental health [corrected] PED visits. Descriptive statistics were used to summarize the results. We observed a 47% increase in the number of mental health presentations compared with a 27.5% [corrected] increase in the number of total visits to the PED over the study period. Return visits represented a significant proportion of all mental health-related visits (32.2% [corrected] yearly). The proportion of mental health visits triaged to a high acuity level has decreased whereas the proportion of visits triaged to the mid-acuity level has increased. Length of stay for psychiatric patients was significantly longer than for visits to the PED in general. We also observed a 53.7% [corrected] increase in the number of mental health-related visits resulting in admission. Mental health-related visits represent a significant and growing burden for the emergency department at a tertiary care PED. These results highlight the need to reassess the allocation of health resources to optimize acute management, risk assessment, and linkage to mental health services upon disposition from the PED.

Epidemiological review of scorpion stings in Qatar. The need for regional management guidelines in emergency departments.

Objectives:To review the epidemiology of scorpion sting in Qatar, to explore both the clinical significance, and the role of the emergency department (ED) in the management of such cases.Methods:In this retrospective study, we reviewed the records of all scorpion sting cases presented to the ED of Hamad General Hospital, Doha, Qatar between October 2010 and May 2013.Results:A total of 111 cases of scorpion stings were reviewed, 81 (72.9%) were males and 30 (27.1%) were females, with a mean age of 38 years. Localized pain was the most frequent presenting complaint (89 [80.2%]), whereas localized redness (44 [39.6%]) and swelling (38 [34.2%]) were the most common clinical signs. Abroug’s classification was used, and all cases were found to be class I. All patients received symptomatic treatment and were sent home.Conclusion:Scorpion sting problem in Qatar has a low clinical significance. Data from such studies should be utilized to create more specific (local) management guidelines, which should be more efficient with more rational utilization of ED resources.

Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis

BackgroundEpidemiologic data regarding biphasic reactions in children with anaphylaxis are sparse. ObjectiveTo investigate the incidence and clinical predictors of biphasic reactions in children presenting to the emergency department (ED) with anaphylaxis. MethodsA health records review of ED visits at 2 large Canadian academic pediatric EDs was conducted. All visits that satisfied anaphylaxis diagnostic criteria of the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network were included. Predictors of biphasic reaction were analyzed using univariate and multiple logistic regression analyses. ResultsOf 1,749 ED records reviewed, 484 visits met the study inclusion criteria. Seventy-one patients (14.7%) developed biphasic reactions. The median age was 6 years (interquartile range 2.7–10.1) and 51 (71.8%) were boys. Forty-nine of the 71 (69%) delayed reactions involved respiratory and/or cardiovascular manifestations and 35 (49%) were treated with epinephrine. Five independent predictors for biphasic reactions were found: age 6 to 9 years (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.5–8.58), delay in presentation to the ED longer than 90 minutes after the onset of the initial reaction (OR 2.58, 95% CI 1.47–4.53), wide pulse pressure at triage (OR 2.92, 95% CI 1.69–5.04), treatment of the initial reaction with more than 1 dose of epinephrine (OR 2.7, 95% CI 1.12–6.55), and administration of inhaled β-agonists in the ED (OR 2.39, 95% CI 1.24–4.62). ConclusionBiphasic reactions seem to be associated with the severity of the initial anaphylactic reactions. We identified clinical predictors that could ultimately be used to identify patients who would benefit from prolonged ED monitoring and enable better utilization of ED resources.

Trends in CT Utilization for Pediatric Fall Patients in US Emergency Departments

Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in computed tomography (CT) utilization for pediatric fall victims in the United States from 2001 to 2010. Using the National Hospital Ambulatory Medical Care Survey from 2001 to 2010, we identified all visits of pediatric (aged <18 years) patients presenting to EDs after falls. This database surveys approximately 500 EDs per year for 4 weeks providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. A total of 9763 unweighted observations for a total of 32,432,686 pediatric fall patients were seen in US EDs from 2001 to 2010. The proportion of pediatric fall patients receiving CT increased from 5.3% in 2001 to a peak of 16.6% in 2009 and decreased to 11.3% in 2010, whereas the proportion of pediatric fall patients with life-threatening conditions fluctuated between 1.2% and 3.3% during this period. In multivariate logistic regression analysis, each increasing year was independently associated with CT utilization (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.14-1.16). Patients aged 0-1 years had higher odds of CT utilization than patients aged 13-17 years (OR, 2.27; 95% CI, 2.26-2.27). There was a twofold increase in CT utilization among pediatric fall visits from 2001 to 2010. When controlling for demographic and clinical variables, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among pediatric fall patients.

Rising utilization of CT in adult fall patients.

OBJECTIVE. Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in CT utilization for adult fall patients in the United States from 2001 to 2010. MATERIALS AND METHODS. Using the National Hospital Ambulatory Medical Care Survey, we identified all visits from 2001 to 2010 of adult patients presenting to EDs after falls. This database surveys approximately 500 EDs annually for 4 weeks, providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions (intracranial hemorrhage, organ laceration, axial skeletal fractures) after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. RESULTS. A total of 22,166 unweighted observations representing 73,241,368 visits were identified. The proportion of adult fall patient visits during which CT was performed increased from 11.4% in 2001 to 28.0% in 2010 (p < 0.0001), whereas the proportion of adult fall visits with life-threatening conditions increased from 5.7% to 8.2% (p < 0.0001). On adjusted analysis (adjusting for life-threatening condition and demographic variables), each successive year was independently associated with CT utilization (odds ratio, 1.21 [95% CI, 1.21-1.21]). The odds of CT utilization in 2010 compared with 2001 were 2.62 (95% CI, 2.61-2.62). CONCLUSION. There was a 2.5-fold increase in CT utilization among adult fall patient visits from 2001 to 2010. When demographic and clinical variables were controlled for, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among adult fall patients.

8 High Risk Care Plans Effectively Decrease Emergency Department Resource Utilization

8 High Risk Care Plans Effectively Decrease Emergency Department Resource Utilization

Diagnostic value of S100B protein in the differential diagnosis of acute vertigo in the emergency department.

Vertigo is a common presenting complaint resulting from central or peripheral etiologies. Because central causes may be life-threatening, ascertaining the nature of the vertigo is crucial in the emergency department (ED). With a broad range of potential etiologies, distinguishing central causes from benign peripheral causes is a diagnostic challenge. Cranial magnetic resonance imaging (MRI) is the recommended neuroimaging method when clinical findings are ambiguous. However, MRI scanning for every patient with an uncertain diagnosis may not be efficient or possible. Therefore, to improve ED resource utilization for patients with vertigo, there is a need to identify the subset most likely to have MRI abnormalities. It has previously been shown that S100B protein provides a useful serum marker of stroke, subarachnoid hemorrhage, and traumatic brain injury. This study evaluated whether S100B levels could predict central causes of vertigo as identified by cranial MRI in the ED. This prospective, observational study was conducted with adult patients with acute-onset vertigo (within 6 hours) in the ED of a teaching hospital in Kocaeli, Turkey. Patients with nausea or dizziness complaints without previously known vertigo or cranial pathology, and who agreed to participate in the study, were included. Patients with trauma or with neurologic findings that developed concurrent with their symptoms were excluded. Serum levels of S100B were measured with an electrochemiluminescence immunoassay kit. All subjects underwent cranial MRI. The predictors of positive MRI results were evaluated using logistic regression analysis. Sensitivity and specificity of S100B​ levels for identifying subjects with central causes of vertigo on MRI were calculated with receiver operating characteristic (ROC) curve. Of the 82 subjects included in the study, 48 (58.5%) were female, and the mean (±SD) age was 51 (±16) years. Thirty-one (37.8%) subjects had positive MRI results. Median (with interquartile range [IQR]) serum S100B levels were significantly different between MRI-negative and MRI-positive groups (median = 27.00 pg/mL, IQR = 10.00 to 44.60 vs. median = 60.94 pg/mL, IQR = 38.25 to 77.95, respectively; p = 0.04). In logistic regression analysis, subjective "he or she is spinning" (p = 0.030, odds ratio [OR] = 1.63, 95% confidence interval [CI] = 1.38 to 2.49), systolic blood pressure (sBP; p = 0.045, OR = 1.044, 95% CI = 1.021 to 1.080), and serum S100B level (p = 0.042, OR = 1.22, 95% CI = 1.018 to 1.445) were found to be independent predictors of MRI abnormalities. In the ROC analysis, S100B > 30 pg/mL predicted the clinical outcome with 83.9% sensitivity (95% CI = 66.3% to 94.5%) and 51.0% specificity (95% CI = 36.6% to 65.2%). The area under the ROC curve was 0.774 (95% CI = 0.666 to 0.881). To the best of our knowledge this is the first study assessing the utility of serum S100B levels for diagnosis of acute-onset vertigo. Serum S100B levels are associated with the presence of central causes of vertigo on cranial MRI. However, serum S100B levels are not sufficiently sensitive to exclude candidates from cranial MRI.

Embedding a surgeon in a civilian tactical team reduces resource utilization and is cost effective.

This study evaluates whether embedding a surgeon in a civilian tactical team (Special Weapons and Tactics [SWAT]) reduces resource utilization during training or deployment and is cost effective. Prospective, non-interventional. All tactical police surgeon (TPS) activities (2011-2013) were prospectively captured via databases (Bento and Excel) including days of activity, training and deployment care (team members, suspects, and bystanders), academic activity, costs incurred for equipment and training, as well as costs avoided by onscene care and evaluation. Umbrella activities related to non-SWAT care and system referral were recorded. None. Resource utilization, costs, and outcomes derived from embedding a surgeon in a civilian tactical team. There were 24 days of training and two deployments; 3 days of staff coverage were required. Team members required 18 distinct care episodes; no suspects required care. Bystander care was required twice; both were treated on-scene avoiding transport and hospital care. Non-SWAT care occurred 36 times. No complications occurred except for one urinary track infection. Comorbid medical condition evaluation and management advice in non-SWAT officers, spouses, or significant others occurred 24 times. New health system referral occurred 26 times. Total TPS equipment charges ($6,000) were offset by reduced scene transport ($3,000) and hospital care ($4,000), as well as reduced team member hospital care ($9,000) leading to a net Police Department (PD) charge surplus of (+)$9,000. New referral initial evaluation ($10,400) and operative charges ($30,800) were balanced against lost work ($6,500/d × 3d = $21,500) for a net health system charge surplus of (+)$19,700. One international presentation, three local presentations, and four peer-reviewed and five lay press publications accrued from these activities. A TPS reduces scene and Emergency Department resource utilization and increases new patient health system entry. Establishing a TPS is cost effective for a PD and an academic health system and supports academic productivity but may not be supportable without nonclinical days.

The Utility of S100 B Protein in the Differential Diagnosis of Vertigo in the Emergency Department

Vertigo is a common presenting complaint resulting from central or peripheral etiologies. Because central causes may be life-threatening, ascertaining the nature of the vertigo is crucial in the emergency department (ED). In this broad range of potential etiologies, distinguishing central causes from those benign peripheral causes is a diagnostic challenge for emergency physicians. There is limited knowledge to guide the emergency physician for risk stratification in this wide diagnostic range. Cranial magnetic resonance imaging (MRI) is the suggested neuroimaging method when clinical findings are ambiguous. However, MRI is not readily available in many EDs. Yet, in busy EDs, MRI scanning for each patient with uncertainty in diagnosis may not be efficient in terms of time and cost-effectiveness. Therefore, to improve ED resource utilization in this subset of patients with vertigo, identifying candidates for MRI is important. S100B protein has been shown to be a useful neurobiochemical marker of stroke, subarachnoid hemorrhage, and traumatic brain injury. This study was conducted to evaluate the value of S100B levels for safely discriminating vertigo etiologies to support neuroimaging decisions in EDs.

768

Introduction: In patients with sickle cell disease (SCD), sickle cell crisis (SCC) is a frequent cause of emergency department (ED) visit. Acute chest syndrome (ACS) is a known complication in patients with SCD and is a major cause of morbidity and mortality. Outcome data are limited to single center studies and there is a paucity of data regarding ED visits and resource utilization for patients with SCC and ACS. Methods: We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS) for the years 2008 to 2010. The NEDS is a part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. All children (aged <=21 years) visiting hospital based EDs with a diagnosis of sickle cell crisis (ICD-9-CM codes of 282.42, 282.62, 282.64, and 282.69) were selected. Occurrence of acute chest syndrome (ICD-9-CM code of 517.3) was estimated for these ED visits. Characteristics examined included age, gender, and type of sickle cell disease leading to crisis. Outcomes examined included disposition information following ED visit, hospital ED charges, and hospital mortality. Results: During the study period, there were a total of 149,472 ED visits for sickle cell crisis. The mean age of these patients was 14.6 years. Males comprised 49.3% of all ED visits. Close to 90.7% of all ED visits had Hb-SS disease with crisis, 3.3% had sickle-cell thalassemia with crisis, and 2.5% had sickle-cell/HB-C disease with crisis. About 3.6% had other sickle-cell disease with crisis. Close to 6.6% had acute chest syndrome. Medicaid was the major payer covering 62.2% of all ED visits. Twenty-six patients died in the ED while 116 died following admission as inpatients into the same hospital. Following ED visit, 42.3% were discharged routinely, 53.9% were admitted as inpatients into the same hospital, and 2.5% were transferred to another short-term hospital. The mean ED charge (inflation adjusted to year 2010) per visit was $2,162 and the total ED charges across the entire United States was $276.7 million. Conclusions: In this large retrospective nationwide emergency department study, sickle cell crisis was a frequent cause of emergency department visits in children with sickle cell disease. Acute chest syndrome is not an uncommon complication and is associated with significant utilization of hospital resources.

High Resource Utilizers From The Multicenter Compact Study Of Complications In Patients With Sickle Cell Disease and Utilization Of Iron Chelation Therapy

IntroductionWhile treating patients (pts) with sickle cell disease (SCD) can be costly, costs are not evenly distributed across pts; rather, a minority of pts accounts for a majority of costs. Identifying those pts who consume a disproportionately large share of healthcare resources can assist payers and providers in directing appropriate and targeted interventions to deliver better pt care with lower costs. The objective of this study was to understand characteristics of pts who have increased utilization of inpatient (IP) and emergency department (ED) resources in a population of SCD pts ≥16 years old. MethodMedical records of 254 SCD pts ≥16 years old were retrospectively reviewed between 8/2011 and 7/2012 at three US tertiary care centers. The high utilization threshold was derived from the literature and defined as pts with ≥ 5 days of IP+ED care (assuming 1 day/ED visit) for SCD-related complications per year (high utilizer group). Pts were also classified into cohorts based on cumulative blood transfusion units and use iron chelation therapy (ICT): <15 units, no ICT (Cohort 1 [C1]), ≥15 units, no ICT (Cohort 2 [C2]), and ≥15 units, with ICT (Cohort 3 [C3]). SCD complication rates were expressed as the number of SCD complications per pt per year (PPPY); rate ratios (RRs) were used for cohort comparisons. A logistic regression was used to identify risk factors associated with high utilization of IP+ED care. ResultsOf the 254 pts (C1: 69, C2: 91, C3: 94), 30% (n =76) were classified as high utilizers (C1: 14 [18.4%], C2: 37 [48.7%], C3: 25 [32.9%]). Patients in the high utilizer group were younger (median [range] (21 years old [16-65], vs. 23 years old [16-59]) and had shorter follow-up (4.2 years [0.6-23.9], vs. 5.4 years [0.5-33.3]) compared to the rest of the sample. Those in the high utilizer group accounted for 68% of all SCD-related complications and over 88% of all IP+ED days for treatment of these complications. Similar to the rest of the sample, pain (81%) and infection (7%) were the two key complications seen in this high utilizer group. The rate of IP +ED days was significantly higher among the high utilizer group with 16.63 [16.28-16.99] IP+ED days PPPY compared to 0.89 [0.84-0.94] PPPY for other pts. Similarly, the high utilizer group had 4.58 [95% CI: 4.39-4.76] IP+ED visits PPPY, compared to 0.34 [0.31-0.37] visits PPPY for other pts (Table). Among regularly transfused pts (C2+C3) in the high utilizer group, those who received ICT had lower rates of IP+ED visits (C2 vs. C3 rate ratio [RR] [95% CI]: 1.31[1.20-1.44]), IP+ED days (C2 vs. C3 RR: 1.30 [1.24-1.36]), and readmission to IP+ED settings within 30 days (1.70 [1.49-1.93]) compared with those who did not (Table). History of infections (odds ratio: 7.45, p<0.0001) was associated with an increased risk of high utilization of IP+ED care. [Display omitted] ConclusionResults from this study show that a relatively small fraction of SCD pts account for the majority of IP+ED visits. Moreover, among regularly transfused pts identified as high utilizers, those who received ICT had lower rates of IP+ED utilization than those who did not. Pts receiving ICT may also receive closer monitoring, which may help with early identification and intervention to delay or prevent the development of complications and improve outcomes. Closer management of pts with SCD, especially those at risk of becoming high utilizers, is critical to lowering IP+ED utilization and reducing the overall costs of care. Disclosures:Jordan:Novartis Pharmaceuticals Corporation: Consultancy. Adams-Graves:Analysis Group, Inc.: Research Funding. Kanter-Washko:Analysis Group, Inc.: Research Funding. Oneal:Novartis Pharmaceuticals Corporation: Honoraria; Analysis Group, Inc.: Research Funding. Sasane:Novartis Pharmaceuticals: Employment. Vekeman:Novartis Pharmaceuticals: Research Funding. Bieri:Novartis Pharmaceuticals Corporation: Research Funding. Marcellari:Novartis Pharmaceuticals Corporation: Employment. Magestro:Novartis Pharmaceuticals: Employment. Adams:Novartis Pharmaceuticals Corporation: Research Funding. Duh:Novartis Pharmaceuticals: Research Funding.

How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

IntroductionThe use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as “low-acuity” by initial EMS protocols. MethodsRecords of all pediatric patients classified as “low acuity” and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. “Under-triage” was defined as a “low-acuity” EMS transport subsequently requiring emergent interventions. ResultsOf the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization. DiscussionWhile this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.

Emergency department (ED) utilization by HIV‐infected ED patients in the United States in 2009 and 2010 – a national estimation

The aim of the study was to describe the emergency department (ED) resource utilization patterns of ED visits by patients reported to be HIV-infected in the USA in 2009 and 2010 and to compare them with those of the general ED patient population. We identified demographics, HIV infection status, and ED utilization patterns in 2009 and 2010 from a weighted sample of US ED visits using the National Hospital Ambulatory Medical Care Survey, a nationally representative survey. Data on visits by patients aged ≥ 13 years were analysed using procedures for multiple-stage survey data. In 2009 and 2010, 1 192 535 visits were documented for HIV-infected patients. The estimated annual ED visit rates were 633 per 1000 known HIV-infected persons and 438 per 1000 non-HIV-infected persons [rate difference 195; 95% confidence interval (CI) 194, 197]. While no difference was recorded in the level of acuity between HIV-infected ED patients and general ED patients, the total number of diagnostic/screening services ordered and medications administered in the ED was significantly higher for visits by HIV-infected patients. HIV-infected patients making ED visits also had a longer duration of stays [mean 5.4 h (95% CI 4.6, 6.2 h) vs. 3.6 h (95% CI 3.5, 3.8 h) for HIV-uninfected patients] and were more likely to be admitted [28% (95% CI 22, 34%) vs. 15% (95% CI 14, 16%), respectively] than their non-HIV-infected counterparts. ED visits by HIV-infected individuals occur at rates higher than those of visits by the general population, and consume significantly more ED resources than visits by the general population. These national findings represent baseline prior to full implementation of the 2010 Patient Protection and Affordable Care Act.

The use of a fully integrated electronic medical record to minimize cumulative lifetime radiation exposure from CT scanning to detect urinary tract calculi

In order to determine the effects of implementation of an electronic medical record on rates of repeat computed tomography (CT) scanning in the emergency department (ED) setting, we analyzed the utilization of CT of the kidneys, ureters, and bladder (CT KUB) for the detection of urinary tract calculi for periods before and after the implementation of a hospital-wide electronic medical record system. Rates of repeat CT scanning within a 6-month period of previous scan were determined pre- and post-implementation and compared. Prior to implementation, there was a 6-month repeat rate of 6.2 % compared with the post-implementation period, which was associated with a 6-month repeat rate of 4.1 %. Statistical analysis using a two-sample, one-tailed t test for difference of means was associated with a p value of 0.00007. This indicates that the implementation of the electronic medical record system was associated with a 34 % decrease in 6-month repeat CT KUB scans. We conclude that the use of an electronic medical record can be associated with a decrease in utilization of unnecessary repeat CT imaging, leading to decreased cumulative lifetime risk for cancer in these patients and more efficient utilization of ED and radiologic resources.

Magnitude of national ED visits and resource utilization by the uninsured

BackgroundFor nearly 51 million persons in the United States who lack health care insurance, the emergency department (ED) functions as a safety net where no patient is denied care based on ability to pay, and much public rhetoric has characterized ED utilization by uninsured patients. We estimated national ED utilization by uninsured patients and compared uninsured and insured ED patients in terms of demographics, diagnostic testing, disposition and final diagnoses. MethodsWe analyzed data from the National Hospital Ambulatory Medical Care Survey (2006-2009) stratified by insurance status. Demographic data, diagnoses, testing, and procedures performed in the ED were tabulated for each visit. Weighted percentages provided by National Hospital Ambulatory Medical Care Survey were used to estimate national rates for each variable, and multivariate models were constructed for predicting testing, procedures, and admission. ResultsThe 135085 ED visits represent 475 million patients visits, of which 78.9 million (16.6%) were uninsured. Compared with insured patients, uninsured patients were more often male (51.1% vs 44.3%) and younger (age 18-44 years, 66.2% vs 35.4%). Uninsured patients had lower rates of circulatory/cardiovascular (7.5% vs 4.1%) and respiratory diagnoses (14.6% vs 11.8%). Uninsured patients had fewer diagnostic tests and procedures and fewer hospital admissions than those with insurance. In our multivariate models, insurance status was predictive of testing and procedures but not hospital admission. ConclusionsUninsured patients account for approximately 20 million or 1 in 6 ED visits annually in the United States and have differences in demographics, diagnoses, and ED utilization patterns from those with insurance.

Interfacility Transfers of Noncritically Ill Children to Academic Pediatric Emergency Departments

We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours. We conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours. Overall, 24,905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions. A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

Emergency Department Use by Nursing Home Residents: Effect of Severity of Cognitive Impairment

To examine the 1-year prevalence and risk of emergency department (ED) use and ambulatory care-sensitive (ACS) ED use by nursing home (NH) residents with different levels of severity of cognitive impairment (CI). We used multinomial logistic regression to estimate the effect of CI severity on the odds of any ED visit and any ACS ED visit in a 2006 national random sample of NH residents, controlling for predisposing, enabling, and need characteristics. Of 132,753 NH residents, 62% had at least one ED visit and approximately 24% had at least one ACS ED visit in 2006. The probability of any ED visit or any ACS ED visit varied with the severity of resident CI. Residents with mild CI had up to 15% higher odds of any ED or any ACS ED visit and those with more moderate CI had 9% higher odds of an ACS ED visit compared with those without CI. The probability of any ED visit was negatively associated with advanced dementia (adjusted odds ratio = 0.60; 95% CI = 0.55-0.65). Earlier identification of persons with mild CI may facilitate patient, family, and staff education, as well as advanced care planning to reduce ACS ED visits. Both ACS ED use and hospitalizations, adjusted for case mix, should be used as quality indicators to help ensure greater accountability for high-quality NH care and more appropriate utilization of ED resources.

Emergency Department Visits by Nursing Home Residents in the United States

To characterize emergency department (ED) use by nursing home residents in the United States. Analysis of the National Hospital Ambulatory Medical Care Survey. U.S. EDs from 2005 to 2008. Individuals visiting U.S. EDs stratified according to nursing home residency. All ED visits by nursing home residents were identified. The demographic and clinical characteristics and ED resource utilization, length of stay, and outcomes of nursing home residents and nonresidents were compared. During 2005 to 2008, nursing home residents accounted for 9,104,735 of 475,077,828 U.S. ED visits (1.9%; 95% confidence interval (CI)=1.8-2.1%). The annualized number of ED visits by nursing home residents was 2,276,184. Most nursing home residents were older (mean age 76.7, 95% CI=75.8-77.5), female (63.3%), and non-Hispanic white (74.8%). Nursing home residents were more likely to have been discharged from the hospital in the prior 7days (adjusted odds ratio (aOR=1.4, 95% CI=1.1-1.9), to present with fever (aOR=1.9, 95% CI=1.5-2.4) or hypotension (systolic blood pressure≤90mmHg, aOR=1.8, 95% CI=1.5-2.2), and to receive diagnostic tests (OR=1.9, 95% CI=1.6-2.2), imaging (OR=1.5, 95% CI=1.3-1.7), or procedures (OR=1.6, 95% CI=1.4-1.7) in the ED. Almost half of nursing home residents visiting the ED were admitted to the hospital. Nursing home residents were more likely to be admitted to the hospital (aOR=1.8, 95% CI=1.6-2.0) and to die (aOR=2.3, 95% CI=1.6-3.3). Nursing home residents account for more than 2.2 million ED visits annually in the United States. Nursing home residents have greater medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the United States.

396 Resource Utilization in the Emergency Department of a Tertiary Care University-Based Hospital in Tokyo Before and After the Sendai Earthquake and Tsunami

396 Resource Utilization in the Emergency Department of a Tertiary Care University-Based Hospital in Tokyo Before and After the Sendai Earthquake and Tsunami