Emergency Department Return Rates Research Articles

Variability in Practice of Buprenorphine Treatment by Emergency Department Operational Characteristics.

We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics. We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates. There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020-May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment. Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.

Development of an Emergency Department Case Management Case-Finding Tool.

Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs). Emergency departments with case management availability and staffing. A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS. The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success. The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study

BackgroundPatients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team....

1112. Evaluating the Effects of Casirivimab-Imdevimab in Mild-to-Moderate COVID-19 Disease: A Matched Cohort Study

Abstract Background In November 2020, the FDA issued an Emergency Use Authorization (EUA) for casirivimab-imdevimab (CAS-IMD) for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in certain high-risk patients. CAS-IMD is a monoclonal antibody cocktail that binds to COVID-19 spike protein receptor. Delta was the predominant strain in the US at the time. The purpose of this study is to evaluate if CAS-IMD administration to COVID-19 patients in the emergency department (ED) resulted in fewer hospitalizations and re-admissions. Methods A retrospective chart review was conducted at Cleveland Clinic Martin Health which is composed of 3 hospitals and 1 free-standing ED. Patients with COVID-19 who met criteria for CAS-IMD in the ED from June 2021 to December 2021 were randomized into those who received CAS-IMD and those who did not. Patients were excluded if they had COVID-19 symptoms for >10 days or met EUA exclusion criteria for CAS-IMD. Cases and controls were matched by propensity score which was calculated by a logistic regression model including age, body mass index (BMI), sex, race and comorbidities. The primary outcome was the percentage of patients discharged from the ED who were hospitalized for COVID-19-related symptoms within 30 days. Secondary outcomes included number of CAS-IMD infusion-related reactions, ED return rate and subset analyses of severity of illness in the hospitalized. Statistical analyses were performed using two-sample t test or Wilcoxon rank sum test for continuous variables based on distribution, and Chi-square test or Fisher’s exact test for categorical variables. Conditional logistic regression was used to compare the odds of hospitalization between groups. Results Patients (N = 176) were matched 1:1 in each group. Eleven (12.5%) of the case group were hospitalized within 30 days of ED discharge vs. 36 (40.9%) in the control group. The odds of hospitalization in the CAS-IMD group were 81% lower than the control group (OR 0.19, 95% CI: 0.081-0.46, p< 0.001). After adjustment of covariates, the adjusted odds ratio remained significant (OR 0.12, 95% CI: 0.025-0.57, p=0.008). Conclusion CAS-IMD use for mild-to-moderate COVID-19 infection in ED patients was associated with a lower incidence of hospitalization. Disclosures All Authors: No reported disclosures.

The impact of follow-up calls after a pediatric emergency department visit

Pediatric emergency department (ED) visits can be a stressful time for patients and their caregivers. This high stress environment can lead to questions and needed clarifications post-discharge. We implemented a post-discharge callback system to resolve these concerns for a focused subset of patients who historically have provided the most negative comment feedback on ED patient experience surveys. We hypothesized that comment types would shift to more positive than negative and the themes of the comments received would change. We developed a discharge callback process that focused on patients who were triaged as ESI level 4 during their emergency department visit. Over a 6-week period, patients were called the day after discharge and asked if they had questions regarding their recent ED visit in addition to questions regarding current health, post-discharge instructions, prescriptions, or follow-up instructions if applicable. A maximum of 3 discharge calls were made if needed in order to contact the patient or family. Any questions regarding health care needs were followed up by a licensed healthcare provider within 24 hours with a maximum of 3 attempts. At the end of the project timeframe we analyzed comments received from our patient experience surveys to identify if there was a shift in comment types and their themes. In addition, we analyzed ED return rates within 72 hours of discharge. During the 6-week period, 2710 calls were made to contact 1618 patients’ caregivers. Follow up was requested by 149 families with a healthcare provider. There was no significant change in the number of comment types received. Thematic analysis of the patient experience survey comments received during this time period, revealed a reduction in questions regarding the recent ED visit and post discharge needs. There was no significant change in 72-hour ED return rates. The institution of an ED discharge callback system can effectively reduce patients’ and families’ questions regarding post-discharge care by providing an opportunity to clarify care after they have left the emergency department.

Evaluation of the BEAT Meth Intervention for Emergency Department Patients with Methamphetamine Psychosis.

Methamphetamine is the second leading cause of overdose death in America and a leading cause of emergency department (ED) visits. Methamphetamine-induced psychosis is a dangerous and difficult-to-treat consequence of methamphetamine use. We describe the pilot implementation and outcomes of a multimodal treatment intervention for ED patients with methamphetamine psychosis, Beginning Early and Assertive Treatment for Methamphetamine Psychosis (BEAT Meth). BEAT Meth was implemented in an urban safety net health system. The protocol includes early identification and treatment of methamphetamine psychosis, a protocolized hospitalization, and support for transitioning patients to specialty addiction treatment. Patients receiving BEAT Meth were compared with ED patients with methamphetamine psychosis who were discharged. Implementation fidelity was measured to assess feasibility. BEAT Meth patients were nearly 3 times more likely to attend an outpatient specialty addiction appointment in the 30 days after discharge than comparison patients (32% vs 11%, P < 0.01). Subsequent ED utilization was common among all patients, and there was no significant difference in 30-day ED return rates between BEAT Meth and comparison patients (28% vs 37%, P = 0.10). Exploratory analyses suggested that increased attendance at outpatient treatment reduced ED utilization. BEAT Meth is an intervention framework to support identification, management, and treatment engagement of ED patients with methamphetamine psychosis. Treatment strategies like BEAT Meth are necessary to manage the unique challenges of methamphetamine addiction. These findings will guide clinical care, program development, and research.

30-Day Morbidity and Bleeding Rates Associated with Transoral Robotic Surgery for HPV Associated Oropharyngeal Squamous Cell Carcinoma: A Retrospective Analysis of Two Prospective Adjuvant Radiotherapy Deescalation Trials (MC1273 & MC1675)

<h3>Purpose/Objective(s)</h3> MC1273 and MC1675 were phase II and III clinical trials examining deescalated adjuvant chemoradiation after margin negative resection for HPV(+)OPSCC. We examine 30-day morbidity and mortality associated with primary transoral robotic (TORS) surgical resection in patients enrolled in these trials. We hypothesize that TORS was associated with low surgical morbidity. <h3>Materials/Methods</h3> Enrollment criteria and the DART regimen utilized in MC1273/MC1675 have been reported. Patients were accrued from 2013-2020. For this analysis, patients undergoing any TORS procedure were included. Prospective study data and retrospective chart review were utilized to identify events. The severity of postoperative transoral bleeding was graded using the Hinni transoral surgery bleeding scale (Grade 0 – none, Grade 1: expected postoperative blood-tinged mucous, Grade 2: resolved without operative intervention, Grade 3: venous bleed requiring cautery, Grade 4: arterial bleed requiring ligation or embolization, Grade 5: life-threatening bleed, Grade 6: death). Continuous variables using mean (SD) and categorical variables were summarized using frequency (%). <h3>Results</h3> 218 patients were included in this retrospective analysis. The mean (SD) age of the cohort was 58.9 (8.2), and 193 (88%) were male. The majority (n=146, 67%) were never smokers. TNM 8^th Edition AJCC staging for patients was as follows: pT1: 80 (37%), pT2: 108 (50%), pT3: 24 (11%), pT4: 6 (3%), pN0: 1 (<1%), pN1: 186 (85%), pN2: 31 (14%). All patients had negative margins, underwent concurrent neck dissection, and the majority (n=196, 90%) had prophylactic ligation of external carotid artery branches in the ipsilateral neck. The mean (SD) length of hospital stay was 3 (4) days. A total of 7 (3.2%) patients required tracheostomy placement at the time of surgery, and all were decannulated within 26 (median: 5, range: 2-26) days of surgery. NGT placement occurred in 98 (45%) patients, with 92% (n=90) removed within 30 days of surgery. Two (1%) patients underwent PEG placement prior to or within 30 days of surgery. There were 32 (15%) returns to the emergency department (ED) within 30 days. 10 (5%) patients required readmission. 7 (3.2%) patients experienced ≥ Grade 3 bleeding (Grade 3: 6; Grade 4: 1), with no Grade 5/6 bleeds. Other postoperative complications included 1 cardiac event (0.5%), 5 chyle leaks (2.3%), 1 pulmonary embolus (0.5%), 1 deep venous thrombosis (0.5%), 2 surgical site infections (0.9%), 1 seroma (0.5%), and 2 hematomas (0.9%). There were no treatment related deaths. <h3>Conclusion</h3> TORS for HPV(+)OPSCC in carefully selected patients undergoing a deescalation protocol at a high volume center was associated with low morbidity and zero mortality. ED return rates of 15%, readmission rates of 5%, and intervention rates of 3% for postoperative bleeds are all comparable to rates after routine pediatric tonsillectomy.

The Safe Discharge Checklist: A Standardized Discharge Planning Curriculum for Medicine Trainees.

Hospital discharge is a challenging time for residents, requiring the completion of many tasks to ensure safe transitions for patients. Despite recognition of the importance of hospital discharge planning, formal curricula are lacking. We sought to improve medicine residents' comfort and skills with discharge planning and enhance the quality of care by introducing a standardized approach to discharge on the medicine wards. The intervention included a didactic, a bedside rounds component, and a discharge checklist. Interns were surveyed at the end of rotations to measure confidence, attitudes, and frequency of completing discharge planning tasks. Results were compared with a control group of experienced interns from the previous academic year. Clinical outcomes included hospital readmission and emergency department return rates and patient satisfaction scores in discharge-related domains. Study interns reported similar confidence to control group interns with discharge planning and endorsed completing four of five discharge tasks more frequently than control interns. There were no differences in clinical outcomes. We did not identify changes in clinical outcomes, although this finding likely reflects the multifactorial nature of hospital readmissions. Interns exposed to the curriculum early in the academic year had a higher reported frequency of completing key discharge tasks and similar confidence around discharge, when compared with end-of-the-year interns. These improvements suggest that the curriculum led to a change in culture surrounding discharge planning and perhaps accelerated learning of skills associated with discharge best practices.

Outcomes of Patients Placed in an Emergency Department Observation Unit of a Comprehensive Cancer Center.

PURPOSE:Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes.METHODS:We performed a retrospective observational study that included all patients age 18 years and older who presented to our emergency department (ED) and were placed in the EDOU between March 1, 2019, and February 29, 2020. The patients' electronic medical records were queried for demographics, comorbidities, diagnosis at the time of placement in the EDOU, length of stay, disposition from the EDOU, ED return within 72 hours after discharge from the EDOU, and mortality outcomes at 14 and 30 days.RESULTS:A total of 2,461 visits were eligible for analysis. Cancer-related pain was the main reason for observation in more than one quarter of the visits. The median length of stay in the EDOU was approximately 23 hours, and 69.6% of the patients were discharged. The ED return rate for unscheduled visits at 72 hours was 1.9%. The 14- and 30-day mortality rates were significantly higher for patients who were admitted than for those who were discharged (14 days: 1.7% v 0.3%, P < .001; 30 days: 5.9% v 1.8%, P < .001).CONCLUSION:Our data suggest that placing patients with cancer in EDOUs is safe, reduces admissions, and reserves hospital resources for patients who can receive the most benefit without compromising care.

Exploring differential response to an emergency department-based care transition intervention.

To identify multivariable subgroups of patients with differential responses to a nurse-delivered care transition intervention after an emergency department (ED) visit in a randomized controlled trial (RCT) using an emerging data-driven method. Secondary analysis of RCT. 512 individuals enrolled in an RCT of a nurse-delivered care transition intervention after an ED visit. All 512 participants were included in a pre-specified subgroup analysis, and 451 of these had sufficient complete case data to be included in a model-based recursive (MoB) partitioning analysis. The primary outcome was having at least one ED visit in 30 days after the index ED visit. Two analytical methods explored heterogeneity of treatment effects: data driven model-based recursive partitioning (MoB) using 37 candidate baseline variables, and a contextual point of comparison with prespecified subgroups defined by ED super-user status (≥ 3 ED visits in previous 6 months or not), sex (male/female), and age, individually examined via treatment arm by subgroup interaction terms in logistic regression models. Internal validation of the MoB analysis via bootstrap resampling with an optimism corrected c-statistic was conducted to provide a bias-corrected estimate. MoB detected treatment effect heterogeneity in a single subgroup, marital status. Unmarried patients randomized to the intervention had a repeat ED use rate of 22% compared to 34% in the usual care group; married patients randomized to the intervention had a 27% ED return rate compared to 12% in the usual care group. Internal validation demonstrated an optimism corrected c-statistic of 0.54. No treatment-by-covariate subgroup interactions were identified among the 3 prespecified subgroups. Although exploratory, the results of the MoB analysis suggest that patient factors related to social relationships such as marital status may be important contributors to differential response to a care transition intervention after an ED visit. These were characteristics that the investigators had not anticipated or planned to examine in the individual prespecified subgroup analysis. Data-driven methods can yield unexpected findings and contribute to a more complete understanding of differential treatment effects in subgroup analysis, which can inform further work on development of effective care transition interventions in the ED setting.

Regional needs assessment for emergency physician audit and feedback.

Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region. We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups. A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners. This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

MP27-20 CAN A SIMPLE PHONE CALL IMPROVE POST-URETEROSCOPY OUTCOMES IN PATIENTS WITH PSYCHIATRIC DISEASE? 6.3.6

INTRODUCTION AND OBJECTIVE: A recent publication from our institution demonstrated that among the 12.6% of patients that return to the emergency department (ED) within 30 days of ureteroscopy (URS) for stone disease, approximately 60% have a history of psychiatric disease (PD). Small-scale quality improvement studies have suggested that postoperative nursing telephone calls reduce unplanned care encounters after URS for all patients. We sought to determine if a postoperative phone call by a urology nurse targeted to this high-risk group would reduce the rate of post-URS ED returns. METHODS: PD was defined as having a DSM-5 psychiatric diagnosis, a prescription for a psychoactive medication, or documentation by a clinician regarding the diagnosis and management of either. Our cohort was identified by prospectively screening the medical record of all patients undergoing URS for stone disease between August 2018 and August 2019. Patients with a history of chronic pain syndromes or substance abuse were excluded. Patients who met inclusion criteria were called by urology triage nurses between postoperative days 1-4. Nurses reviewed a standardized script with the patient and then used a templated form to document information regarding symptomatology and medication usage. Information regarding ED presentation was obtained by chart review, and outcomes were compared with our previously published retrospective population. RESULTS: At 12-months follow-up, 42% of 360 patients undergoing URS were identified as having PD. The overall 30-day ED return rate following URS for stone disease was 10.8%, and 56% of the patients who returned had PD. PD patients had an ED return rate of 14.4% (previously 16.7%), and 56% of these visits resulted in admission (previously 36%). The proportion of PD patients returning to the ED with a chief complaint of pain was 32%, whereas previously it was 46%. CONCLUSIONS: PD is a risk factor for post-op ED presentation and is prevalent in patients undergoing URS. Our findings demonstrate that phone calls targeted to these patients may lead to a reduction in 30-day ED returns for reasons that do not require admission, such as pain. Compared with our published retrospective data, the findings of this study reflected an overall reduction in ED returns for PD patients following initiation of postoperative phone calls. Source of Funding: NA

Use of a telehealth follow-up system to facilitate treatment and discharge of emergency department patients with severe cellulitis.

Novel long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with cellulitis who require intravenous antibiotics. Telehealth systems have shown success in remote management of dermatologic conditions; we implemented a telehealth follow-up program for patients diagnosed with cellulitis in the ED, treated with single-dose dalbavancin, and discharged. This was a prospective, multi-center observational study. Patients were included based on clinical criteria and ability to complete follow-up using a smartphone and enroll in an online care portal. We examined the rate of successful telehealth follow-up at 24- and 72-hour intervals from discharge. We also examined the ED return rate within 14days, reviewed any visits to determine cause of return, and for admission. 55 patients were enrolled. 54/55 patients completed at least one telehealth follow up encounter (98.2%). 13 patients (23.6%) had a return ED visit within 14days; no patients required admission for worsening cellulitis. Patient engagement in the telehealth program decreased over time; there was an approximately 11% decrease in engagement between the 24 and 72-hour follow-up call, and a 15% decrease in engagement between the 24 and 72-hour image upload. Patients over 65 had a lower rate of image upload (31%) than younger patients (80.6%). A telehealth follow-up system for discharged emergency department patients with cellulitis demonstrated high rates of engagement. In these patients who -may have otherwise required admission for intravenous antibiotics, telehealth-facilitated outpatient management resulted in a low ED return rate and no inpatient admissions for cellulitis.

Case Management Featuring Community Health Workers Reduces Inpatient Health Care Utilization in Adults with Sickle Cell Disease

Background: Hospital readmission rates and acute care utilization among adults with sickle cell disease (SCD) are almost twice the rates of children. Adult patients may have complex medical and psychosocial needs that are not adequately addressed in fragmented healthcare systems. Few systems have implemented evidence-based, comprehensive care for SCD adults, shown to improve both medical and psychosocial outcomes in chronic diseases. Case management (CM) and community health workers (CHWs) are two evidence-based health management strategies that can help reduce health risks, reduce readmission rates, and improve patient-provider relationships. Methods: After years of attempting adult SCD CM with two MDs and one advanced practice provider (APP), Virginia Commonwealth University Medical Center (VCU) built upon a pilot study of CM and CHWs and implemented a multi-disciplinary Adult Sickle Cell Medical Home that assigned one of two CHWs for CM of the 50 highest SCD adult utilizers ranked by calendar year (CY) 2017 VCU charges, then by CY 2017 inpatient days. CHWs followed patients in and out of the hospital, and met with them at home. They were joined by a social worker who provided CM and behavioral therapy, an additional APP, and a project manager. This team met weekly. Medical Home leaders and quality improvement (QI) specialists enlisted other periodic caregivers to form QI teams with Medical Home workers focusing on behavioral health, ambulatory management, inpatient management, and emergency department (ED) management. A prior authorization specialist handled administrative access to opioids. Evaluation compared utilization during CY 2017 (pre-intervention) versus CY 2018 (intervention). For all patients we compared the average 30-day readmission rate, the average length of stay (ALOS), the average 3-Day ED return rate, the number of ED discharges, the numbers of inpatient days, inpatient discharges, and outpatient visits, the number of patients who used the ED, and total VCU charges. For the 50 highest utilizers, we compared the 30-day readmission rate, ALOS, total inpatient days and total VCU charges. VCU had no ambulatory SCD infusion unit, and the VCU ED did not have a special SCD rapid triage protocol. There was no control group. Analysis consisted of chi square and paired and unpaired t-tests. Results: Among 567 SCD adults (Table), including 231 males and 336 females, ages 18 - 80, comparing pre-intervention to intervention, average utilization and VCU charges were either numerically or statistically significantly reduced, with the exception of outpatient visits, which remained flat. For the 50 highest utilizers, mean 30-day readmission rates were flat (45.98% vs 44.35%, p=0.7257), ALOS was significantly reduced (6.1 days vs 4.8 days, p&lt;0.0001), inpatient days were reduced (206 days vs 106 days), and total charges were significantly reduced (25.43%, $5,297,323.73 vs $3,950,267.26, p=0.0037). Conclusions: At VCU, a multi-disciplinary Adult Sickle Cell Medical Home that featured intensive CM and CHWs, but no infusion center or rapid ED triage, reduced annual utilization for adult SCD patients. CM program elements that were most effective should be studied in the future. A randomized controlled trial of CM and CHWs would strengthen evidence of their efficacy in improving utilization. Table. Disclosures Smith: Novartis: Consultancy, Honoraria. Lipato:Novartis: Honoraria. Roberts:Truven Health Analytics: Consultancy; Community Health Network of Connecticut: Consultancy.

P069: Does specialist referral influence emergency department return rate for patients with renal colic? A retrospective cohort study

Introduction: Renal colic is a common presentation which exerts a significant burden on healthcare infrastructure. A significant proportion of patients managed with observation may return to the Emergency Department (ED) prior to spontaneous passage due to inadequate analgesia. It is unclear whether early urologist consultation would limit the burden of renal stones by reducing returns to the ED. We wished to determine whether urologist referral from the ED department is associated with fewer returns to the ED with renal colic. Methods: We conducted a retrospective chart review using RECORD methodology of consecutive patients diagnosed with CT-confirmed, ureteric or renal calculi in our ED over a two-year period. Disposition was categorized as either hospital admission, outpatient urologist referral, follow up with primary care, or no follow up. The primary outcome was the 30-day ED re-presentation for renal colic. Multivariate logistic regression was used to identify predictors for ED-return. Results: In total, 232 patients met our inclusion criteria. Urgent or outpatient urologist referral was not associated with a significantly lower ED return rate when compared to patients with no follow-up. Surprisingly, urologic intervention and stent placement were both independent predictors for ED return (OR: 2.03; 95% CI: (1.06-3.88); p:0.03) and (OR:2.08; 95% CI: (1.07-4.05). Conclusion: A significant proportion of patients who underwent urologist-led intervention returned to the ED with renal colic. Further study may help clarify the role of early urologist referral for renal calculi, as this may not reduce ED return rates when compared to conservative management.

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

BackgroundWe aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.MethodsThis is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients’ general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.ResultsStudy enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).ConclusionsThough ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

6.43 Reducing Repeat Emergency Department Visits Among Pediatric Patients With Mental Health Concerns: Providing Rapid Access to Outpatient Follow-Up Care

The emergency department (ED) is increasingly used to address pediatric mental health needs. Children and adolescents in mental health crisis who present to the ED often do not receive follow-up outpatient care, leading to high rates of ED return. Interventions aimed at improving linkage to aftercare may decrease ED return rates. Evidence suggests that access to rapid follow-up evaluation, in particular, may improve engagement in outpatient care, preventing the need for ED return. The current investigation evaluated the effectiveness of an integrated pediatric mental health (IPMH) clinic designed to promote continuity of care between emergency and outpatient settings in an effort to reduce ED return visits. It was hypothesized that outpatient follow-up evaluation completed within 3 days of ED discharge would be associated with decreases in ED return rates.

Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation.

Atrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate-controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life-threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm. Study design is a retrospective cohort analysis pre- and postimplementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3- and 30-day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013-February 2014) and after (March 2015-February 2016) implementation. Chi-square tests and logistic regressions were run to test for significant changes in the three outcome variables. A total of 1,108 individuals met inclusion criteria with 586 patients in the preimplementation group and 522 in the postimplementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs. 67.4% post, adjusted odds ratio [OR]=3.4, p < 0.001). Despite this difference there was no change in ED return rates within 3 or 30 days (adjusted ORs=0.93 and 0.89, p =0.91 and 0.73, respectively). Implementation of a novel algorithm to identify and treat low-risk patients with AFib can significantly decrease the rate of hospital admissions without increased ED returns. This simple algorithm could be adopted by other community hospitals and help lower costs.

Telephone Follow-Up for Older Adults Discharged to Home from the Emergency Department: A Pragmatic Randomized Controlled Trial.

Telephone calls after discharge from the emergency department (ED) are increasingly used to reduce 30-day rates of return or readmission, but their effectiveness is not established. The objective was to determine whether a scripted telephone intervention by registered nurses from a hospital-based call center would decrease 30-day rates of return to the ED or hospital or of death. Randomized, controlled trial from 2013 to 2016. Large, academic medical center in the southeast United States. Individuals aged 65 and older discharged from the ED were enrolled and randomized into intervention and control groups (N = 2,000). Intervention included a telephone call from a nurse using a scripted questionnaire to identify obstacles to elements of successful care transitions: medication acquisition, postdischarge instructions, and obtaining physician follow-up. Control subjects received a satisfaction survey only. Primary outcome was return to the ED, hospitalization, or death within 30 days of discharge from the ED. Rate of return to the ED or hospital or death within 30 days was 15.5% (95% confidence interval (CI) = 13.2-17.8%) in the intervention group and 15.2% (95% CI = 12.9-17.5%) in the control group (P = .86). Death was uncommon (intervention group, 0; control group, 5 (0.51%), 95% CI = 0.06-0.96%); 12.2% of intervention subjects (95% CI = 10.1-14.3%) and 12.5% of control subjects (95% CI = 10.4-14.6%) returned to the ED, and 9% of intervention subjects (95% CI = 7.2-10.8%) and 7.4% of control subjects (95% CI = 5.8-9.0%) were hospitalized within 30 days. A scripted telephone call from a trained nurse to an older adult after discharge from the ED did not reduce ED or hospital return rates or death within 30 days. Clinicaltrials.gov identifier: NCT01893931z.

Ondansetron Prescription for Home Use in a Pediatric Emergency Department.

Ondansetron has been shown to decrease admission rate and the need for intravenous fluids among pediatric emergency department (ED) patients with acute gastroenteritis, but there is limited evidence regarding its use after ED discharge. This study describes prescribing patterns for ondansetron and assesses the effects of ondansetron home prescription on rate of return. Data were gathered from the electronic health record on 2 separate but overlapping groups of patients seen in a pediatric ED from 2012 to 2014. The Gastroenteritis Group included all patients with a discharge diagnosis of gastroenteritis by International Classification of Diseases, Ninth Revision, code. The All Ondansetron Group included any child prescribed ondansetron at discharge. Patterns of ondansetron use and 3- and 7-day ED return rate were assessed for both groups. Discharge diagnosis was evaluated for the All Ondansetron Group. A total of 996 patients with acute gastroenteritis were identified during the study period. Of these, 76% received ondansetron in the ED, and 71% were discharged with prescriptions for ondansetron. Seven-day ED return rates were similar between groups (6% with prescription, 5% without, P = 0.66). A total of 2287 patients received home prescriptions for ondansetron. Fifty-four percent of these patients' discharge diagnoses were classed as gastrointestinal complaints, 14% other infectious conditions, 9% respiratory, and 4% injuries. Their return rate was 6%. There was wide variation in the number of doses prescribed. Home-use ondansetron is widely prescribed in this urban academic pediatric ED for a variety of indications, without effect on 3- or 7-day ED return. Further prospective studies are necessary to determine the efficacy of this practice.