Rates Of Emergency Department Research Articles

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.

Differentials and trends in emergency department visits due to alcohol intoxication and co-occurring conditions among students in a U.S. public university

BackgroundFew studies have explored the epidemiology of students presenting to the emergency department (ED) as a consequence of hazardous drinking. This study examined differentials and trends in ED visits following alcohol intoxication and co-occurring conditions among students presenting to a major U.S. university health system. MethodsThe ED electronic medical records from academic years 2010–2015 were queried for student visits and their records were linked to the university’s student admission datasets. Student alcohol-related visits were identified based on ICD-9 codes. Student characteristics and trends in the rate of alcohol intoxication per 100 ED student visits were analyzed. A random sample of 600 student clinical records were reviewed to validate diagnostic codes. ResultsThere were 9616 student ED visits (48% males) to the ED of which 1001 (10.4%) visits involved alcohol intoxication. Two thirds of ED visits with alcohol intoxication had a co-occurring diagnosis, with injuries (24%) being the most common condition. The rate of alcohol intoxication varied greatly by student demographics and campus-related factors. There was a linear increase in the rate of alcohol intoxication from 7.9% in 2009–10 to 12.3% in 2014–15 (p<0.01). The increase was greater among female students, students below 20 years of age, Asian students, and student athletes. In the sample reviewed, only two thirds of ED visits with alcohol intoxication were recorded by diagnostic codes. ConclusionThe rate of ED visits following alcohol intoxication varied by student demographic characteristics and campus-related factors with a rising trend over the study period.

Factors influencing recurrent emergency department visits for epistaxis in the elderly

ObjectiveOur objective is to determine the risk factors associated with recurrent epistaxis requiring emergency department (ED) visits in the elderly. MethodsWe used a 5% national sample of Medicare data from January 2012 through December 2013. Our cohort included patients with a new diagnosis of epistaxis in the ED, defined as no epistaxis in the prior 12 months. We assessed the rates of ED visits for recurrent epistaxis in the 12 months following the incident visit. Our variables included demographics, geographic location, procedures performed during the incident visit and comorbidities. ResultsOut of the 4120 patients with incident epistaxis, 775 were readmitted with recurrent epistaxis within 12 months. 60% presented in the first 30days and 75% within 90 days. There was a significant increase in ED visits for patients over 75 years of age and in men compared to women. Recurrent ED visits for epistaxis was higher in patients with congestive heart failure, diabetes mellitus, and obstructive sleep apnea compared to those without these comorbidities. ConclusionAdditional ED visits for epistaxis are more common in the elderly and in males. Congestive heart failure, diabetes mellitus and obstructive sleep apnea were found to be independent risk factors.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED

Study objectiveThis study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic. MethodsDirect nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED. ResultsA total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively). ConclusionsThe Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.

Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability.

Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions. To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14650 members, were studied. There were 106919 ED visits, with 21214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings. Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services.

Potentially inappropriate prescribing and its association with health outcomes in middle-aged people: a prospective cohort study in Ireland

ObjectivesTo determine the prevalence of potentially inappropriate prescribing (PIP) in a cohort of community-dwelling middle-aged people and assess the relationship between PIP and emergency department (ED) visits, general practitioner (GP)...

233 Effectiveness of Rural Emergency Department-Based Pain Contract on Emergency Department Visits Among Emergency Department Frequent Users

Caring for patients with non-acute pain in the emergency department (ED) can be particularly challenging, both for patients and for physicians. This study seeks to determine, in a rural setting, the effect of an ED-based pain contract on the rate of ED visits among patients with frequent visits for pain or complaints of chronic pain not related to cancer. This is a multi-ED, retrospective, before-and after chart review assessing the effect of a rural ED-based pain contract on the number of ED visits. The study consisted of 4 rural EDs representing over 80,000 annual visits. Medical records of all patients that were eligible for pain contract were reviewed for the periods between December, 2005 and December, 2015. Only visits with complaints of pain were included. The mean number of visits during the year period to contract initiation was compared with the number of visits during the year after enrollment, using a paired t-test. We enrolled 314 patients, 185 (59%) of whom were female. The median of age was 48 years (48.5 years for female and 46 years for male). The mean ED visits one year pre-contact was 12.4 visits (95% CI 11.5,13.3) and the mean ED visits one year post-contract was 6.5 visits (95% CI 5.6,7.3) with P < .0001. Pain contract protocol implementation was associated with a significant reduction in the number of ED visits to multiple rural EDs. Additional studies using similar protocols are needed to establish the impact on patient well-being, experience, experience and potential to reduce health care costs.

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions.

IntroductionHospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center.MethodsWe conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates – WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement.ResultsEPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001].ConclusionA rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.

Postdischarge Outcomes of Pyogenic Liver Abscesses: Single-Center Experience 2007-2012.

BackgroundPyogenic liver abscesses (PLA) are increasingly managed by percutaneous treatment instead of surgery, but there are limited data about postdischarge outcomes. Postdischarge services and factors predicting poor outcomes have not been described.MethodsWe performed a retrospective, descriptive case series at a single center assessing treatment and outpatient follow-up for patients treated for PLA from 2007 to 2012. We reviewed the electronic medical record for patient characteristics and outcomes. Data for care received at other facilities were not available. In our analysis, we compared patients with malignancy with those without and attempted to determine predictors of emergency department (ED) visits and hospital readmissions.ResultsOf 125 patients identified with PLA, 12 had surgical drainage, 23 had percutaneous aspiration, 78 had percutaneous drainage (PD), 11 had no drainage, and 1 was made comfort measures only. Seventy (60%) were discharged with a drain, and 31 (25%) were discharged on intravenous (IV) antibiotics. After discharge, 46 (38%) had ED visits and 36 (30%) were readmitted within 30 days of discharge. Fourteen (12%) had complications from antibiotics, and 4 (13%) had complications from peripherally inserted center catheter lines. A total of 8 patients, 5 in-hospital and 3 postdischarge, died. In our analysis of risk factors for 90-day postdischarge ED visit/readmission, only malignancy was a predictor.ConclusionsPyogenic liver abscess patients have intense postdischarge needs (drain management, IV antibiotics) and a high rate of ED visits and readmissions. Although PD provides source control without surgery, ambulatory needs are now more complex, requiring multidisciplinary collaboration.

Assessment of Selected Overdose Poisoning Indicators in Health Care Administrative Data in 4 States, 2012.

In 2012, a consensus document was developed on drug overdose poisoning definitions. We took the opportunity to apply these new definitions to health care administrative data in 4 states. Our objective was to calculate and compare drug (particularly opioid) poisoning rates in these 4 states for 4 selected Injury Surveillance Workgroup 7 (ISW7) drug poisoning indicators, using 2 ISW7 surveillance definitions, Option A and Option B. We also identified factors related to the health care administrative data used by each state that might contribute to poisoning rate variations. We used state-level hospital and emergency department (ED) discharge data to calculate age-adjusted rates for 4 drug poisoning indicators (acute drug poisonings, acute opioid poisonings, acute opioid analgesic poisonings, and acute or chronic opioid poisonings) using just the principal diagnosis or first-listed external cause-of-injury fields (Option A) or using all diagnosis or external cause-of-injury fields (Option B). We also calculated the high-to-low poisoning rate ratios to measure rate variations. The average poisoning rates per 100 000 population for the 4 ISW7 poisoning indicators ranged from 11.2 to 216.4 (ED) and from 14.2 to 212.8 (hospital). For each indicator, ED rates were usually higher than were hospital rates. High-to-low rate ratios between states were lowest for the acute drug poisoning indicator (range, 1.5-1.6). Factors potentially contributing to rate variations included administrative data structure, accessibility, and submission regulations. The ISW7 Option B surveillance definition is needed to fully capture the state burden of opioid poisonings. Efforts to control for factors related to administrative data, standardize data sources on a national level, and improve data source accessibility for state health departments would improve the accuracy of drug poisoning surveillance.

Dental-Related Use of Hospital Emergency Departments by Hispanics and Non-Hispanics in Florida.

To examine differences between Hispanics and non-Hispanics in Florida in the dental-related use of hospital emergency departments (EDs). We used ambulatory ED discharge records from 2013 to 2015 to compute rates of ED visits for dental complaints per 10 000 population, by region, age, gender, and the percentage distribution visits by primary payer, day of the week, and hour of arrival. There were 64 100 ED visits for dental complaints by Hispanics and 425 162 by non-Hispanics. Medicaid was the most common primary payer for Hispanics (42.2%) and for non-Hispanics (38.1%). Rates of ED utilization for dental problems per 10 000 population were 45.5 for Hispanics and 95.2 for non-Hispanics. Rates of ED utilization for dental problems were different between Hispanics and non-Hispanics. Public Health Implications. Effective interventions need to be developed in the context of a social-ecological model to better understand factors such as health, economics, and education, among others. Understanding and intervening with the individual, communities, and policy could help to modify behaviors and improve access to dental care.

Reducing Unplanned Admissions: Focusing on Hospital Admissions and Emergency Department Visits for Patients With Head and Neck Cancer During Radiation Therapy .

Head and neck cancer (HNC) treatments cause severe toxicities, leading to high rates of emergency department (ED) visits and unplanned hospital admissions (UHAs). . The study aimed to evaluate a quality improvement project to reduce ED visits and UHAs. . A weekly nurse/nurse practitioner-led symptom management clinic was created for patients with HNC receiving radiation therapy deemed at high risk for an ED visit or UHA. Primary quality metrics were rate of visits or unplanned admissions. Time-to-event actuarial analysis and log-rank tests (two-tailed) were performed to compare observed to historic rates. . Rates of ED visits and UHAs were 11% and 16%, respectively. Having more symptom management visits marginally correlated with reduction in UHA. The authors estimate six ED visits and four UHAs were prevented, which is a $176,848 cost reduction.

Impact of a Sepsis Guideline in Emergency Department on Outcome of Patients with Severe Sepsis

Objective A dedicated program with guideline to enhance sepsis care was launched in July 2014 in Emergency Department (ED) of two regional hospitals. The study aimed to evaluate the effectiveness of the interventional program for severe sepsis patients, in antibiotic delivery rate and survival outcome. Methods It is a before-and-after interventional study with data from July to December 2013 and August 2014 to January 2015. A dedicated program for severe sepsis patients was introduced in July 2014. The outcome measures were blood culture rate, antibiotic administration rate in ED and mortality. Kaplan-Meier analysis and log-rank test was used for comparison of the survival. Multivariate Cox proportional hazards model was constructed to predict time to mortality adjusted for covariates. Results 64 patients were included, 31 patients were in the pre-intervention group whereas 33 post-intervention. Both blood culture rate (29% vs 72.7%; p&lt;0.001) and antibiotics administration in ED (38.7% vs 72.7%, p=0.0011) were significantly increased. Survival outcome was significantly improved in patients receiving timely antibiotics in ED (log-rank test p=0.016). Antibiotics administered in ED had hazard ratio of 0.178 (95% CI 0.053 to 0.595; p=0.005) in the Cox Proportional hazard regression model with adjustment of covariates. Age (adjusted odds ratio 1.06, 95% CI 1.01 to 1.12, p=0.033) and initial hypotension (adjusted odds ratio 0.97, 95% CI 0.95 to 0.99, p=0.005) were significant predictors of mortality. Conclusion A dedicated guideline for severe sepsis management could improve blood culture rate, early antibiotics administration in the emergency department. Patients received early antibiotic had better outcome and survival.

MP01: The canary in the coal mine: Does palliative care consultation influence emergency department utilization?

Introduction: For cancer patients undergoing active treatment, emergency department (ED) visits may be an indicator of a breakdown in continuity and quality of care. Palliative care (PC) may be an important resource for patients in need of symptom management even during treatment with curative intent. This study aims to describe ED utilization by cancer patients and determine if PC consults impact ED use. Methods: Patient data from the Tom Baker Cancer Center (TBCC) was linked to PC and ED data as a retrospective cohort study. ED data was obtained from two administrative databases and PC data was obtained from four administrative databases and restricted to the first four hundred days following diagnosis. Univariate and Multivariate analyses were used. Results: Three actively treated cancer patient cohorts were identified based on first presentation following intake at the TBCC: 1) Used ED first (n=1637), 2) Used PC first (n=539), and 3) Only used services at the TBCC (n=2153). Using Multivariate analysis, patients living alone or who had a diagnosis of prostate or breast cancer were more likely to access the ED first or to only use services at the TBCC rather than access PC first. Patients who were divorced, on income support, or diagnosed with a lung or GI cancer, were more likely to access PC first rather than access the ED or only use services at the TBCC. A subgroup analysis was performed on those who accessed the ED at some point during their care, consisting of three groups: 1) ED Only Users (n=1091), 2) ED First Users, who also accessed PC (n=546), and 3) PC First Users, who also accessed the ED. There was a significant difference in rates of ED visits between the three groups: ED Only Users went to the ED at a rate of 3.8 per 1000 patient days; ED First Users, who also accessed PC, went to the ED at a rate of 7.7 per 1000 patient days; and PC First Users, who also accessed the ED, went to the ED at a rate of 9.2 per 1000 patient days (p&amp;lt; 0.001). Conclusion: In a tertiary cancer centre, patients who were divorced, on income support, or diagnosed with lung or GI cancer were more likely to access PC. Amongst those patients who presented to the ED, those who accessed PC first had higher rates of ED use. Further explorations of presenting complaints, utilization patterns, and symptom burdens will be analyzed to determine if early PC consults can influence or decrease ED utilization.

LO27: System outcomes associated with an emergency department clinical decision unit

Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment &amp;amp; observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment &amp;amp; treatment. A CDU was established at BC Children’s Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED. Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted &amp;amp; entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED &amp;amp; b) the number of RTED that were clinically unnecessary. Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) &amp;amp; therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) &amp;amp; families’ understanding of disease symptom range &amp;amp; duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of &amp;gt;8 hours, thus were considered averted hospitalizations attributable to the CDU. Conclusion: The CDU has had a positive impact on patient &amp;amp; system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary &amp;amp; 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.

Opioid management strategy decreases admissions in high-utilizing adults with sickle cell disease.

A subset of adults with sickle cell disease (SCD) heavily utilizes the emergency department (ED) and hospital. The objective of our study was to determine the efficacy of a multidisciplinary strategy to address unmet needs in highly utilizing adults with SCD. In a prospective study, adults with SCD with ≥10 admissions per year were assessed by a multidisciplinary team for gaps in medical, social, and psychological care. Thereafter, the team decided upon the subject's predominant domain that drove admissions and instituted an interventional plan. All plans included an opioid management strategy. Preintervention and postintervention admission rate, as well as opioid use, was compared. Twelve subjects were enrolled. Median rate of ED and hospital admissions preintervention was 25 per year. The predominant domains identified were social needs (n = 6), psychological disorder (n = 1), and substance use disorder (n = 5). Multifaceted interventional plans were developed to address a wide range of gaps in care, but an opioid management strategy was the only intervention successfully completed. Even so, when the preintervention versus postintervention admission rate was compared, regardless of the domain, there was a 40 percent decline in hospital admissions (p = 0.03). Consistent with the successful implementation of an opioid management plan, the decrease in admissions was accompanied by a 37 percent decrease in intravenous opioid use (p = 0.02) and 10 percent decrease in oral opioid use (p = 0.04). An opioid management strategy, as part of a larger effort to improve care for high-utilizing adults with SCD, decreased rate of admissions and opioid use.

Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO.

Accountable care organizations (ACOs) appear to lower medical spending, but there is little information on how they do so. We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending. We used data for the period 2009-14, exploiting naturally staggered program entry to create concurrent controls to help isolate the program effects. The care management program (the ACO's primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6percent and 8percent, respectively, and Medicare spending was reduced by 6percent. Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs.

P009: Improving elderly care transitions through the local adaptation and implementation of the Acute Care for Elderly (ACE) program

Introduction: Decreasing readmission rates and return emergency department (ED) visits represent a major challenge for health organizations. Seniors are especially vulnerable to discharge adverse events which can result in unplanned readmissions and loss of physical, functional and/or cognitive capacity. The ACE Collaborative is a national quality improvement initiative that aims to improve care of elderly patients. We aimed to adapt Mount Sinai’s Care Transitions program to our local context in order to decrease avoidable readmissions and ED visits among seniors. Methods: We performed a prospective pre/post implementation cohort study. We recruited frail elderly hospitalized patients (≥50 years old) discharged to home and at risk of readmission (modified LACE index score≥7/12). We excluded patients being discharged to long-term nursing homes or institutions. Our intervention is based on selected strategic ACE Care Transitions best practices: transition coach, telehealth personal response services and a structured discharge checklist. The intervention is offered to selected patients before hospital discharge. Our primary outcome is a 30-day post-discharge composite of hospital readmission and return ED visit rate. Our secondary outcomes are functional autonomy, satisfaction with care transition, quality of life, caregiver strain and healthcare resource use at recruitment and at 30-days follow-up. Hospital-level administrative data is also collected to measure global effect of practice changes. Results: The project is currently ongoing and preliminary results are available for the pre-implementation cohort only. Patients in this cohort (n=33) were mainly men (61%), aged 75±10 years and presented an OARS score (Activities of Daily Living instrument that ranges from 0-28) of 5.6±4.9. At 30 days post-discharge, the patients in our cohort had a 42.4% readmission rate (14 hospitalisations) and a 54.5% return ED visit rate (18 visits). For the same time period, readmission and return ED rates for all patients in the same corresponding age-group at the hospital level were 14.4% and 21.9%, respectively. Further results for our post-intervention cohort will be presented at CAEP 2017. Conclusion: Our cohort of elderly patients have high readmission and return ED visit rates. Our ongoing quality improvement project aims to decrease these readmissions and ED visits.

MP66-01 EMERGENCY DEPARTMENT REVISITS FOR CHILDREN FOLLOWING AN ACUTE URINARY STONE EPISODE

You have accessJournal of UrologyPediatrics: Testis, Varicocele & Stones1 Apr 2017MP66-01 EMERGENCY DEPARTMENT REVISITS FOR CHILDREN FOLLOWING AN ACUTE URINARY STONE EPISODE Jane Kurtzman, Lihai Song, Michelle Ross, Charles Scales Jr., and Gregory Tasian Jane KurtzmanJane Kurtzman More articles by this author , Lihai SongLihai Song More articles by this author , Michelle RossMichelle Ross More articles by this author , Charles Scales Jr.Charles Scales Jr. More articles by this author , and Gregory TasianGregory Tasian More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Revisiting the emergency department (ED) after discharge is an undesired clinical outcome that remains unstudied in children with kidney stones. We sought to determine the rate of stone-related ED revisits among children, to characterize the reasons for revisiting and to identify patient-, hospital- and clinical characteristics associated with ED revisit. METHODS In a retrospective population-based cohort study of patients ≤18 years with urinary stone disease, ED revisits within 180 days of the index visit were identified in the South Carolina Medical Encounter database. This database includes all ED visits in the state from December 30, 1995 to September 30, 2015. We used discrete time failure models to describe the rate of ED revisit risk over the 180-day period following the index visit. Multivariable logistic regression models were used to estimate the association between patient, hospital and clinical characteristics and ED revisit. RESULTS Among 5,642 index stone episodes, 11% led to a stone-related ED revisit within 180 days of discharge. Nearly 60% of these revisits occurred within 30 days of discharge. The odds of revisit within the first 2 days after discharge were 23 times higher than the odds of revisit after 2 weeks from discharge (OR 22.6, 95% CI 18.0 - 28.5, Figure 1). The most common documented symptom at revisit was pain, which occurred in 40% of patients. Nearly 40% of patients underwent surgery and/or hospital admission at the time of revisit. Each year increase in age (OR 1.06, 95% CI 1.03 - 1.10) and public insurance (OR 1.46, 95% CI 1.21 - 1.77) were associated with an increased risk of ED revisit. Patients with a history of stone disease were two times more likely to revisit than patients with no prior history (OR 2.1, 95% CI 1.74 - 2.56). Patients evaluated by a urologist were 40% less likely to revisit the hospital than those who were not (OR 0.6, 95% CI .42 - 0.86). CONCLUSIONS Children who present to the ED with kidney stones are at most likely to return to the ED within 48 hours of discharge. Older children, publicly insured patients and repeat stone-formers are at greatest risk of ED revisit. Urology consultation is associated with a decreased risk of revisit. Future studies should seek to identify processes of care that decrease ED revisits among high-risk patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e862 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jane Kurtzman More articles by this author Lihai Song More articles by this author Michelle Ross More articles by this author Charles Scales Jr. More articles by this author Gregory Tasian More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...