Freestanding Emergency Departments Research Articles

Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation.

Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0h if they had a hs-cTnI<4ng/L and at 1h if the initial value were 4ng/L and the 1-h value ≤7ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37min, CI: -62, 12min) and reduced health system cost (-$112, CI: -$250, $25). Overall, the implementation of AP using hs-cTn does not result in higher costs.

Who do freestanding emergency departments treat? Comparing Texas hospitals to satellite and independent freestanding departments in 2021 and 2022.

The objective was to describe characteristics of emergency department visits to Texas satellite and independent freestanding emergency departments (FrEDs) relative to hospital emergency departments (EDs). The study used all 2021-2022 hospital and FrED discharges from the publicly available Texas Emergency Department Public Use Data Files (PUDF). We conducted a descriptive analysis, comparing patient and visit characteristics at satellite and independent FrEDs and hospital EDs using chi-square tests. We characterized the top 20 diagnoses and procedures ranked by volume, treatment intensity, and potentially avoidable ED use. Discharge data from 2021 to 2022 were combined for the analysis, and ED data at critical access hospitals were excluded. Our sample consisted of 21,605,421 ED visits, 76% occurring at hospitals, 12% at satellite FrEDs, and 12% at independent FrEDs. Compared with hospitals and satellite FrEDs, patients to independent FrEDs were younger, healthier, more likely covered by private insurance, and less likely to be identified as non-Hispanic Black or Hispanic. Visits at satellite and independent FrEDs were more likely to be of moderate and low intensity and potentially avoidable. Our results underscore the need to address potentially avoidable utilization of emergency services.

Individual Attributes and Environmental Conditions of Registered Nurses Working in Freestanding Emergency Departments in the United States: A Descriptive Exploratory Study

IntroductionFreestanding emergency departments (FSEDs) are emergency facilities not connected to inpatient services. The percentage of FSEDs of all EDs grew from 1% in 2001 to 12% in 2017, making FSEDs a substantial subset of US emergency care. The purpose of this study was to describe the individual attributes and environmental conditions of registered nurses working in FSEDs in the US. MethodsA quantitative descriptive exploratory design with cross-sectional survey methodology. ResultsA total of 364 emergency nurses responded to the survey. Most reported their FSED was open 24 hours/day (99.5%), with board-certified emergency physicians onsite (91.5%) and a mean of 3.6 RNs working per shift. Resources immediately available in more than 50% of FSEDs included laboratory and imaging services, and in fewer than 30% of FSEDs included behavioral health care, MRI, obstetric care, orthopedic care, neurologic care, and surgical consult care. Respiratory therapy was reported by 39.6% of respondents as being immediately available. A significant minority of respondents expressed concerns about adequacy of resources and training and the effect on patient care in both survey (30% of respondents) and open-ended questions (42.5% of respondents). DiscussionThe practice environment of emergency nurses in FSEDs was reported as having positive elements; however, a substantial subpopulation reported serious concerns. FSEDs adhere to some of the standards put forward by the American College of Emergency Physicians, with notable exceptions in the areas of staffing RNs, staffing ancillary staff, and availability of some resources.

Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments

Background: Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees. Methods: Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards. Results: There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time. Conclusion: Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.

Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital

We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study. We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate. Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure. We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Effectiveness of dry hydrogen peroxide in reducing air and surface bioburden in a multicenter clinical setting.

To determine the effectiveness of dry hydrogen peroxide (DHP) in reducing environmental bioburden in occupied areas. Prospective environmental cohort study. The study was conducted in 2 tertiary-care hospitals and 1 free-standing emergency department. Environmental air and surface sites were cultured before and after continuous deployment of DHP systems in targeted hospital areas. In total, 1,554 surface and 1,036 air samples were collected from 74 patient areas among the 3 facilities on 3 consecutive days before DHP deployment and on days 14, 30, 60, and 90 after deployment. At each sampling time, 2 air samples were collected at each facility from 1 room without DHP, along with 2 outdoor samples from each facility. The impact of negative-pressure usage on the efficacy of DHP was also evaluated, with 1 hospital continuously using negative pressure, another utilizing it only in patient isolation scenarios, and another without negative pressure. In the 2 facilities without continuous negative pressure, exposure to DHP was associated with a significant reduction in surface bioburden, characterized as total colony-forming units (P = .019; P = .002). Significant associations between DHP exposure and reductions in airborne bacterial load at the 2 hospitals were observed (P ≤ .001; P = .041), and the free-standing emergency department experienced a reduction that did not achieve statistical significance (P = .073). Our findings confirm that DHP has the potential to reduce microbial air and surface bioburden in occupied patient rooms with standard ventilation parameters.

Remote triage practices in general surgery patients from freestanding emergency departments: A 6-year analysis

BackgroundFreestanding emergency departments have risen in popularity as a means to expand access to care. Although some evaluation of freestanding emergency department utility in specific patient populations exists, management of surgical patients via remote triage and disposition has not been previously described. We report our experience with remote triage to discharge home, level I trauma center, or community hospital admission for general surgery patients who present to an affiliated freestanding emergency department. MethodsA retrospective cohort study of patients presenting to freestanding emergency departments requiring surgical consultation between 2016 and 2021 was conducted. Outcomes included disposition, length of stay, surgical intervention, 30-day mortality, and readmission. Undertriage and overtriage rates were calculated and defined as the following: (1) discharge undertriage—discharge home with 30-day emergency department visit/readmission; 2) transfer undertriage—transfers to community hospital requiring transfer to trauma center; and (3) overtriage—admissions <24 hours without surgery. ResultsOf 1,105 patients, 15% were discharged home, 27% were transferred to trauma centers, and 58% were transferred to community hospitals. Patients admitted to trauma centers were older and had higher acuity pathology, whereas patients admitted to community hospitals had higher operative rates with shorter lengths of stay, operating room time, 30-day readmission, and mortality. Transfer undertriage was 0.9% (n = 6), with only 1 patient requiring transfer from a community hospital to a trauma center for disease acuity. Discharge undertriage was 12% (n = 20) due to worsening or persistent pathology. Overtriage was 5.5% (n = 52), with most having a partial small bowel obstruction or ambiguous diagnostic imaging requiring observation. ConclusionRemote surgery triage at freestanding emergency departments, without an in-person examination, demonstrated both low undertriage and overtriage rates, reflecting appropriate triage practices.

Ventricular Tachycardia.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of ventricular tachycardia (VT) that is refractory to single dose anti-arrhythmic management. Electrical storm, defined as three or more episodes of sustained VT, ventricular fibrillation, or appropriate shocks from an implantable cardioverter defibrillator within 24 hours,1 has a mortality rate up to 14% in the first 48 hours.2 Ventricular tachycardia may present in a heterogenous fashion, not only with stable versus unstable clinical presentations, but also with different electrocardiographic morphologies and etiologies.1 Understanding how to rapidly diagnose, treat, and utilize second or third-line treatments is vital in the setting of refractory ventricular tachycardia rather than relying on the success of first-line agents. Appreciation for what medications are readily available in your crash cart and medication dispensing cabinet is critical for timely management for refractory ventricular tachycardia. At the conclusion of the simulation session, learners will be able to: 1) identify the different etiologies of VT, including structural heart disease, acute ischemia, and acquired or congenital QT syndrome; 2) describe confounding factors of VT, such as electrolyte abnormalities and sympathetic surge; 3) describe how to troubleshoot an unsuccessful synchronized cardioversion, including checking equipment connections, increasing delivered energy, and changing pad placement; 4) compare and contrast treatments of VT based on suspected underlying etiology; 5) describe reasons to activate the cardiac catheterization lab other than occlusive myocardial infarction; and 6) identify appropriate disposition of the patient to the cardiac catheterization lab. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of VT. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form3 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Twelve learners completed a feedback form. This session received 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated 5 scores. The lowest average score was 6.67 for "Before the simulation, the instructor set the stage for an engaging learning experience." The highest average score was 7 for "The instructor helped me see how to improve or how to sustain good performance." The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Excellent care and debrief." Specific scores are available upon request. This is a cost-effective method for reviewing VT diagnosis and management. The case may be modified for appropriate audiences, such as describing what medications may be readily available in a free-standing emergency department or pre-hospital setting. Medical simulation, ventricular tachycardia, cardiac emergencies, dysrhythmias, cardiology, emergency medicine.

Computed Tomography Utilization for Patients Presenting with Chest Pain

IntroductionComputed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain. MethodsA retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 – April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain. ResultsThere were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81–0.90). ConclusionCT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.

Randomized Controlled Study in the Use of Aromatherapy for Pain Reduction and to Reduce Opioid Use in the Emergency Department

IntroductionThis study aimed to evaluate the effects of aromatherapy on emergency department patients' perception of pain and its ability to reduce the use of opioids in an emergency department. MethodsThis randomized, controlled, single-blinded study was conducted in a suburban/rural freestanding emergency department with a therapeutic group, sham group, and control group. ResultsA total of 230 patients, 171 females and 59 males, completed the study. Of those who received the therapeutic agent, an average reduction in pain of 1.04 points on the pain scale was reported, whereas the sham group averaged 0.38 and the control group 0.23. There was a statistically significant reduction of pain scores in the therapeutic group. A total of 13 received opioid pain medication during their visit. Of these, the therapeutic group averaged a total of 2.67 morphine milligram equivalents for their visit compared with 3.63 in the sham group and 4.36 in the control group; however, statistical significance was not achieved. DiscussionThis study supported what other studies have found, indicating that aromatherapy is effective in reducing pain. A difference between the placebo effect and a true therapeutic effect was seen by using a control group apart from the sham and therapeutic groups. Despite the small effect size (0.3), implementation of aromatherapy into standard practice may be practical considering the anxiolytic effects that have been shown in other studies. Aromatherapy with essential oils should be considered as another tool to use in a multimodal approach in the treatment of pain in the emergency department setting.

Virtual triage from freestanding emergency departments: a propensity score-weighted analysis of short-term outcomes in emergency general surgery.

Freestanding emergency departments (FSEDs) have generated improved hospital metrics, including decreased ED wait times and increased patient selection. Patient outcomes and process safety have not been evaluated. This study investigates the safety of FSED virtual triage in the emergency general surgery (EGS) patient population. A retrospective review evaluated all adult EGS patients admitted to a community hospital between January 2016 and December 2021 who either presented at a FSED and received virtual evaluation from a surgical team (fEGS) or presented at the community hospital emergency department and received in-person evaluation from the same surgical group (cEGS). Patients' demographics, acute care utilization history, and clinical characteristics at the onset of the index visit were used to build a propensity score model and stabilized Inverse Probability of Treatment Weights (IPTW) were used to create a weighted sample. Multivariable regression models were then employed to the weighted sample to evaluate the treatment effect of virtual triage compared to in-person evaluation on short-term outcomes, including length of stay (LOS) and 30-day readmission and mortality. Variables which occurred during the index visit (such as surgery duration and type of surgery) were adjusted for in the multivariable analyses. Of 1962 patients, 631 (32.2%) were initially evaluated virtually (fEGS) and 1331 (67.8%) underwent an in-person evaluation (cEGS). Baseline characteristics demonstrated significant differences between the cohorts in gender, race, payer status, BMI, and CCI score. Baseline risks were well balanced in the IPTW-weighted sample (SD range 0.002-0.18). Multivariable analysis found no significant differences between the balanced cohorts in 30-day readmission, 30-day mortality, and LOS (p > 0.05 for all). Patients who undergo virtual triage have similar outcomes to those who undergo in-person triage for EGS diagnoses. Virtual triage at FSED for these EGS patients may be an efficient and safe means for initial evaluation.

Modeling the value of an emergency department influenza vaccination program

BackgroundSeasonal influenza continues to present a significant annual burden as the vaccination rate in the United States is 51.8%. Emergency Department (ED) based influenza programs have been successfully implemented and improve vaccine uptake, reduce incidence and costs, and improve outcomes. ObjectiveTo develop a predictive model to assess preventable influenza cases, hospitalizations, fatalities, and incremental cost avoidance based on the unvaccinated population. MethodsA retrospective cohort of ED encounters limited to Medicare and Medicaid populations was performed across 14 tertiary care hospital EDs and six freestanding EDs for 2020. The total number of unvaccinated individuals was identified to determine the potential impact of an ED vaccination campaign. The average cost and loss per inpatient stay was identified from prior industry Medicare benchmark data and was utilized to extrapolate Medicaid losses. Results from published cost-effectiveness studies identified the vaccination thresholds to prevent one additional case of influenza, one additional hospitalization, and one additional fatality. ResultsA total of 39,463 unvaccinated individuals were identified, with 14,064 classified as Medicare, and 25,379 classified as Medicaid. Assuming a 95% target outreach, 90% medical eligibility, and 70% acceptance rate, 414 influenza cases would be prevented (266 Medicaid, 148 Medicare), 28 hospitalizations would be prevented (18 Medicaid, 10 Medicare), and eight deaths would be prevented (5 Medicaid, 3 Medicare). Accordingly, a reduction in admissions would prevent $409,360 in total inpatient medical costs and $36,232 in losses to healthcare systems. ConclusionAn ED-based influenza vaccination program would have a measurable impact on patient influenza disease burden and associated medical expenditures.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study.

The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

From Stressful to Mindful: Reactions to a Proposed Emergency Department Design for Enhancing Mindfulness and Stress Reduction Among Healthcare Clinical Staff.

This study explored design solutions that can help clinicians manage work-related stress, pursue mindful work, and practice relaxation and coping strategies. Clinicians are experiencing burnout at increasingly higher rates, leading to compromised patient care. While self-care and stress management strategies are shown to be effective in healthcare settings, little is known about how the design of healthcare settings can facilitate these strategies. Using findings of a preceding study by the authors, a virtual walk-through video of a design proposal for a free-standing emergency department was built. Feedback data were collected from clinicians in 10 in-depth interviews, and emerging themes were identified using qualitative content analysis. Our findings suggest that work environments that reflect intentional efforts to meet clinicians' needs for stress management can enhance their feeling of being valued and sense of professional worth. Clinicians are more likely to step away from work if there are multiple spaces for bio breaks and rest breaks. Primary break rooms are preferred to be close to patient care areas, but respite/escape spaces are preferred to be distant and private from patient care areas. Participants endorsed the provision of at least one staff bathroom large enough for extra seating and one outdoor respite space. Multiple workspaces should allow the completion of various tasks with adjustable levels of privacy. We suggest special attention to non-institutional aesthetics, providing choice and control, increasing flexibility, promoting privacy for focused work, maximizing access to daylight and outdoors, and providing opportunities for grief support.

Resilience After Defeat.

On Being a Patient18 April 2023Resilience After DefeatJonathan Zygowiec, DO, MPH, MAJonathan Zygowiec, DO, MPH, MAAtrium Health, Charlotte, North CarolinaSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-0559 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail As I stared at the ceiling, the words were sinking in slowly. “Unfortunately, we found cancer outside the liver that was not visible on any of your imaging studies. I’m sorry, but we couldn’t finish the surgery … .” The surgeon’s words were slow, purposeful, and caring as my postanesthesia brain tried to comprehend the gravity of what he was saying.In April of last year, I had gone into my usual shift in the emergency department as the overnight physician and began having severe abdominal pain and nausea followed by vomiting. At a freestanding emergency department, I was the ... Author, Article, and Disclosure InformationAuthors: Jonathan Zygowiec, DO, MPH, MAAffiliations: Atrium Health, Charlotte, North CarolinaCorresponding Author: Jonathan Zygowiec, DO, MPH, MA, Atrium Health, 10628 Park Road, Charlotte, NC 28210; e-mail, jonathan.[email protected]com.This article was published at Annals.org on 18 April 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Latest ePublished: 18 April 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

MP06-14 QUALITY METRICS FOR PATIENTS REQUIRING URGENT SURGICAL INTERVENTION - COMPARING A FREESTANDING EMERGENCY DEPARTMENT TO A HOSPITAL-BASED EMERGENCY DEPARTMENT

You have accessJournal of UrologyCME1 Apr 2023MP06-14 QUALITY METRICS FOR PATIENTS REQUIRING URGENT SURGICAL INTERVENTION - COMPARING A FREESTANDING EMERGENCY DEPARTMENT TO A HOSPITAL-BASED EMERGENCY DEPARTMENT Ginnie Jeng, Alexa Meyer, Adam Hass, Eric Cruzen, Yves Duroseau, and Lee Richstone Ginnie JengGinnie Jeng More articles by this author , Alexa MeyerAlexa Meyer More articles by this author , Adam HassAdam Hass More articles by this author , Eric CruzenEric Cruzen More articles by this author , Yves DuroseauYves Duroseau More articles by this author , and Lee RichstoneLee Richstone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the past decade, there has been a dramatic increase in the number of freestanding emergency departments (EDs) affiliated and located near existing hospital-based EDs. Given freestanding EDs do not have in-house surgical specialty providers, the purpose of this study was to determine whether differences exist in the quality of care and clinical outcomes of patients presenting to freestanding versus hospital-based EDs for urgent surgical conditions. METHODS: Retrospective analysis of patients that presented to Lenox Health Greenwich Village (freestanding) and Lenox Hill Hospital (hospital-based) EDs in New York City between 01/2019 and 02/2021 with urgent surgical conditions was performed. Data collected include patient demographics, ED and procedure time data, principal diagnosis and procedure, and post-operative data. Statistical analyses include Mann-Whitney test, Chi square test, COX regression, and logistic regression, with p<0.05 considered statistically significant. RESULTS: 1220 patient were included in this study, with 356 presenting to freestanding and 864 to hospital-based ED for surgically urgent conditions, including testicular torsion (Table 1). Median times from ED arrival to surgical intervention were 14.7 hours in freestanding and 12.7 hours in hospital-based ED (p=0.073). Factors associated with significantly longer time intervals include African American race (HR=0.75, 95% CI: 0.57-0.90), Medicaid (HR=0.80, 95% CI: 0.68-0.95), and Medicare (HR=0.63, 95% CI: 0.49-0.81). Patients who presented to freestanding ED had significantly shorter ED length of stay (p<0.0001) and more accurate ED diagnoses (p=0.022). There were no statistical differences in ICU admission (p=0.188), post-operative complication (p=0.957), 30-day readmission (p=0.256), and mortality rates (p=0.524) between the two groups. CONCLUSIONS: Within our system, the quality of care and clinical outcomes of patients requiring urgent surgical intervention are comparable for those presenting to a freestanding ED versus a hospital-based ED. Thus, freestanding EDs in an urban environment may be beneficial for both patients and health care facilities. However, differences in care across race and insurance group must be further explored. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e58 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ginnie Jeng More articles by this author Alexa Meyer More articles by this author Adam Hass More articles by this author Eric Cruzen More articles by this author Yves Duroseau More articles by this author Lee Richstone More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of missed influenza vaccination opportunities in the emergency department

BackgroundSeasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018–2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. MethodsThis was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 – April 30) over a two-years, 2018–2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. ResultsA total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. ConclusionPatients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

DO HIGHER DOSES OF NALOXONE INCREASE THE RISK OF PULMONARY COMPLICATIONS?

Background: Although naloxone has proven to be an effective opioid reversal agent, concern that high doses of naloxone can cause pulmonary edema may prevent health care providers from administering it in initial high doses. Objective: Our aim was to determine whether increased doses of naloxone are correlated with an increase in pulmonary complications in patients presenting to the emergency department (ED) after an opioid overdose. Methods: This was a retrospective study of patients treated with naloxone by emergency medical services (EMS) or in the ED at an urban level I trauma center and three associated freestanding EDs. Data were queried from EMS run reports and the medical record and included demographic characteristics, naloxone dosing, administration route, and pulmonary complications. Patients were grouped by naloxone dose received, defined as low (≤ 2 mg), moderate (> 2 mg to ≤ 4 mg), and high (> 4 mg). Results: Of the 639 patients included, 13 (2.0%) were diagnosed with a pulmonary complication. There was no difference in the development of pulmonary complications across groups (p = 0.676). There was no difference in pulmonary complications based on the route of administration (p = 0.342). The administration of higher doses of naloxone was not associated with longer hospital stays (p = 0.0327). Conclusions: Study results suggest that the reluctance of many health care providers to administer larger doses of naloxone on initial treatment may not be warranted. In this investigation, there were no poor outcomes associated with an increase in naloxone administration. Further investigation in a more diverse population is warranted.

Abstract TP42: Door To Thrombolysis Administration Times Before And After Tenecteplase Implementation Across Different Hospital Types

Background: The switch from alteplase to tenecteplase as a thrombolytic in acute ischemic stroke has been reported to be associated with faster door-to-needle (DTN) times. We aimed to study the effect of the early transitional experience after tenecteplase switch on DTN across different hospital types. Methods: We retrospectively analyzed prospectively collected data of patients that underwent thrombolysis at 7 free-standing emergency departments (FSEDs), 8 primary stroke centers (PSC), 3 thrombectomy-capable stroke centers (TSC), and a comprehensive stroke center (CSC) in a large healthcare system. The distributions of DTN time before (January 2021-January 2022) and after (January 2022-June 2022) tenecteplase implementation were compared. The Mann-Whitney test was used to compare door-to-needle time differences between alteplase and tenecteplase treatment groups. Results: Alteplase was given to 318 patients with a median DTN of 40 minutes (interquartile range [IQR]: 27;57) and 154 received tenecteplase with a median DTN of 46 minutes (IQR: 33;63). Patients in the two groups had similar demographic characteristics, NIH Stroke Scale scores, and patient distribution across hospital types. Among tenecteplase-treated patients, 68 (44%) were from FSEDs and PSCs, 67 (44%) were from TSCs, and 19 (12%) were from CSCs. The median DTN time at FSEDs and PSCs increased from 39 (IQR: 27;55) to 56 minutes (IQR: 41;72) after tenecteplase implementation (P&lt;0.0001). At the TSCs the median DTN was 40 minutes (IQR: 29;55) and did not change after the switch to tenecteplase (P=0.31). The median DTN at CSC in the alteplase group was 41 minutes (IQR: 26;72) and 33 minutes (IQR:20;45) in the tenecteplase group (P=0.06). Conclusion: For the first 6 months of tenecteplase implementation the DTN time increased at FSEDs and PSCs but remained unchanged in higher volume centers.

Abstract WP41: Should They Stay Or Should They Go? The Impact Of AI-based Care Coordination On Stroke Patient Transfers Across A Hospital Network

Introduction: A key decision facing non-thrombectomy capable hospitals is whether to transfer a suspected large vessel occlusion (LVO) patient to a thrombectomy-capable stroke center (TSC). We report our experience with a commercially available AI-based care coordination platform (Viz.ai) designed to detect and alert LVOs on imaging (CTA) and improve communication among spoke and hub providers. Methods: All patients presenting across our community hospital network (consisting of two primary stroke centers, one stroke-ready hospital, and two freestanding emergency departments) with the diagnosis of acute stroke were included. We investigated the effect of the Viz.ai software platform on the number of stroke patients transferred out of our health system to the TSC and CTA utilization by comparing transfer patterns in a cohort of patients before (pre-Viz, 12/2018 - 10/2020) and after (post-Viz, 10/2020 - 08/2022) implementation. Results: A total of 1778 pre-Viz and 1779 post-Viz patients were compared. The post-Viz transfers significantly decreased by 33% (158 post-Viz vs 236 pre-Viz, p&lt;0.0001) and the post-Viz patients receiving a CTA within our system increased by 64% (1167 post-Viz vs 710 pre-Viz, p&lt;0.0001). The proportion of patients receiving a thrombolytic (tPA or TNK) who were cared for at the spokes was significantly higher post-Viz (74% vs 63%, p=0.02). The baseline clinical characteristics and study outcomes are summarized in the Table. Conclusions: In a consecutive cohort of stroke patients across a system of community hospitals that are not thrombectomy-capable, the implementation of the Viz.ai software platform was associated with reduced transfers to the thrombectomy center and an increased use of in-house CTA for LVO screening. There was an increase in the proportion of patients treated with intravenous thrombolysis who did not undergo transfer and received care locally suggesting improved identification of patients who benefit from transfer.