General Emergency Department Population Research Articles

Prescription history of emergency department patients prescribed opioids.

Introduction: To use Colorado's prescription drug monitoring program (PDMP) to describe the recent opioid prescription history of patients discharged from our emergency department (ED) with a prescription for opioid pain medications.Methods: Retrospective cohort study of 300 adult ED patients who received an opioid prescription. We abstracted prescription histories for the six months prior to the ED visit from the PDMP, and abstracted clinical and demographic variables from the chart.Results: There were 5,379 ED visits during the study month, 3,732 of which were discharged. Providers wrote 1,165 prescriptions for opioid analgesics to 1,124/3,732 (30%) of the patients. Median age was 36 years. Thirty-nine percent were male. Patients were 46% Caucasian, 26% African American, 22% Hispanic, 2% Asian and 4% other. These were similar to our overall ED population. There was substantial variability in the number of prescriptions, prescribers and total number of pills. A majority (205/296) of patients had zero or one prescription. The 90th percentile for number of prescriptions was seven, while the 10th percentile was zero. Patients in the highest decile tended to be older, with a higher proportion of Caucasians and females. Patients in the lowest decile resembled the general ED population. The most common diagnoses associated with opioid prescriptions were abdominal pain (11.5%), cold/flu symptoms (9.5%), back pain (5.4%), flank pain (5.0%) and motor vehicle crash (4.7%).Conclusion: Substantial variability exists in the opioid prescription histories of ED patients, but a majority received zero or one prescription in the preceding six months. The top decile of patients averaged more than two prescriptions per month over the six months prior to ED visit, written by more than 6 different prescribers. There was a trend toward these patients being older, Caucasian and female.

Gunshot Victims at a Major Level I Trauma Center: A Study of 343,866 Emergency Department Visits

BackgroundDisturbing trends regarding the sex, age, and race of gunshot victims have been reported in previous national studies; however, gunshot trends have not been well documented in individual cities in the southeastern United States. Objectives1) Analyze trends in gunshot wounds, particularly the association between gunshot wounds and race, among victims presenting to a Level I Trauma Center in Middle Tennessee; 2) Compare specific characteristics of gunshot victims to the general Emergency Department (ED) population. MethodsThis is a retrospective cohort study of 343,866 ED visits from 2004 to 2009. ResultsCompared to the general ED population, gunshot victims were more predominantly male (87.5% vs. 43.4%), black (57.6% vs. 29.5%), younger (47.8% under age 25 years vs. 31.6%), and demonstrated higher Medicaid enrollment (78.6% vs. 44.7%). The majority of black gunshot victims were aged 18–25 years (47.1%) and victims of assault (65.9%). Non-black gunshot victims suffered more unintentional (40.2% vs. 28.2%) and self-inflicted (9.1% vs. 0.4%) injuries and were more evenly distributed among ages 18–55 years. Black patients were 3.03 (95% confidence interval 2.93–3.14) times more likely to present to this ED for gunshot wounds than non-black patients, after controlling for age, sex, and insurance status (p < 0.001). ConclusionsOur study demonstrates that black patients between 18 and 25 years of age presenting to this trauma center are more likely to be victims of gun violence than their non-black counterparts. Our study evaluates trends in gun violence in the Southeast, particularly in relation to race, age, and insurance status.

Leaving the paediatric emergency department without being seen: Understanding the patient and the risks

The aim of this study is to examine the left-without-being-seen (LWBS) patient population of a tertiary paediatric emergency department (ED) to provide quality assurance and risk management data. This is a prospective observational study of patients who LWBS after presenting to the Royal Children's Hospital Melbourne ED between July and November 2005. Information was collected from electronic databases and follow-up telephone interviews performed by the principal investigator 3-5 days after the presentation. Over the 17-week study period, 7.6% of attendances were recorded as having LWBS. These patients and their presentations resembled the general ED population in many respects. However, there were several significant differences, particularly in relation to age, insurance status, mode of arrival, referral status, arrival time and illness severity. Most families (74%) indicated they would have been equally happy to visit a general practitioner instead had one been available. Prolonged waiting times and recognition that their child's illness was not severe were the most frequent reasons for leaving. Most parents subsequently accessed alternate health care or were planning to do so, and the majority stated their child's illness was improving. Parents maintained a surprisingly positive attitude to their ED presentation. The individual risks associated with leaving the ED before a child has been medically assessed are small. However, when multiplied several thousandfold as a function of the frequency of LWBS patients, the chance of serious adverse events becomes real. Potential risk management strategies include decreasing absolute LWBS numbers by addressing ED overcrowding and providing alternate sources for non-urgent care.

The profile and follow-up of patients who attend the Emergency Department following a fall

Falls in the older population are associated with increased morbidity and mortality especially in the absence of risk reduction measures. The study aims were to compare the characteristics of older people who present to the Emergency Department (ED) following a fall with the general older ED population and examine referral patterns following ED discharge. Face-to-face interviews were carried out with 306 people aged 65 years or older. Data was collected on demographic, socio-economic, health and social support factors. Descriptive and inferential statistics (Pearson chi-square test or independent t-test) were used to compare the falls and non-falls group. Falls occurred in 17% (53/306) of the study population and 43% sustained an injury requiring medical intervention. Patients in the falls group were significantly more likely to be female (68%), older (79 years (SD 6.6)) and living alone (59%). The physical and mental health profile of the falls and non-falls group was similar with 30-40% of people in both groups experiencing moderate to severe physical health impairment. A third of the falls group was discharged from the ED without evidence of referrals. The older population that present to the ED following a fall requires comprehensive risk factor assessment especially physical function and referrals that include falls prevention. Implications for staff: ED staff need to examine current practice within their ED in relation to falls assessment, management and referral pathways.

Expectations of Care, Perceived Safety, and Anxiety following Acute Behavioural Disturbance in the Emergency Department

Objective. We explored perspectives of emergency department users (patients and visitors) regarding the management of acute behavioural disturbances in the emergency department and whether these disturbances influenced their levels of anxiety. Methods. Emergency department patients and visitors were surveyed using the State-Trait Anxiety Inventory, and a purpose-designed questionnaire and semistructured interview. The main outcome measures were themes that emerged from the questionnaires, the interviews, and scores from the state component of the State-Trait Anxiety Inventory. Results. 70 participants were recruited. Users of the emergency department preferred behaviourally disturbed people be managed in a separate area from the general emergency department population so that the disturbance was inaudible (n = 32) and out of view (n = 40). The state anxiety levels of those that witnessed an acute behavioural disturbance were within the normal range and did not differ to that of ED patients that were not present during such a disturbance (median, control = 37, Code Grey = 33). Conclusions. Behavioural disturbances in the emergency department do not provoke anxiety in other users. However, there is a preference that such disturbances be managed out of visual and audible range. Innovative design features may be required to achieve this.

Derivation and reliability of an instrument to estimate medical benefit of emergency treatment

Objectives For many patients, it is difficult to define the benefit derived from a visit to the emergency department (ED). No criterion standard exists that defines benefit from emergency treatment compared to routine outpatient care, and our limited ability to estimate benefit from emergency treatment has significant implications for emergency care-related health services research. The objectives of this study were to develop a decision algorithm to be used in estimating benefit of emergency treatment (EBET) and to assess its reliability when applied to patients making unscheduled ED visits. Methods The EBET instrument defines benefit as a 3-level outcome, namely, significant, possible, or unlikely, and its content validity was assessed through expert review. The instrument was independently applied by multiple investigators to 3 different ED patient cohorts. A consensus-based process was used to determine the final EBET for each patient visit. Weighted κs and their 95% confidence intervals were calculated to assess the reliability of the EBET Instrument applied individually, and the Spearman-Brown formula was used to assess the overall reliability of the EBET instrument when applied using multiple raters and a standardized consensus process. Results A total of 875 visits (300 from a general ED population, 300 from a homeless ED population, and 275 from an HIV-infected ED population) were scored using the EBET instrument. The consensus process included independently scoring groups ranging from approximately 50 to 100 patient visits, determining the level of agreement, discussing the discordant results among the investigators, and assigning a final EBET category to each visit. This process was repeated sequentially until all visits within each cohort were scored. The overall weighted κs ranged from 0.66 to 0.76, and the Spearman-Brown correlation ranged from 0.83 to 0.87. Conclusions The EBET instrument demonstrated good to excellent reliability when applied independently by raters to both unselected and selected ED patients. Its reliability, however, was excellent to outstanding when multiple raters applied it using a consensus process. The EBET instrument may serve as a useful tool for defining benefit from emergency treatment.

97: An Analysis of Emergency Department Utilization by Intellectually Disabled Adults

Intellectually disabled (ID) adults are a growing and rarely studied emergency department (ED) population. To aid in their ED management, our objectives were to identify what factors increase the likelihood of ED utilization among ID adults and determine how their ED and hospital discharge diagnoses differ from the general adult ED population.

Hyper-use of the ED

Objectives This study aims to describe the population that averages one or more emergency department (ED) visits per month and compare them to the general ED population to determine if there are associated characteristics. Methods A retrospective cohort study conducted in a teaching hospital between January 1, 2001, and December 31, 2004, identified all patients with more than 35 visits. This hyper-user (HU) cohort (n = 49) was compared to a randomly selected group of non-HU patients (n = 50) on the following measures: age, sex, insurance coverage, primary medical doctor (PMD), dwelling location, chief complaint, comorbidities, and disposition. Results The HU group was significantly older (mean, 49.45 years) than the non-HU group (37.32 years) with a P < .0001. There was no difference between the groups in sex, insurance coverage, PMD, dwelling location, and disposition. A univariant logistical regression found that previous cardiovascular, genitourinary, or psychiatric disease were predictors of hyper-use. Conclusions The HU group is older and more likely to have a history of cardiovascular, genitourinary, and psychiatric disease but is similar to the non-HU group in other measured parameters. The HU group appears to have equal access to a PMD and is not more likely to be admitted to the hospital than the non-HU group.

105: Emergency Department Hyperutilization

Emergency Department (ED) overcrowding is a significant issue across the U.S. Recent studies attempting to identify frequent utilizers of the ED have set the threshold very low (2-3 visits/year). We have coined a novel term, Hyperutilizer (HU) to define that population that averages 1or more visits/month over the study period of three years. Our purpose was to describe this population, and compare this group to the general ED population to determine if there are identifiable risk factors associated with hyperutiliaztion.

A Descriptive Study of Heavy Emergency Department Users at an Academic Emergency Department Reveals Heavy ED Users Have Better Access to Care Than Average Users

Emergency department (ED) overcrowding has been a significant problem for the last 10 years. Several studies have shown that a relatively small number of ED patients are responsible for a disproportionate amount of ED visits. This study aims to describe the frequent users of our emergency department. This was an institutional review board-approved descriptive study performed by a retrospective review of electronic records. This pilot describes and compares patients who had 12 or more ED visits during the study year with those who visited less. The 234 patients who met criteria for high-frequency use (HFU) of the emergency department were responsible for a total of 4633 visits. Sex, race, and age distribution of HFU patients were similar to those of general ED patients. Eighty-four percent of HF users have insurance and 93% have primary care providers. A relatively small percentage of HFU visits, 4%, were mental health-related visits and 3% were alcohol- and drug-related visits. The HFU visits are socially connected: 93% have their own homes; 94% have relatives or friends; 73% have a religious affiliation. Pain or pain-related conditions are the most common diagnoses. These patients are also frequent users of ambulatory care services. The similarities between our HFU and the general ED population are more numerous than their differences. The HFU patients of our emergency department are different in terms of age, employment status, and type of insurance. IMPLICATIONS FOR NURSES: A detailed description of local HFU may help to inform planning and better meet ED patients' needs. As one of many results of this study, the ED chairman met with the Hematology-Oncology team and reviewed the protocol for ED management of sickle cell crisis. The meeting resulted in a revised protocol, including an immediate change in their pain medication from meperidine to either morphine or hydromorphone.

Patients who leave the emergency department without being seen by a physician: a control-matched study

To describe the socio-demographic characteristics and clinical outcomes of patients who leave the emergency department (ED) without being seen by a physician. This 3-month prospective study was conducted at a downtown Toronto teaching hospital. Patients who left the ED without being seen (LWBS) were matched with controls based on registration time and triage level. Subjects and controls were interviewed by telephone within 1 week after leaving the ED. During the study period, 386 (3.57%) of 10,808 ED patients left without being seen. One-third of these had no fixed address or no telephone, and only 92 (23.8%) consented to a telephone interview. They cited excessive wait time as the most common reason for leaving the ED (in 36.7% of cases). Despite leaving the ED without being seen, they were no more likely than those in the control group to seek follow-up medical attention (70 % in both groups). Among those from both groups who did seek follow-up, the LWBS patients were more likely to do so the same day or the day after leaving the ED. The LWBS patients often lacked a regular physician (39.1% v. 21.7%; p = 0.01) and were more likely to attend an ED or urgent care clinic (34.8% v. 12.0%; p < 0.001). Controls were more likely to follow up with a family physician (37.0% v. 23.9%; p = 0.06). The LWBS and control groups did not differ in subjective health status at 48 hours after leaving the ED, nor in subsequent re-investigation in hospital. Patients who leave the ED without being seen have different socio-demographic features, methods of accessing the health care system, affiliations and expectations than the general ED population. They are often socially disenfranchised, with limited access to traditional primary care. These patients are generally low acuity, but they are at risk of important and avoidable adverse outcomes.

An academic emergency department experience with prosthetic hip dislocation: A five-year retrospective study

Study objectives: Dislocation is a common complication after total hip arthroplasty (THA) that occurs in 2% to 5% of primary THA patients and up to 27% of patients after revision THA. Few medical publications have addressed the proper management and potential complications of prosthetic hip dislocation. No large emergency department (ED) series on this entity has been reported to date. The purpose of this study is to determine the rate of successful reduction in the ED and the incidence and type of acute complications seen with prosthetic hip dislocation patients. Methods: This was a retrospective explicit medical record review approved by the institutional review board and conducted in an academic ED with an annual census of 52,000 visits. Study dates were February 1, 1999, to February 22, 2004. Patients were identified using ED admission and discharge diagnosis. All patients recognized as having prosthetic hip dislocation were included in the study, with exclusion of nonprosthetic injuries. Two trained abstractors used a standardized sequential medical record review to extract predefined variables including age, location of reduction, physician(s) performing the reduction, and the presence of any orthopedic complication. An orthopedic complication was defined as any reported osseous, hardware, neurologic, or vascular injury. Results: The cohort was composed of 116 patient encounters during a 5-year period made up of 66 individuals with prosthetic hip(s). The mean age was 65 years. Four of the 116 patients were taken directly to the operating room for closed reduction without any attempts in the ED. Of the remaining 112 patients, 102 (91%) had successful reductions performed in the ED. Eighty-one patients had hip reduction attempted by an emergency physician, with a 91% success rate. Twenty-eight (90%) of the remaining 31 patients had successful reduction performed by either an orthopedic surgeon or an emergency physician and an orthopedic surgeon while in the ED. No pre- or postreduction complications were recorded. Conclusion: Previous published series of hip dislocation have come from orthopedic literature and have largely focused on demographics and operative theory. We sought to determine the incidence of successful relocation by emergency physicians in a general ED population while accounting for any associated orthopedic complications. The finding that ED staff was successful in reducing prosthetic hip dislocations in a large majority of the patients is significant, as is the fact that it can be done without evident complication.

Is the adult emergency department really adults only?

AbstractObjectivesTo quantify the use of an adult emergency department (ED) by paediatric patients and identify the acuity and spectrum of these presentations.To determine the seniority and paediatric experience of emergency department staff involved with these patients.To address the appropriateness of the paediatric guidelines in an ‘adult only’ emergency department.SettingThe Royal Melbourne Hospital, an ‘adult only’ metropolitan tertiary hospital with 40,000 ED presentations annually and an admission rate of 30%.MethodsPaediatric (18 years and under) ED attendances were recorded retrospectively over 12 months. Prospective data were then gathered for two weeks on acuity, clinical data and disposition for each patient as well as seniority and extent of paediatric training of medical staff involved.ResultsPaediatric patients accounted for 3.9% of presentations in the retrospective study and 2.8% in the prospective study. In the younger age groups, paediatric patients were of higher acuity, with greater admission rates and less trauma than average, with opposite trends in adolescents. Amongst the adolescent group the rate of patients ‘who did not wait’ was double that of the general ED population. Most patients (74%) were managed by staff with no paediatric training. Australasian College for Emergency Medicine (ACEM) advanced trainees were the most confident in managing children.ConclusionsPaediatric patients do present to this ‘adult only’ ED. In this setting medical staff experience and training in paediatric management is variable. Suitable training and guidelines should be considered to address this issue. This study supports the ACEM requirement for paediatric training and has implications for emergency medicine paediatric training and Continuing Medical Education programs in the future. Multicentre studies, incorporating patient outcome data, would further clarify these issues.

Prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury.

To assess the prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury, a prospective, nonconsecutive case series with nonrandomized controls was used. All patients presenting to a 60,000-visit public hospital emergency department with alcohol-related illness or injury were eligible; patients were excluded if they had received folate in our health care facility within the previous 4 months. An alcohol and brief dietary history was obtained, and a complete blood cell count and red blood cell folate level was performed on each patient. Analysis was undertaken by chi 2 to evaluate the prevalence of folate deficiency in the alcohol-related versus the control population. One hundred three patients were entered into the study. Three patients were subsequently excluded from analysis. Of 52 study patients, three (5.8%) were found to be folate deficient. Of 48 controls, two (4.2%) were found to be folate deficient. This difference is not statistically significant (P greater than .05, chi 2; mean difference 1.6%, 95% confidence interval -6.9% to 10.1%). The prevalence of folate deficiency in patients presenting to this emergency department with alcohol-related illness or injury is low, and does not differ from the general emergency department population. Empiric folate therapy in these patients is not indicated.