Higher Emergency Department Research Articles

The Complexity of Complex Patients.

A s the population of the United States ages, and more and more people live with multiple chronic conditions, the issue of complex patients is receiving increasing attention. Physicians have recognized that disease-centric approaches to clinical management have serious limitations for patients with multiple co-occurring medical conditions. This dialogue has been broadened to include multiple sources of complexity, moving well beyond pathophysiology and multiple co-occurring medical conditions, to behavioral and psychosocial sources of complexity that often overshadow physiology as a barrier to achieving optimal health. In this issue of JGIM, Hong, et al. cite their earlier studies demonstrating that this broad conceptualization of complexity resonates with primary care physicians. In those studies, primary care physicians recognized multiple influences on what makes a patient complex, including psychosocial and behavioral domains, not just medical comorbidities. The fact that these doctors considered the ‘whole patient’ in their conceptualizing of complexity is reassuring and bodes well for primary care. This broad primary care perspective raises interesting issues for scientists wishing to develop tools to identify complex patients using data extracted from the electronic health record and insurance claims. The novel prediction tool developed by Hong et al. and reported in this issue of JGIM was designed to mimic physician designation of complexity, and it did indeed identify many individuals not identified by more established tools specifically designed to predict utilization—including the Charlson index modified for use in ambulatory care data and a commercial risk prediction tool. An important finding of the study by Hong et al. is that these established tools did very well in predicting emergency department (ED), hospital utilization, and 30-day readmission rates. It is perhaps not surprising that these older tools were not as good at predicting other processes (primary care visits and no-shows) and outcomes of care (cancer screening, risk factor control), for which they were, after all, not designed. The authors rightly conclude that their novel approach may be utilized as a complement to other methods to identify additional at-risk patients, depending on the context. However, all of the methods evaluated in the report by Hong et al. have important limitations for identifying complex patients. For example, the novel prediction tool demonstrated low sensitivity (<50 %) for identifying patients with physician-designated complexity. The more established tools in this study were designed primarily to identify high utilizers, but additional endpoints, such as preventive services and risk factor control, are important in primary care. On the other hand, the tool described by Hong et al. missed many patients identified by the more established risk-prediction tools. Each of these approaches, considered alone, may be insufficient to meet the needs of ambulatory population health managers. One potential strategy to overcome these limitations would be to recognize that one tool is unlikely to suffice for identifying all complex patients. Indeed, especially from the broad perspective of primary care physicians, it quickly becomes clear that interventions will likely differ dramatically depending on which aspect of complexity is the primary driver. For example, a patient who is complex because of multiple endstage conditions, such as co-occurring heart failure and chronic obstructive lung disease, is likely to require very different interventions to preserve health and functioning than one who is complex because of depression. And these patients will require altogether different approaches than a patient who is complex due to homelessness. It therefore follows that we need more work to reliably identify at-risk patients for specific influences along a spectrum of complexity—e.g., psychosocial influences, biological influences, environmental influences—in addition to more generic tools such as the one presented in the study by Hong et al. Of course, in many cases, there will not be a single driver, and amore individualized case management approach may be most effective. To some extent, health system leaders are already employing strategies to identify and manage complex patients. For example, patients who frequently use the ED are being identified for case management using the simple approach of creating a registry of patients who use the ED frequently. Managers of patient-centered medical homes identify patients who miss appointments as targets for outreach and problemsolving. This straightforward approach is most useful when one particular type of complexity is the main driver of unwanted outcomes—e.g., homelessness and high ED use in winter—and the reason for unwanted outcomes is obvious. Published online August 11, 2015

What we have learned from a decade of ED crowding research.

What we have learned from a decade of ED crowding research.

Emergency department use among children with tracheostomies: Avoidable visits.

To characterize high emergency department (ED) use by children with tracheostomies and complex chronic conditions, to distinguish avoidable from unavoidable ED visits, and to describe the financial impact of avoidable visits. Children with tracheostomies in a pediatric tertiary care center with the highest ED utilization were identified via analysis of administrative data. Six experts in interdisciplinary dyads reviewed the records from all ED visits for these children, and distinguished avoidable from unavoidable visits. Hospital cost data for avoidable visits is described. Among 75 children with tracheostomies and complex chronic conditions, 23 (31%) were high ED utilizers. These 23 children accounted for 74% of all ED discharges the total group of 75 children from 2008 to 2011. Four of these 23 children with high utilization were excluded, leaving 19 subjects for review. These 19 children had 312 ED visits, of which 103 (33%) were deemed avoidable. Leading reasons for avoidable visits were uncomplicated upper respiratory infections, gastrointestinal infections, and enteral feeding system problems. Avoidable visits cost the hospital {$}67,940. One-third of ED visits by children with tracheostomies and complex chronic conditions may be avoidable. Increased ambulatory access to interdisciplinary teams of providers familiar with these children's unique needs might reduce avoidable ED visits and improve health outcomes. Further studies on how this model of ambulatory care might affect ED utilization and total healthcare costs are needed.

Using Syndromic Surveillance Data to Describe Chronic High Frequency ED Utilization

Study aims to use existing syndromic surveillance data to describe demographic and utilization characteristics among chronic high frequency emergency department (ED) users in order to better understand the health complaints affecting this population. A retrospective study was conducted from 44 acute care hospital EDs between January 1, 2012 and December 31, 2013. Analyses were conducted at the patient level based on medical record number and at the visit level based on chief complaint to characterize health complaints. This assessment determined a portion of visits by high frequency ED users could be directed to other health care services for appropriate treatmenterin.austin@vdh.virginia.gov

Predictors of Low-Acuity Emergency Department Use by Patients Enrolled in a Family Health Team.

The primary aim of this study was to determine the characteristics and develop a predictive model describing low acuity users of the emergency department (ED) by patients followed by a family health team (FHT). The secondary aim was to contrast this information with characteristics of high acuity users. We also sought to determine what factors were predictive of leaving without being seen (LWBS). This retrospective descriptive correlational study explored characteristics and factors predictive of low acuity ED utilization. The sample included all FHT patients with ED visits in 2011. The last ED record was chosen for review. Sex, age, Canadian Triage and Acuity Scale (CTAS), presenting complaint(s), time of day, day of week, number of visits, and diagnosis were recorded. Of 1580 patients who visited the ED in 2011, 56% were CTAS 1-3 visits, 24% CTAS 4-5 and 20% had no CTAS recorded. Patients who were older than age 65 were approximately half as likely to have a CTAS level of 4-5 compared to younger patients (OR=0.605, CI=0.441,0.829). Patients older than age 65 were 1.75 times more likely to be CTAS level 1-2 (OR=1.745, CI=1.277, 2.383). Patients who went to the ED during the day were less likely to LWBS compared to night visits (OR=0.697, CI=0.532, 0.912). Interpretation Most low acuity ED utilization is by patients under the age of 65, while high acuity ED utilization is more common among patients older than age 65. Patients are more likely to LWBS during late evening and overnight periods (9 pm-7 am).

Spatial patterns of epilepsy-related emergency department visits in california.

BackgroundSocio-demographic factors are associated with increased emergency department (ED) use among patients with epilepsy. However, there has been limited spatial analysis of such visits.Design and methodsCalifornia ED visit at the patient ZIP Code level were examined using Kulldorf’s spatial scan statistic to identify clusters of increased risk for epilepsy-related visits. Logistic regression was used to examine the relative importance of patient socio-demographics, Census-based and hospital measures.ResultsDuring 2009-2011 there were 29,715,009 ED visits at 330 hospitals, of which 139,235 (0.5%) had epilepsy (International Classification of Disease-9 345.xx) as the primary diagnosis. Three large urban clusters of high epilepsy-related ED visits were centred in the cities of Los Angeles, Oakland and Stockton and a large rural cluster centred in Kern County. No consistent pattern by age, race/ethnicity, household structure, and income was observed among all clusters. Regression found only the Los Angeles cluster significant after adjusting for other measures.ConclusionsGeospatial analysis within a large and geographically diverse region identified a cluster within its most populous city having an increased risk of ED visits for epilepsy independent of selected socio-demographic and hospital measures. Additional research is necessary to determine whether elevated rates of ED visits represent increased prevalence of epilepsy or an inequitable system of epilepsy care.Significance for public healthThere have been few spatial analyses regarding treatment for epilepsy. This paper significantly expands upon previous work by simultaneously considering multiple urban centres and sparsely populated agricultural and desert/mountain areas in a large state. Furthermore, most epilepsy studies involve one system of care or funding source (such as Department of Veterans Affairs, Medicare, Medicaid, or private insurance plans). This paper considers all funding sources at community-based hospitals. Patient socio-demographics, area-based summaries of socio-demographics, and basic hospital characteristics explain most of the observed spatial variation in rates of emergency department (ED) visits related to epilepsy. However, preliminary spatial analysis demonstrated that an area within downtown Los Angeles did have a higher rate of epilepsy-related visits compared to the rest of the state. A more comprehensive surveillance approach with ED visit data could be readily applied to other large geographic areas and be useful both for on-going monitoring and public health intervention

Preemptive Genotyping of CYP2C8 and CYP2C9 Allelic Variants Involved in NSAIDs Metabolism for Sickle Cell Disease Pain Management.

Interindividual variability in analgesic effects of nonsteroidal anti-inflammatory drugs prescribed for sickle cell disease (SCD) pain is attributed to polymorphisms in the CYP2C8 and CYP2C9 enzymes. We described CYP2C8 and CYP2C9 genotype/phenotype profiles and frequency of emergency department (ED) visits for pain management in an African American SCD patient cohort. DNA from 165 unrelated patients was genotyped for seven CYP2C8 and 15 CYP2C9 alleles using the iPLEX ADME PGx multiplexed panel. CYP2C8*1 (0.806),*2 (0.164), *3 (0.018), and *4 (0.012) alleles were identified. Genotype frequencies were distributed as homozygous wild type (66.7%), heterozygous (27.8%), and homozygous variant/compound heterozygous (5.4%), respectively. CYP2C9*1 (0.824), *2 (0.027), *3 (0.012), *5 (0.009), *6 (0.009), *8 (0.042), *9 (0.061), and *11(0.015) were observed with extensive (68.5%), intermediate (18.1%) and poor predicted metabolizers (0.6%), respectively. Fifty-two and 55 subjects, respectively had at least one variant CYP2C8 or CYP2C9 allele. Although the distribution of the CYP2C9 (p = 0.0515) phenotypes was marginally significantly in high and low ED users; some CYP2C8 and CYP2C9 allelic combinations observed in 15.2% (25) of the cohort are associated with higher risks for analgesic failure. CYP2C8 and CYP2C9 preemptive genotyping could potentially enable clinicians to identify patients with impaired metabolic phenotypes.

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study.

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

Creatinine, Lactate Dehydrogenase, and C-Reactive Protein As Indicators of Acute Vaso-Occlusive Crisis and Sickle Cell Disease Severity in the Emergency Department

Sickle cell disease (SCD) patients often seek care in the Emergency Department (ED) due to vaso-occlusive crisis (VOC), the most common complication of SCD. Currently, no diagnostic test can determine if a SCD patient is having an acute VOC. This study analyzed the utility of creatinine (Cr), C-reactive protein (CRP), and lactate dehydrogenase (LDH) as indicators of acute VOC and increased disease severity. We hypothesized that increased levels of these markers correlated with acute VOC and increased SCD severity because they are suggestive of renal injury, accelerated hemolysis, and inflammation with VOC onset.Data was collected from a cohort of 171 patients followed at an adult sickle cell clinic from 2005 to 2012. Eligibility criteria included a minimum age of 18 with SCD genotypes Hb S/S, Hb S/C, Hb S/B+, or Hb S/B0. Marker values were collected prospectively, with baseline values obtained during non-crisis visits to the sickle cell clinic, and crisis values obtained during treatment for VOC in the ED. Patients were categorized as high or low ED users to approximate disease severity using two methods. Aggregate (AG) analysis assigned patients to the high user group, 65 patients (38%), if they had >3 VOC ED visits in any year. The low user group, 106 patients (62%), had 3 or less VOC ED visits in any year. Since disease severity fluctuates in individual patients over time, a second analysis divided the groups using an individual (IN) analysis where high user-years were defined as >3 VOC ED visits/year. IN analysis resulted in 226 (47%) high user-years and 259 (53%) low user-years. Statistical analysis using R Version 3.1.0 compared overall average baseline and crisis values to determine if biomarker levels increased in acute VOC. High and low user values were compared with respect to baseline and crisis averages to determine if biomarker levels correlated with SCD severity. Analysis of baseline and crisis values over the study period evaluated changes with age. Statistical significance was set to p<0.05.Table 1 summarizes the significant results of the statistical analysis. Changes in Cr and LDH between high and low users with respect to baseline, crisis, and difference between baseline and crisis were not statistically significant in both analyses. However, crisis CRP values between high and low user-years differed significantly. In both analyses, overall baseline and crisis Cr and LDH differed significantly. Crisis Cr and baseline LDH increased significantly over the 7-year time span.Table 1MarkerVariableMeanSDP-valueCr (mg/dL)AG overall baseline0.800.6870.0053AG overall crisis1.081.55IN overall baseline0.8170.9310.0178IN overall crisis1.001.48Overall crisis start1.021.590.0087Overall crisis end1.101.76LDH (U/L)AG overall baseline3871967.90E-5AG overall crisis463227IN overall baseline3952280.0194IN overall crisis445269Overall baseline start3731810.0015Overall baseline end417234CRP (mg/dL)IN high user crisis2.614.310.0247IN low user crisis1.051.02Creatinine, a urinary muscle metabolite, is a marker of kidney function. Dehydration, a potential cause of VOC, may explain the rise in Cr during crisis. LDH increase in crisis reflects increased intravascular hemolysis during VOC. The results support the utility of Cr and LDH as indicators of acute VOC in the ED. However, both AG and IN analyses reveal no distinction between high and low users of the ED. LDH and Cr increase with age, suggesting potential for monitoring SCD disease progression. Increased Cr crisis levels with age may reflect kidney dysfunction due to medullary ischemia from multiple VOCs. Increased non-crisis LDH levels with age suggest increased disease severity, progressive organ damage, and steady state pro-inflammatory conditions.CRP, an acute phase reactant indicative of systemic inflammation, was higher during crisis in high user-years than in low user-years. The correlation of increased crisis CRP to increased ED usage may represent a higher inflammatory state in these patients. Further studies are needed to determine the cause and effect relationship of this correlation.The data supports the utility of Cr and LDH as markers for acute VOC. LDH and Cr also demonstrate potential as indicators of SCD disease severity in a long-term context, while CRP demonstrates potential to monitor for short-term inflammatory states leading to increased severity in frequency and possibly intensity of VOC. DisclosuresNo relevant conflicts of interest to declare.

Elevated Steady State WBC and Platelet Counts Are Associated with Frequent Emergency Room Use in Adults with Sickle Cell Disease

Patients with sickle cell disease (SS/Sβ0) often utilize the emergency department (ED) for treatment of painful vaso-occlusive crisis and other sequalae of their disease. However there is significant variation in use, with a minority of patients making up the majority of visits. We studied whether objective steady state laboratory parameters might be associated with frequent ED use and whether hydroxyurea use modified this relationship.Methods: We identified all patients with sickle cell disesase seen at our medical center in 2012. Patients were identified as having sickle cell disease if hemoglobin (Hb) electrophoresis demonstrated sickle hemoglobin (HbS), fetal hemoglobin (HbF) and HbA2 but no Hemoglobin A, C, or other detectable hemoglobinopathies. ED, clinic, and inpatient admissions over the entire year were calculated and ED use was categorized as either 0-1, 2-5, or >6 visits a year. Steady state laboratory tests were defined as those not within a day of an ED visit or a week of a hospital admission. All 2012 steady state parameters retrieved for a given laboratory test for a given patient were averaged. “Active” laboratory tests, defined as those within one day of an ED visit, were averaged separately. HbF and weight were not separated by activity. Data were analyzed for normality; parametric values were assessed by mean and SD, non-parametric values were assessed as medians and interquartile ranges. Parametric and non-parametric bivariate tests of association were used as appropriate.Results: 432 adult sickle cell patients were identified, ages 18-87yrs; 54% were female. 181 patients had 0-1 ED visits within the year, 143 had 2-5 visits in the year and 96 had >6 visits for a total of 2259 visits. Patients who had >6 visits accounted for 1750 (77%) of the total visits for the year. When steady state labs were examined, high WBC and platelet counts were most strongly associated with frequent admissions. Steady state WBC of >12.0 x10^9/L were significantly more likely to have >6 visits/year (OR 2.6; 95% CI: 1.6-4.2, p=.0004). Platelet counts of >420 x10^9/L were also strongly associated with >6 ED visits (OR 2.6, 95% CI:1.5-4.4, p=.0007). LDH and AST were also shown to correlate significantly with ED (p=0.02 and 0.005 respectively) use while Hb and albumin were negatively associated (p<0.001 and 0.02 respectively). Hydroxyurea scripts were associated with increased ED visits (p<0.001); 38.1% of the population had been given a script for hydroxyurea within the year; patients with frequent ED use were 2.8x more likely to have been given a script for hydroxyurea within the year. These patients had higher MCV and Hb levels and lower, but still elevated, WBC and platelet counts per ED visit cohort stratification, a suggestion that hydroxyurea was being taken, but despite this, had similar significant associations with ED visits as the non-hydroxyurea group. MCV, MCHC, absolute reticulocyte count, weight, and %HbF did not demonstrate an association with ED visit frequency. When “active” parameters were examined, leukocytosis was present in all categories and WBC count could no longer predict a predisposed cohort; Hb level, LDH and AST were also no longer significant. Albumin and platelet count remained associated with ED visits. When older patients >40 yrs (n=124) were compared with <40yrs (n=308 ), high WBC and platelet counts remained significantly associated with high (>6) ED visits in both cohorts.Conclusions: Our data suggest that baseline WBC and platelet count are strongly associated with frequent ED utilization and may be better predictors than Hb, HbF, and other red cell or hemolytic parameters. Hydroxyurea use was not associated with fewer ED visits but those patients with frequent ED use still have relatively higher WBC and platelet counts than those with less frequent ED use, suggesting that hydroxyurea under-dosing may be an important issue. To what extent objective steady state parameters can identify a population that needs more aggressive baseline care and to what extent maximization of therapy can decrease frequent ED visits needs further study. DisclosuresNo relevant conflicts of interest to declare.

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.

An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI. We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older. We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses. Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.

Emergency department use and expenditures among cancer survivors in the United States, 2008-2011.

3 Background: The number of cancer survivors in the US surpassed 13 million in 2012. In response to rising costs or care and greater demand for services, recent national reports and policies promote cancer care coordination to reduce costly and potentially avoidable services such as Emergency Department (ED) visits. Such efforts must be informed by reliable estimates and improved understanding of ED use and costs among oncology patients. This study quantifies the extent to which cancer survivors use the ED compared to individuals with other chronic conditions and estimates related annual expenses. Methods: Data from the 2008-2011 Medical Expenditure Panel Survey (MEPS) and survey-weighted regression models were used to determine the odds of any ED use (logistic), counts of ED visits (negative binomial) and mean annual medical expenditures attributed to ED use (generalized linear models) in three groups of respondents: cancer survivors, those with chronic conditions other than cancer, and those with neither (reference group). All models were adjusted for important confounding variables (age, sex, race/ethnicity, education, health insurance and health status). Estimates are generalizable to US non-institutionalized populations. Results: Among individuals with cancer, other chronic conditions, and neither condition, 17%, 15% and 9% visited the ED, respectively. Mean annual expenditures attributed to ED use among those with visits were $1471 (95% CI: $1262-$1678), $1517 (95% CI:$1395-$1640) and $1106 (95% CI: $984-$1228). Cancer survivors and individuals with other chronic conditions consistently had significantly higher ED use and costs than did the reference group. The likelihood of having any ED visit was similar between cancer survivors and those with other conditions, however cancer survivors incurred more visits (IRR: 1.17; 95% CI: 1.01, 1.36). Conclusions: ED use and expenditures are substantial among cancer survivors and equal or exceed the same outcomes in individuals with other chronic conditions. Future research is recommended to explore specific areas of unmet health need that may be driving increased frequency of ED visits in the growing population of cancer survivors.

Is low health literacy associated with increased emergency department utilization and recidivism?

The objective was to determine whether patients with low health literacy have higher emergency department (ED) utilization and higher ED recidivism than patients with adequate health literacy. The study was conducted at an urban academic ED with more than 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross-sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (S-TOFHLA) and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis and retaining those significant at an alpha of 0.05 in the final model. Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days.

Summertime acute heat illness in U.S. emergency departments from 2006 through 2010: analysis of a nationally representative sample.

Background: Patients with acute heat illness present primarily to emergency departments (EDs), yet little is known regarding these visits.Objective: We aimed to describe acute heat illness visits to U.S. EDs from 2006 through 2010 and identify factors associated with hospital admission or with death in the ED.Methods: We extracted ED case-level data from the Nationwide Emergency Department Sample (NEDS) for 2006–2010, defining cases as ED visits from May through September with any heat illness diagnosis (ICD-9-CM 992.0–992.9). We correlated visit rates and temperature anomalies, analyzed demographics and ED disposition, identified risk factors for adverse outcomes, and examined ED case fatality rates (CFR).Results: There were 326,497 (95% CI: 308,372, 344,658) cases, with 287,875 (88.2%) treated and released, 38,392 (11.8%) admitted, and 230 (0.07%) died in the ED. Heat illness diagnoses were first-listed in 68%. 74.7% had heat exhaustion, 5.4% heat stroke. Visit rates were highly correlated with annual temperature anomalies (Pearson correlation coefficient 0.882, p = 0.005). Treat-and-release rates were highest for younger adults (26.2/100,000/year), whereas hospitalization and death-in-the-ED rates were highest for older adults (6.7 and 0.03/100,000/year, respectively); all rates were highest in rural areas. Heat stroke had an ED CFR of 99.4/10,000 (95% CI: 78.7, 120.1) visits and was diagnosed in 77.0% of deaths. Adjusted odds of hospital admission or death in the ED were higher among elders, males, urban and low-income residents, and those with chronic conditions.Conclusions: Heat illness presented to the ED frequently, with highest rates in rural areas. Case definitions should include all diagnoses. Visit rates were correlated with temperature anomalies. Heat stroke had a high ED CFR. Males, elders, and the chronically ill were at greatest risk of admission or death in the ED. Chronic disease burden exponentially increased this risk.Citation: Hess JJ, Saha S, Luber G. 2014. Summertime acute heat illness in U.S. emergency departments from 2006 through 2010: analysis of a nationally representative sample. Environ Health Perspect 122:1209–1215; http://dx.doi.org/10.1289/ehp.1306796

A test of the diathesis-stress model in the emergency department: Who develops PTSD after an acute coronary syndrome?

Most acute coronary syndrome (ACS) patients first present to the emergency department (ED). Patients who present to overcrowded EDs develop more posttraumatic stress disorder (PTSD) symptoms due to the ACS than do patients who present to less crowded EDs, but no research has indicated whether some patients may be more vulnerable to the effects of ED crowding than others. In an observational cohort study, we tested whether depressed patients developed more ACS-induced PTSD symptoms under conditions of ED overcrowding than patients who had never been depressed. We conducted psychiatric interviews for current and past depression in 189 ACS patients admitted through the ED within a week of hospitalization, and screened for PTSD symptoms 1 month later using the Impact of Events Scale-Revised. The sum of ED admissions for the 12 h prior to and 12 h after each participant's admission was categorized into tertiles for analysis. In a 3 (ED crowding tertile) by 3 (never, past, current depression) analysis of covariance adjusted for demographic and clinical factors, we found significant effects for ED crowding, depression status, and their interaction (all p's < .05). Mean PTSD scores were significantly higher (p = .005) for participants who were currently depressed and were treated during times of high ED crowding [25.38, 95% CI = 16.18–34.58], or had a history of depression [10.74, 95% CI = 6.86–14.62], relative to all other participants, who scored 5.6 or less. These results suggest that depressed ACS patients may be most vulnerable to the stress-inducing effects of ED crowding.

Rate, characteristics, and factors associated with high emergency department utilization

BackgroundPatients with high emergency department (ED) utilization account for a disproportionate number of ED visits. The existing research on high ED utilization has raised doubts about the homogeneity of the frequent ED user. Attention to differences among the subgroups of frequent visitors (FV) and highly frequent visitors (HFV) is necessary in order to plan more effective interventions.In the Netherlands, the incidence of high ED utilization is unknown. The purpose of this study was to investigate if the well-documented international high ED utilization also exists in the Netherlands and if so, to characterize these patients. Therefore, we assessed the proportion of FV and HFV; compared age, sex, and visit outcomes between patients with high ED utilization and patients with single ED visits; and explored the factors associated with high ED utilization.MethodsA 1-year retrospective descriptive correlational study was performed in two Dutch EDs, using thresholds of 7 to 17 visits for frequent ED use, and greater than or equal to 18 visits for highly frequent ED use.ResultsFV and HFV (together accounting for 0.5% of total ED patients) attended the ED 2,338 times (3.3% of the total number of ED visits). FV and HFV were equally likely to be male or female, were less likely to be self-referred, and they suffered from urgent complaints more often compared to patients with single visits. FV were significantly older than patients with single visits and more often admitted than patients with single visits. Several chief complaints were indicative for frequent and highly frequent ED use, such as shortness of breath and a psychiatric disorder.ConclusionsBased on this study, high ED utilization in the Netherlands seems to be less a problem than outlined in international literature. No major differences were found between FV and HFV, they presented with the same, often serious, problems. Our study supports the notion that most patients with high ED utilization visit the ED for significant medical problems.

Data mining of common laboratory tests can be used to identify patients at risk

In deteriorating hospital patients, delayed intervention is associated with increased risk. Common laboratory tests may help identify such patients earlier. We studied the relationship between commonly measured laboratory variables and the occurrence within the next day of a rapid response team (RRT) call or unplanned intensive care unit (ICU) admission or death in patients admitted to hospital for >24h or presenting to the Emergency Department (ED) over a 6 year period. We analysed 5.9 million individual measurements and 559,612 multi-test batches of laboratory tests. We specifically studied 405,826 batches in 41,417 ward patients (average age 64.8 ± 17.5 years) and 153,786 batches in 65,363 ED patients (average age 58.1 ±20.7 years). Among 106,780 patients admitted to hospital, 1024 had at least one RRT call, 142 at least one unplanned ICU admission and 1286 died. In ward patients, total CO 2 (bicarbonate equivalent) had an AUC-ROC of 0.713 for imminent unplanned ICU admission and plasma urea had an AUC-ROC of 0.774 for imminent death. In ED patients, pH had an AUC-ROC of 0.819 for imminent unplanned ICU admission and creatinine had an AUC-ROC of 0.756 for imminent death. In addition, combinations of variables resulted in AUC-ROC values in the 0.80-0.88 range. Laboratory tests could, on average, predict an RRT call 10.2 (ward) or 11.9 (ED) hours before it occurred. In conclusion, data mining of common laboratory tests can be used to quantify risk and assist in the identification of high risk ward or ED patients

High-needs hematology/oncology patients: A quality improvement project.

197 Background: St. Michael’s Hospital (SMH) is an academic, inner-city hospital in Toronto, Canada. In the hematology/oncology (hem/onc) program, a small number of patients appeared to contribute disproportionately to hospital admissions and emergency department (ED) visits. We hypothesized that high needs hem/onc patients could be recognized early in their care and that ED visit and admission rates among these patients could be decreased through targeted interventions. Methods: Members of the hem/onc team were interviewed regarding characteristics, which they felt predicted higher needs and greater liklihood for hospital admission/ED visit. A list of high risk features was generated. ED visit and admission rates for a prospectively identified high needs cohort were compared to rates for the entire hem/onc clinic. An intervention targeting high needs hem/onc patients is on-going. Pre and post-intervention ED visit and admission rates will be compared. Results: Interviews with 3 nurses, 1 social worker, 1 discharge planner, and 4 physicians identified 10 factors that the hem/onc team believed were predictive of higher needs and subsequent higher ED visit and admission rates. Between December 1, 2012, and February 28, 2013, 42 high needs hem/onc out-patients were prospectively identified. The ED visit and admission rates for this cohort were retrospectively compared to those of the entire hem/onc clinic and found to be dramatically higher (Table). Begininng in June 2013, hem/onc patients identified as “high needs” were offered enrollment in a NP-based program offering telephone assessments following ED visits, hospital admissions or discharges. Assessment of the impact of this intervention is ongoing. Conclusions: It is possible to prospectively identify hem/onc patients who are at risk of higher than usual ED visit and admission rates. Identifying this population may provide an opportunity to decrease their ED visit and admission rates. An evaluation of an intervention targeting high needs hem/onc patients is ongoing. Preliminary data will be presented. [Table: see text]

Implementing the Central Venous Catheter Infection Prevention Bundle in the Emergency Department: Experiences Among Early Adopters

Central line-associated bloodstream infections (CLABSI) cause preventable morbidity and mortality. Hospitals have reduced CLABSI by using a bundle of evidence-based infection prevention practices. Systems factors in the emergency department (ED) present unique barriers to bundle adoption, and no guidelines exist for bundle implementation. We aim to identify barriers and facilitators to central line bundle adoption in EDs. We used a qualitative, grounded theory approach, enrolling 6 EDs that were early adopters of the central line bundle. We interviewed 49 administrators and staff (nurses and physicians) through 26 semistructured interviews and 3 focus groups of 6 to 8 individuals. Investigators read each transcript and then iteratively built and refined a set of themes that emerged from the data. Barriers to central line bundle adoption included high acuity, time constraints, staffing, space, ED culture, high ED volume and acuity, role ambiguity, and a lack of methods to track compliance and infection surveillance. Facilitators included champions, staff engagement, workflow redesign that includes a checklist and central line kit or cart, clear staff responsibilities, observer empowerment, and compliance and infection surveillance data. The strategies for implementing and sustaining a central line infection prevention bundle in the ED are distinct from those of other clinical settings. Our findings describe the central line bundle workflow in the ED, staff motivations, and the critical systems factors that impede and foster its use. Knowledge of these systems factors should improve bundle adoption in the ED and thereby reduce hospital incidence of CLABSIs.

Adverse events related to emergency department care: a systematic review.

ObjectiveTo systematically review the literature regarding the prevalence, preventability, severity and types of adverse events (AE) in the Emergency Department (ED).MethodsWe systematically searched major bibliographic databases, relevant journals and conference proceedings, and completed reference reviews of primary articles. Observational studies (cohort and case-control), quasi-experimental (e.g. before/after) studies and randomized controlled trials, were considered for inclusion if they examined a broad demographic group reflecting a significant proportion of ED patients and described the proportion of AE. Studies conducted outside of the ED setting, those examining only a subpopulation of patients (e.g. a specific entrance complaint or receiving a specific intervention), or examining only adverse drug events, were excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality with the Newcastle Ottawa Scale.ResultsOur search identified 11,624 citations. Ten articles, representing eight observational studies, were included. Methodological quality was low to moderate with weaknesses in study group comparability, follow-up, and outcome ascertainment and reporting. There was substantial variation in the proportion of patients with AE related to ED care, ranging from 0.16% (n = 9308) to 6.0% (n = 399). Similarly, the reported preventability of AE ranged from 36% (n = 250) to 71% (n = 24). The most common types of events were related to management (3 studies), diagnosis (2 studies) and medication (2 studies).ConclusionsThe variability in findings and lack of high quality studies on AE in the high risk ED setting highlights the need for research in this area. Further studies with rigorous, standardized outcome assessment and reporting are required.