Hospital-based Emergency Department Research Articles

Nonresponse Bias against the Underserved in Emergency Department Patient Experience Surveys: A Cross-Sectional Analysis: Nonresponse to Patient Surveys

BackgroundPatient experience scores are used to assess emergency physicians, but only a small fraction of patients actually respond to patient experience surveys. No prior studies have determined patient characteristics that predict emergency department (ED) patient experience survey response. ObjectivesTo determine which patient characteristics are associated with ED patient experience survey response. MethodsThis was a cross-sectional analysis of a random sample of 2500 patients from our hospital system who were discharged from an ED between January 1 and June 30, 2022. Our hospital system has one hospital-based ED and two freestanding EDs, one of which is in an economically disadvantaged area. For each randomly selected patient, we used chart review to gather the following data points: ED visited, patient age, gender, race, preferred language, primary residence, time of arrival, marital status, health insurance, and emergency severity index for that visit. We used multivariable logistic regression to determine which of those variables were associated with patient experience survey response. ResultsAmong 2500 patients sent surveys, 207 (8.3%) responded. Those with the lowest response rates were from a freestanding ED in an economically disadvantaged area (5.9%), were uninsured (4.9%), or were homeless (2.1%). On multivariable analysis, adjusted odds ratios for survey response for those characteristics were as follows: 0.54 (95% CI 0.33-0.84), 0.56 (95% CI 0.34-0.90), and 0.30 (95% CI 0.02-1.44), respectively. ConclusionMultiple markers of lower socioeconomic status were associated with decreased patient experience survey response rates, suggestive of nonresponse bias against these individuals.

Understanding uptake of information about innovations among emergency department clinicians during the COVID-19 pandemic.

Early in the COVID-19 pandemic, little was known about managing sick patients, but emergency department (ED) clinicians had to decide which treatments and care processes to adopt. Our objective was to describe how ED clinicians learned about innovations and how they assessed them for credibility during the pandemic. We purposively sampled clinicians from hospital-based EDs to conduct focus groups with ED clinicians and staff. We used both inductive and deductive approaches to conduct thematic analysis of transcripts. We conducted focus groups with clinicians from eight EDs across the United States. We found that ED clinicians in our sample relied on friends and colleagues or departmental and institutional leadership for information on innovations. They used social media sources when they came from credible accounts but did not directly seek information from professional societies. Clinicians reported a range of challenges to obtain credible information during the pandemic, including a fractured and changing information environment, policies misaligned across clinical sites or that conflicted with clinical knowledge, high patient volume, fear of harming patients, and untimely information. Facilitators included access to experienced and trusted colleagues and leaders and practicing at multiple EDs. Participants cited anecdotal evidence, institutional practice, and word-of-mouth-rather than peer-reviewed evidence and professional society communications-as their primary sources of information about care innovations during the early phases of the pandemic. These results underscore the importance of developing trusted local mechanisms and wider networks to identify and vet information for frontline clinicians during rapidly emerging public health emergencies.

Innovation adoption, use and implementation in emergency departments during the COVID-19 pandemic

IntroductionDuring a public health emergency like the COVID-19 pandemic, emergency department (ED) clinicians may be able to save more lives if they rapidly identify and implement innovations that are safe...

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

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

Emergency Department-Based Medication for Opioid Use Disorder Program: Addressing Gaps in Linkages to Care.

Background Emergency department (ED)-based medication for opioid use disorder (MOUD) has been shown to be effective in providing ease of access and successful treatment rates for patients with opioid use disorder (OUD). This study examined the social determinants of health (SDOH) of patients entering an ED-based MOUD program through individual and focus group surveys. SDOHmay impact treatment retention for current and future patients. Methods A survey of all patients entering our MOUD program at two hospital-based EDs and two free-standing EDs was conducted from January to March 2022.Addiction care coordinators (ACCs) used standardized screening tools to enroll patients into the MOUD program, and trained research coordinators used a standardized form, using previously validated survey questions,to examine the role of SDOH.Focused group surveys were also collected. The survey measured patients' perspectives of the program and solicited feedback on SDOH and program barriers. Results Of the 60 OUD patients inducted into the ED-based MOUD program during our survey period, 19 (32%) participated in an individual or focus group interview. Of these, 16 patients (27%) completed all survey questions. The mean age was 42 years old, 94% identified as Caucasian, and 65% were males. Over 94% of subjects found the ACCs helpful in providing follow-up care.Nearly 40% experienced transportation and financial issues.The vast majority found the MOUD program beneficial in coping with withdrawal symptoms, dealing with their addiction, and supporting recovery. Conclusion OUD patients found the ACCs and the MOUD program helpful for their transition to the treatment stage. The MOUD program can improve some patients' reluctance to engage with a healthcare system by addressing barriers related to transportation to appointments and financial issues.

Prevalence and Characteristics of Emergency Department Visits by Pregnant People: An Analysis of a National Emergency Department Sample (2010-2020).

The number and characteristics of pregnant patients presenting to the emergency department (ED) has not been well described. Our objective in this study was to determine the prevalence and characteristics of pregnant patients presenting to EDs in the US between 2010-2020. We completed a retrospective, cross-sectional study of patient encounters at hospital-based EDs in the US from 2010-2020. Using the ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS) we identified ED visits for female patients aged 15-44years. We defined a subsample of these as visits for pregnant patients using discharge diagnosis codes specific to pregnancy. We compared this population of pregnant patient visits to those for non-pregnant patients and computed point estimates for nationally weighted values. Multivariable linear regression was used to determine factors independently associated with pregnant patient visits. The 2010-2020 NHAMCS dataset included 255,963 ED visits. Of these visits 59,080 were for female patients 15-44years old, and 6,068 of those visits were for pregnant patients. Pregnant patients accounted for 3% (95% confidence interval [CI] 2.7-3.2) of all ED visits and 8.6% (95% CI 8-9.3) of all visits among female patients 15-44years. Weighting to a national sample, this equates to 2.77 million pregnant patients presenting for ED visits annually. Pregnant patients were more likely to be Black, Hispanic, or to use public insurance. Pregnant patients make up a significant number of ED visits annually and are more likely to be people of color or publicly insured. Interventions to address the effects of changing abortion legislation on emergency medicine practice may benefit from consideration that certain populations of pregnant people are more likely to present to the ED for care.

Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study

BackgroundTransferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios.MethodsA Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics.ResultsSeventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions.ConclusionsTransfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.

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.

Freestanding Emergency Departments: Opportunities, Challenges, and Implications for Emergency Care Delivery in the Middle East: A review

Freestanding Emergency Departments (FSEDs) have become increasingly important in healthcare, especially in rural and hospital-consolidated areas. This review evaluates their impact on emergency care, focusing on patient satisfaction, the work environment for healthcare professionals, and their potential to reduce overcrowding in hospital-based emergency departments (H-EDs). It acknowledges the challenges in these areas, particularly in ensuring standardized, high-quality care. The review advocates for state-level legislation to establish uniform standards for FSEDs, incorporating criteria from the American College of Emergency Physicians (ACEP). It also addresses the need for FSEDs in underserved areas, noting their current tendency to be located in more affluent regions. Additionally, the review highlights the necessity for increased price transparency to differentiate FSEDs from other acute care options and to avoid contributing to higher healthcare costs. By addressing these issues and implementing recommended changes, FSEDs can enhance healthcare access while maintaining quality and efficiency in emergency care delivery.

Prevalence of frailty and associated factors in older adults seeking care at Swedish emergency departments

BackgroundInternationally, prolonged length of stay for older adults in the emergency department (ED) is associated with increased risk of in-hospital adverse events. In Sweden patients 65 years and older account for 35% of emergency visits, and according to consensus from an international expert group, all persons over 70 should be screened for frailty. This is not routinely done in Swedish EDs, and therefore, knowledge about prevalence, characteristics and clinical outcomes associated with frailty is limited.AimTo describe the prevalence of frailty and associated factors in older adults seeking care at Swedish EDs.MethodsThe study has a cross-sectional design. Data was collected at three hospital-based EDs, varying in level and size of setting, for one month. Patients age 70 and older presenting at the EDs and agreed to participate were screened for frailty using the FRail Elderly Support researcH group (FRESH) instrument. Data were analysed using descriptive statistics to assess the distribution of patient characteristics and clinical outcomes. Multivariate logistic regression was used to model the association between frailty and demographic characteristics, and Cox regression was used to model the association between frailty and clinical outcomes.ResultsA total of 3101 patients were eligible for inclusion; of these, 984 (32%) were included and screened for frailty. Of the final sample, 57.3% were assessed as frail. Characteristics significantly associated with frailty were living in a residential care facility, age (> 80 years), being a woman and arriving with emergency medical service (EMS). There was a significant association between frailty and admittance to in-hospital care.ConclusionOur study shows a high prevalence of frailty in older people. Factors associated with frailty were living in a residential care facility, age ≥ 80 years, being a woman and arriving with EMS to the ED and being admitted to in-hospital care. Frailty screening should be incorporated in the triage system to identify frail patients who need tailored interventions. More studies using the FRESH instrument are needed to further confirm our findings and to develop the methods for screening for frailty in the ED.

Emergency department crowding is not being caused by increased inappropriate presentations.

Contrary to the prevailing wisdom, there may be little or no room to move with respect to reducing emergency department (ED) utilisation, as ED utilisation in Aotearoa New Zealand is low by world standards and is not driven by patients presenting inappropriately with minor conditions. We should continue the excellent work done in the primary care sector to maintain our low ED presentation rate and support primary and urgent care providers to provide alternatives to the ED for people with minor conditions. However, to reduce the system pressure and harms caused by ED crowding due to access block for admitted patients, we also need to adequately resource our hospital-based inpatient teams and EDs so that the (appropriate) acute care workload can be managed safely.

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.

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.

Exploring Which Patients Use Their Closest Emergency Departments Using Geocoded Data

BackgroundEach year, roughly 20% of U.S. adults visit an emergency department (ED), but little is known about patients’ choice of ED. ObjectivesExamine the discretion patients have to choose among EDs, characteristics associated with ED choice, and relationship between ED choice and self-reported care experiences of ED patients. MethodsWe surveyed adult patients discharged to the community (DTC) in January–March 2018 from 16 geographically dispersed hospital-based EDs, geocoded patient and hospital-based ED addresses within 100 miles of patient addresses, and calculated travel distances. We examined the likelihood of visiting the closest ED based on patient and ED characteristics. Linear regression models examined the association of choosing the closest ED with seven measures of patient experience of care (scaled 0–100), adjusting for patient characteristics. Results43.6% of 4647 responding patients visited the ED nearest their home (on average, 5.7 miles away). Patients who chose a farther ED had more urgent conditions, were more educated, and were less likely to be non-Hispanic White. They were significantly more likely to have visited an ED in a higher-rated, metropolitan, network hospital with major teaching status, a cardiac intensive care unit, and a certified trauma center. Patients who chose a farther ED were more likely to recommend that ED, with “medium-to-large” differences in scores (+4.3% more selected “definitely yes”, p < 0.05). ConclusionsFewer than half of patients visited the closest ED. Patients who chose a farther ED tended to seek higher-rated hospitals and report more favorable experiences.

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 ...

The role of social connections and support in the use of emergency care among older adults

ObjectivesLimited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. MethodsThis is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. ResultsMedium (IRR 0.77; 95% CI 0.59–0.99) and high (IRR 0.77; 95% CI 0.56–0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. ConclusionsED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults.

Health care provider reporting practices related to self-managed abortion

BackgroundHealth care providers reporting patients to government authorities is a main way people attempting self-managed abortion (SMA) become exposed to legal risks. Little is known about health care provider decision-making regarding SMA reporting.MethodsWe conducted semi-structured interviews with 37 clinicians who provided care in hospital-based obstetrics or emergency departments (13 obstetricians/gynecologists, two advance practice registered nurses providing obstetrics care, 12 emergency medicine physicians, and 10 family medicine physicians) throughout the United States. The interview guide asked participants to describe one or more cases of caring for a patient who may have attempted SMA and about related reporting decisions. We coded responses to answer two questions: What comes to mind for health care providers when asked to think about experiences caring for a patient who may have attempted SMA? Based on health care provider experiences, how might people who providers suspect may have attempted SMA end up reported?ResultsAbout half of participants had cared for someone who may have attempted SMA for that pregnancy. Only two mentioned SMA with misoprostol. Most participants described cases where they were unsure whether the patient had attempted to end their pregnancy on purpose. In most instances, participants mentioned that that the possibility of reporting never occurred to them nor came up. In some cases, participants described a reporting “adjacent” practice – e.g. beginning processes that could lead to substance use, domestic violence, or self-injury/suicide-related reports – or considered reporting related to a perceived need to report abortion complications. In two cases, hospital staff reported to the police and/or Child Protective Services related to the SMA attempt. These involved passing of a fetus after 20 weeks outside the hospital and a domestic violence incident.ConclusionReporting patients who may have attempted SMA may occur via provider perception of a need to report abortion complications and fetal demises, particularly at later gestations, and other reporting requirements (e.g. substance use, domestic violence, child maltreatment, suicide/self-harm).

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.

Impact of enhancing GP access to diagnostic imaging: A scoping review.

Direct access to diagnostic imaging in General Practice provides an avenue to reduce referrals to hospital-based specialities and emergency departments, and to ensure timely diagnosis. Enhanced GP access to radiology imaging could potentially reduce hospital referrals, hospital admissions, enhance patient care, and improve disease outcomes. This scoping review aims to demonstrate the value of direct access to diagnostic imaging in General Practice and how it has impacted on healthcare delivery and patient care. A search was conducted of 'PubMed', 'Cochrane Library', 'Embase' and 'Google Scholar' for papers published between 2012-2022 using Arksey and O'Malley's scoping review framework. The search process was guided by the PRISMA extension for Scoping Reviews checklist (PRISMA-ScR). Twenty-three papers were included. The studies spanned numerous geographical locations (most commonly UK, Denmark, and Netherlands), encompassing several study designs (most commonly cohort studies, randomised controlled trials and observational studies), and a range of populations and sample sizes. Key outcomes reported included the level of access to imaging serves, the feasibility and cost effectiveness of direct access interventions, GP and patient satisfaction with direct access initiatives, and intervention related scan waiting times and referral process. Direct access to imaging for GPs can have many benefits for healthcare service delivery, patient care, and the wider healthcare ecosystem. GP focused direct access initiatives should therefore be considered as a desirable and viable health policy directive. Further research is needed to more closely examine the impacts that access to imaging studies have on health system operations, especially those in General Practice. Research examining the impacts of access to multiple imaging modalities is also warranted.

Fundamental nursing actions for frail older people in the emergency department: A national cross-sectional survey and a qualitative analysis of practice guidelines.

To map how frailty among older people is assessed at Swedish emergency departments and to describe fundamental nursing care actions for these patients. Descriptive national survey and a qualitative analysis of text. A majority (82%, n=54) of the Swedish hospital-based emergency departments for adults were included, representing all six healthcare regions. An online survey was used to collect data, together with submitted local practice guidelines for older people at the emergency departments. Data were collected during February-October 2021. Descriptive and comparative statistics were performed together with a deductive content analysis framed by the Fundamentals of Care framework. Sixty-five per cent (35 of 54) of the emergency departments identified frailty, with less than half of them using an established assessment instrument. Twenty-eight (52%) of the emergency departments have practice guidelines containing fundamental nursing actions for the care of frail older people. The majority of nursing actions in the practice guidelines were related to patients' physical care needs (91%), followed by psychosocial care needs (9%). No actions could be identified as relational actions (0%) according to the Fundamentals of Care framework. Many Swedish emergency departments identify frail older people, but they use a range of different assessment instruments. While practice guidelines directing fundamental nursing actions for frail older people are often in place, a holistic, person-centred view addressing the patient's physical, psychosocial and relational care needs is missing. The population is growing older, and more people are needing more complex hospital care. Frail older people have an increased risk of negative outcomes. The use of a variety of assessment instruments for frailty may pose a challenge to equal care. To ensure a holistic, person-centred view of frail older people, the Fundamentals of Care framework can be used in developing and reviewing practice guidelines. Clinicians and non-health professionals were invited to review the survey to ensure face and content validity.