Hospital-based Emergency Department Research Articles

SCREENING FOR SUICIDAL THOUGHTS AND BEHAVIORS AMONG OLDER PATIENTS VISITING THE EMERGENCY DEPARTMENT

Depression, suicide ideation (SI) and suicide attempts (SA) are common among older adults, representing serious public health problems. Individuals with multiple comorbidities and frequent contact with hospital–based emergency departments (ED) may have elevated – but unrecognized – risk. To inform future interventions, we describe the prevalence of self-harm/SI/SA among older ED patients, including differences by age, sex, and race/ethnicity. We reviewed consecutive patient charts (2011–2014) at 8 EDs in 7 states, all with protocols to screen every patient for suicide risk. Among 142,534 patient visits, 23% were by patients aged ≥60 years. Documented screening for self-harm/SI/SA declined with age, from 81% in younger age groups to 68% among those aged ≥85 years. This decline may be due to age biases or to patient-level factors precluding screening (e.g., altered mentation). Our findings support the need for more detailed examination of the best methods for identifying – and treating – suicide risk among older adults.

Facial Fractures in Patients With Firearm Injuries: Profile and Outcomes

Firearm injuries (FAIs) are a major public health issue in the United States. The objective of this study was to examine characteristics and outcomes of patients presenting to emergency departments (EDs) with facial fractures attributed to FAIs. The Nationwide Emergency Department Sample for the years 2008 to 2013 was used. All patients who visited EDs with FAIs and facial fractures were selected. The study focused on the following variables: 1) demographic characteristics, 2) types of facial fractures, 3) disposition status after ED visit or subsequent hospitalization, 4) charges (ED and hospitalization), and 5) patient outcomes. The inclusion criteria were a visit to a hospital-based ED with facial fractures and an external cause of FAI. Descriptive statistics were used to summarize findings. Multivariate logistic regression analysis was used to examine the simultaneous effects of patient-related factors on ED death. During the study period, a total of 15,469 patients (mean age, 34years) visited hospital-based EDs with facial fractures attributed to FAIs. Most were uninsured male patients. The most common etiology of FAIs was assault. The most common facial fractures were open mandibular fractures andopen maxillary and/or malar bone fractures. Approximately 27% of patients had a concomitant intracranial injury. After the ED visit, 74% were admitted. The mean ED charge per patient was $6,403, and the total ED charge across the United States was $76.48 million. The mean hospitalization charge perpatient was $167,203. The total hospitalization charge across the United States was $1.9 billion. Patients with intracranial injuries (odds ratio [OR], 21.21; 95% confidence interval [CI], 7.16 to 62.85; P<.01), uninsured patients (OR, 4.24; 95% CI, 1.44 to 12.51; P<.01), and patients residing in areas with high household incomes (OR, 5.60; 95% CI, 2.51 to 12.46; P<.01) were high-risk groups for ED death. FAIs require substantial resources for stabilization and treatment by EDs.This study highlights the burden and impact of facial fractures in patients with FAIs in the United States.

The dangers of extreme body mass index values in patients with Clostridium difficile.

To examine the association between body mass index (BMI) and in-hospital mortality in patients presenting with Clostridium difficile infections in emergency department visits (ED) in the USA. Infected patients with extreme BMIs may have an elevated mortality risk, but prior studies examining this question have been too small to reach definitive conclusions. Data were from the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality during 2012. NEDS records emergency department (ED) visits across the USA and provides statistical sampling weights to approximate a nationally representative sample of US hospital-based EDs. Inclusion criteria were adults age 18 or older with an ICD-9 code for C. difficile infection (008.45) and a documented body mass index ICD-9V code (V85.x). Logistic regression was used to predict mortality after adjusting for demographic variables and chronic comorbidities defined by Elixhauser. A weighted sample of 22,937 ED visits met all inclusion criteria. The cohort's mean age was 66. 64.6% were female. The unadjusted mortality rate was 6.5%. Patients with a BMI<19kg/m2 had an adjusted odds ratio of 2.73; 95% CI (1.80, 4.16), p<0.001 compared to patients with a BMI of 19.0-4.9kg/m2 (the referent category). In obese patients, only BMI values >40kg/m2 were associated with significantly greater mortality risk. Being underweight (BMI<19) or morbidly obese (BMI>40) was associated with increased risk of in-hospital mortality in patients presenting with C. difficile infections.

Functional Symptoms and Syndromes in the General Danish Population

This paper explores whether occupational safety and health (OSH) risk perceptions, behaviour and exposure differ among Emergency Department (ED) doctors, nurses and medical secretaries, and whether observed safe working conditions and behaviour in EDs vary across work shifts. Staff from four public hospital-based EDs completed a survey regarding safety climate, risk behavior, work pressure, exposure to and reporting of injuries, violence and threats. Furthermore, safety observations of working conditions (e.g. order and tidiness) and behavior (e.g. discarding hypodermic needles) were carried out during day, evening and night shifts. Rates of self-reported violence and threats in ED doctors and nurses were two to three times greater than rates seen for doctors and nurses at hospitals in general. However, ED respondents perceived a greater managerial focus on certain aspects of the safety climate. Work pressure and lack of time (among doctors and nurses) and social pressure (among medical secretaries) were the primary reasons given for taking OSH risks. If OSH incidents (e.g. injuries or violence) were not reported, it was often because the process was perceived as too laborious, and some incidents were considered ‘part of the job’. Observations of order and tidiness in the EDs showed a gradual lower score in safety conditions from the day to the evening and night shift. Multifaceted and integrated interventions for educating and training ED personnel need to take into account their varying risk exposures, perceptions and behaviors in creating and sustaining an efficient, safe and healthy working environment.

Intranasal Steroid Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement.

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

An agent-based model for quantitatively analyzing and predicting the complex behavior of emergency departments

Hospital based emergency departments (EDs) are highly integrated service units devoted primarily to handling the needs of patients arriving without prior appointment, and with uncertain conditions. In this context, analysis and management of patient flows play a key role in developing policies and decisions for overall performance improvement. However, patient flows in EDs are considered to be very complex because of the different pathways patients may take and the inherent uncertainty and variability of healthcare processes. The agent-based model provides a flexible platform for studying ED operations, as it predicts the system-level behavior from individual level interactions. In this way, policies such as staffing can be changed and the effect on system performance, such as waiting times and throughput, can be quantified. The overall goal of this study is to develop tools to better understand the complexity, evaluate policy and improve efficiencies of ED units. The main contribution of this paper includes: an agent-based model of ED, a flexible atomic data monitoring layer for agent state tracing, and a master/worker based framework for efficiently executing the model and analyzing simulation data. The presented model has been calibrated to imitate a real ED in Spain, the simulation results have proven the feasibility of using agent-based model to study ED system.

Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications.

Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers. We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims-based definition, 2) facility claims-based definition, and 3) CMS Research Data Assistance Center (ResDAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions. Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other definitions including 17% more ED visits than the provider definition and 2% fewer visits than the ResDAC definition. Differences in ED visitation counts between each definition occurred for several reasons including the inclusion of critical care or observation services in the ED, discrepancies between facility and provider billing regulations, and operational decisions of each definition. Current operational definitions of ED visitation using administrative claims produce different estimates of ED visitation based on the underlying assumptions applied to billing data and data set availability. Future analyses using administrative claims data should seek to validate specific definitions and inform the development of a consistent, consensus ED visitation definitions to standardize research reporting and the interpretation of policy interventions.

Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers

We compare utilization, price per visit, and the types of care delivered across freestanding emergency departments (EDs), hospital-based EDs, and urgent care centers in Texas. We analyzed insurance claims processed by Blue Cross Blue Shield of Texas from 2012 to 2015 for patient visits to freestanding EDs, hospital-based EDs, or urgent care centers in 16 Texas metropolitan statistical areas containing 84.1% of the state's population. We calculated the aggregate number of visits, average price per visit, proportion of price attributable to facility and physician services, and proportion of price billed to Blue Cross Blue Shield of Texas versus out of pocket, by facility type. Prices for the top 20 diagnoses and procedures by facility type are compared. Texans use hospital-based EDs and urgent care centers much more than freestanding EDs, but freestanding ED utilization increased 236% between 2012 and 2015. The average price per visit was lower for freestanding EDs versus hospital-based EDs in 2012 ($1,431 versus $1,842), but prices in 2015 were comparable ($2,199 versus $2,259). Prices for urgent care centers were only $164 and $168 in 2012 and 2015. Out-of-pocket liability for consumers for all these facilities increased slightly from 2012 to 2015. There was 75% overlap in the 20 most common diagnoses at freestanding EDs versus urgent carecenters and 60% overlap for hospital-based EDs and urgent care centers. However, prices for patients with the same diagnosis were on average almost 10 times higher at freestanding and hospital-based EDs relative to urgent care centers. Utilization of freestanding EDs is rapidly expanding in Texas. Higher prices at freestanding and hospital-based EDs relative to urgent care centers, despite substantial overlap in services delivered, imply potential inefficient use of emergency facilities.

Commentaries on health services research

Commentaries on health services research

The use of a Swedish telephone medical advice service by the elderly – a population-based study

Objective: The present study aimed to describe contact made by the elderly to Sweden’s nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres.Design: De-identified data from recorded calls to HGP was extracted for analysis (n = 7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system.Setting: Västerbotten County, Sweden.Subjects: Patients over 80 years.Main outcome measures: Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations.Results: The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r = 0.30, p < 0.05) and calls that were given advice correlated with acute primary healthcare visits (r = 0.38, p = 0.005).Conclusion: The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service’s present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly’s medication regimens.Key pointsPatients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups.Drug-related questions were the most common reason for contact.A significant proportion of all calls made resulted in further heatlhcare contacts.

Insurance Expansion and Hospital Emergency Department Access: Evidence From the Affordable Care Act.

Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA). To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits. Quasi-experimental observational study from 2012 to 2014. 126 investor-owned, hospital-based EDs. Uninsured and Medicaid-insured adults aged 18 to 64 years. ACA expansion of Medicaid in January 2014. Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done. There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states. Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types. Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities. Robert Wood Johnson Foundation.

Emergency Department Utilization related to dental conditions and distribution of Dentists, Nebraska 2011-2013

PurposeThis study aims to provide estimates of hospital-based emergency department (ED) visits due to dental conditions in Nebraska and to examine patient-related characteristics associated with ED charges. In addition, this study provides dental-related ED visits and distribution of dentists by county. MethodsFor the study, we used the State Emergency Department Database for Nebraska for the years 2011 through 2013 and the Health Resources and Services Administration's Area Health Resource File. All ED visits with dental conditions in Nebraska were selected. The primary outcome variable was hospital-based ED charges. Multivariable linear regression model was used to examine the effects of patient-related factors on ED charges. ResultsDuring the study period, a total of 9943 dental-related ED visits occurred. Of these, 55.5% patients aged between 25 and 44 years. Thirty-nine percent of all dental ED visits had patients who were self-financed or uninsured. Twenty counties in Nebraska do not have a dentist, and nine counties had more than 50 ED visits per 10,000 population. Patients residing in urban areas paid significantly higher charges than those living in rural towns, small rural towns, or isolated rural areas. The mean and total ED charges attributed to dental conditions for the entire study period were $934 and $9.3 million, respectively. ConclusionPatients who are uninsured, aged 25-44 years, covered by private insurance, and residing in urban areas are identified to be at high risk. There is a need to develop health policies and programs to improve access to dental care in rural states.

Emergency Department Utilization By Hemophilia Patients in United States

INTRODUCTIONPatients with hemophilia are prone to life threatening bleeds and central line associated morbidities. It is pivotal that emergency departments (ED) are both equipped and trained to address these complications with acuity. The purpose of this study is to determine the utilization of ED for hemophilia related complaints. METHODSRetrospective review of information collected from the National Emergency Department Database Sample (NEDS) was performed. The NEDS is a stratified sample of hospital-based ED visits and publically available for purchase as a component of the Healthcare Cost and Utilization Project. We are presenting the results of comparative analysis and frequencies computed from the database.The ED visits with hemophilia, listed as one of the diagnoses, were selected. Patient demographics and hospital stratification variables were recorded. A snapshot of these variables from years 2006 to 2013 was obtained but due to large sample size, we elected to perform detailed analysis on data from the year 2012. Hospital charges and other variables were computed from the database and projected to national levels using the discharge weighted variables. Study was funded by "Bayer Healthcare, Investigator Initiated Research Grant". RESULTSDuring the 8 years period studied, ~163,000 ED visits were made by hemophilia patients. This represented 0.016% of total visits to EDs nationwide. The two age groups that were most likely to utilize ED were children under 18 years and adults under 45 years (37% each). More than half of these patients resided in large metropolitan cities or their suburbs. Interestingly 20% of patients had annual household income greater than $63,000. Although Medicaid and Medicare were the largest primary payers (54%), 30% had private insurance listed as primary payer. About 45% of the ED visits were at a non-teaching hospital. As a snap shot of frequencies the trends in above mentioned results had remained unchanged from 2006 to 2013.Detailed analysis of the purchased database for the year 2012 was performed. Out of 31 million ED visits in the year 2012; 4,488 visits were made by patients with hemophilia and 84% of them had hemophilia A (Sample representing 20% of target universe). Mean age at presentation was 29 years. There was not a significant difference in the number of ED visits among different months of the year or days of the week. Most visits were made in June (358) and least visits during February (294). Average charge per visit was $4,000; the highest charge for a single ED visit was $150,000. National estimate of total charges for ED visits by patients with hemophilia in the year 2012 was over 60 million dollars. Average charge for ED visits at a private hospital was $2,988 compared to $2,254 at a public hospital (p=0.03). The cost of ED utilization by lower income group patients was greater than patients from higher income group; however the difference in average charges was not statistically significant.There were over 21,000 diagnoses codes recorded during 4,488 ED visits by hemophilia patients. Cardiovascular complaints (n=2060) were the most frequently reported, followed by injuries and poisoning (n=2038). Hemorrhage was the presenting complaint 32% (n=1452) of times. The breakdown of bleeds included 682 contusions, 317 hemarthrosis, 163 gastrointestinal bleeds, 96 hematuria, 83 epistaxis, 47 intracranial bleeds and 18 menstrual bleeds. Injuries were reported as primary diagnosis, 26% of times. Septicemia was diagnosed during 147 visits. Around 70% of patients were treated and released from the ED. Two patients reportedly died in the ED while 35 died after being admitted to the hospital. Cause of death included Sepsis and brain hemorrhage in 26 and 4 patients respectively. In pediatric patients only, injuries were the most frequent complaints (n=870) followed by joint and soft tissue disorders (n=366); fever (n=92) and central line complications (n=63). CONCLUSIONHemophilia is a rare hematologic disease but patients with hemophilia have a high tendency to utilize ED. Proper education of patients and ED staff could help reduce the economic burden and ensure optimum care delivery in the ED. To our knowledge this is the first study to analyze ED utilization by hemophilia patients from a national database. Based on our study results, patients were evenly distributed in low and high income groups and utilized teaching and non-teaching hospital EDs alike. DisclosuresZakieh:Bayer Healthcare Investigator Initiated research Grant: Research Funding. Al-Ghafry:Bayer Healthcare Investigator Initiated research Grant: Research Funding. Siddiqui:Bayer Healthcare Investigator Initiated research Grant: Research Funding.

Factors Associated With the Likelihood of Hospitalization Following Emergency Department Visits for Behavioral Health Conditions.

Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States. Using Andersen's Behavioral Model of Health Service Use for guidance, the study examined the relationship between predisposing (characteristics of the individual, i.e., age, sex, race/ethnicity), enabling (system or structural factors affecting healthcare access), and need (clinical) factors and the likelihood of hospitalization following ED visits for behavioral health conditions (n = 28,716 ED visits). In the adjusted analysis, a logistic fixed-effects model with blockwise entry was used to estimate the relative importance of predisposing, enabling, and need variables added separately as blocks while controlling for variation in unobserved hospital-specific practices across hospitals and time in years. Significant predisposing factors associated with an increased likelihood of hospitalization following an ED visit included increasing age, while African American race was associated with a lower likelihood of hospitalization. Among enabling factors, arrival by emergency transport and a longer ED LOS were associated with a greater likelihood of hospitalization while being uninsured and the availability of community-based behavioral health services within 5 miles of the ED were associated with lower odds. Among need factors, having a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, dementia, or an impulse control disorder as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit. The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness.

Impact of Minimally Invasive Benign Prostatic Hyperplasia Therapies on 30- and 90-Day Postoperative Office Encounters

To compare the frequency of postoperative encounters in the 30-day and 90-day postoperative periods for various bladder outlet obstruction surgical therapies. All patients who underwent transurethral resection of the prostate (TURP), GreenLight laser photovaporization of the prostate (GL-PVP) (American Medical Systems Inc.), and holmium laser enucleation of the prostate (HoLEP) from January 1, 2012 to December 31, 2014 were followed for 6 months postoperatively. All postoperative encounters such as patient calls or questions, catheter exchanges or removals, and hospital-based readmissions or emergency department visits were recorded in the electronic medical record. Two hundred and ninety-one consecutive patients underwent outlet procedures during the study period: TURP (N = 199; mean age, 71 years; mean body mass index [BMI], 28.5), HoLEP (N = 60; mean age, 68 years; mean BMI, 28.1), or GL-PVP (N = 32; mean age, 72 years; mean BMI, 29.3). No statistically significant difference was observed for age, BMI, preoperative American Urological Association symptom score, or preoperative maximum flow velocity between the 3 groups. Thirty-day postoperative encounters differed significantly between the 3 surgery types (P < .001). Specifically, there were fewer encounters within 30 days of surgery for TURP compared to both HoLEP (≥1 encounter: TURP = 48.7%, HoLEP = 66.7%; P = .006) and GL-PVP (≥1 encounter: TURP = 48.7%, GL-PVP = 93.7%; P < .001). The number of encounters within 90 days postoperatively was also significantly lower for TURP patients (P < .001). TURP results in fewer postoperative encounters in both the 30-day and 90-day postoperative periods compared to HoLEP and GL-PVP. Laser prostate therapies may place increased burden on clinic staff during the 30-day and 90-day postoperative periods.

State Regulation Of Freestanding Emergency Departments Varies Widely, Affecting Location, Growth, And Services Provided.

Freestanding emergency departments (EDs), which offer emergency medical care at sites separate from hospitals, are a rapidly growing alternative to traditional hospital-based EDs. We evaluated state regulations of freestanding EDs and describe their effect on the EDs' location, staffing, and services. As of December2015, thirty-two states collectively had 400 freestanding EDs. Twenty-one states had regulations that allowed freestanding EDs, and twenty-nine states did not have regulations that applied specifically to such EDs (one state had hospital regulations that precluded them). State policies regarding freestanding EDs varied widely, with no standard requirements for location, staffing patterns, or clinical capabilities. States requiring freestanding EDs to have a certificate of need had fewer of such EDs per capita than states without such a requirement. For patients to better understand the capabilities and costs of freestanding EDs and to be able to choose the most appropriate site of emergency care, consistent state regulation of freestanding EDs is needed.

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States

We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located. We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED's location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights. We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs. In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states.

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010

IntroductionSexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. MethodsThis study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. ResultsWe analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). ConclusionAlthough patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured.

Trends in dental-related emergency department visits in the State of California from 2005 to 2011

Objectives of this study were to provide trends in hospital-based emergency department (ED) visits involving dental conditions in California and to identify clinical and patient characteristics associated with these trends. We used 2005 to 2011 data from the California Emergency Department Database. We examined all ED visits related to dental conditions. During the study period (2005-2011), 402,077 ED visits were attributed to dental conditions. The number of ED visits that were dental-related increased from 44,516 (in 2005) to 70,385 (in 2011). Most of these visits were for dental caries (44.0%) and pulp/periapical lesions (48.6%) in 2011. Nearly one third of patients visiting the ED were uninsured, and the percentage of Medicaid patients increased from 30.3% in 2006 to 35.1% in2011. The number and rate of visits to the ED for dental-related problems has increased substantially in recent years in California. A large proportion of these patients are uninsured and those covered by Medicaid.

Worker, workplace, and community/environmental risk factors for workplace violence in emergency departments

ABSTRACTWorkplace violence committed by patients and visitors has high propensity to occur against emergency department employees. This article reports the association of worker, workplace, and community/environmental factors with violence risks. A cross-sectional research design was used with 280 employees from six emergency departments in the Midwest United States. Respondents completed the Survey of Violence Experienced by Staff and a 10-item demographic questionnaire. Data were analyzed using frequencies, percentages, Chi-square tests, and adjusted relative risks with 95% confidence intervals. Over 80% of respondents experienced at least one type of workplace violence with their current employer and approximately 40% experienced all three types. Risks for workplace violence were significantly higher for registered nurses and hospital-based emergency departments. Workplace violence can impact all employees in the emergency department regardless of worker, workplace, and community/environmental factors.