Hospital-based Emergency Department Research Articles

Efficacy of the Probiotic Probiotical Confirmed in Acute Gastroenteritis.

PurposeSome probiotic strains reduce the duration of acute diarrhea. Because of strain and product specificity, each product needs to be supported by clinical data. This study aimed to test the efficacy of the synbiotic food supplement Probiotical (Streptococcus thermophilus, Lactobacillus rhamnosus, Lactobacillus acidophilus, Bifidobacterium lactis, Bifidobacterium infantis, fructo-oligosaccharides) in children with acute gastroenteritis of likely infectious origin. The primary endpoint was the number of children with normal stool consistency during the treatment duration.MethodsA total of 46 children (aged 3.6 months to 12 years) with acute gastroenteritis that started less than 48 hours prior to their visit at a hospital-based emergency department were included in this prospective, randomized, placebo-controlled trial. All children were treated with oral rehydration solution and placebo (n=20) or the test product (n=26).ResultsSignificantly more children had a normal stool consistency on days 1 and 2 in the probiotic group: 5 children (20%) on day 1 in the probiotic group compared with none in the placebo group (p=0.046). On day 2, 11 children in the probiotic group (46%) and 3 (16%) in the placebo group (p=0.024) had a normal stool consistency. The mean duration of diarrhea was shorter in the probiotic group compared with that in the placebo group (3.04±1.36 vs. 4.20±1.34 days) (p=0.018).ConclusionThe test product was shown to normalize stool consistency significantly more rapidly than the placebo. These data confirm the findings from a previous study in a larger group of children performed in a primary healthcare setting.

Characteristics and Operational Performance of Hospital-affiliated Freestanding Emergency Departments.

As there has been increasing pressure on acute care services to redefine how their care is delivered, hospital-affiliated freestanding emergency departments (FREDs) have rapidly expanded in some markets. Little is known about the populations served or the quality of care provided by these facilities. The objective of this study was to compare patient visit characteristics, geographic catchment areas, and operational performance between hospital-affiliated FREDs and hospital-based emergency departments (HEDs). This was a population-based retrospective observational analysis of 19 FREDs and 5 HEDs in a single health system over a 1-year period. We abstracted patient visit data from the electronic health record and supplemented catchment area data with the 2016 American Community Survey. We analyzed lengths of stay using generalized linear models adjusted for age, severity, and insurance status. FREDs had lower proportions of visits from nonwhite patients and more visits from privately insured patients than HEDs, with similar proportions of uninsured patient visits. These trends were mirrored in catchment area analyses. FRED visits were lower acuity, with fewer imaging and laboratory tests performed. The adjusted mean length of stay for discharged patients was 109 minutes for FREDs compared with 169 minutes for HEDs. For admitted or transferred patients, adjusted lengths of stay were 213 minutes at FREDs and 287 minutes at HEDs. Hospital-affiliated FREDs serve more affluent and less diverse patient populations and geographic communities. Relative to HEDs, they have lower acuity patient visits with fewer tests, and they have shorter lengths of stay, even after adjustment for patient visit characteristics.

Maybe It's Time to Rethink Freestanding Emergency Departments.

Maybe It's Time to Rethink Freestanding Emergency Departments.

153 Freestanding vs. Hospital-Based Emergency Department Utilization and Throughput Metrics Across the United States

Freestanding emergency departments (EDs) have grown significantly in the past decade and represent approximately 10% of EDs in the United States. The objective of this study was to compare throughput metrics and utilization measures for freestanding ED versus hospital-based EDs of similar volume and geographic region. ED Benchmarking Alliance data for freestanding EDs (FSED) and hospital-based EDs (HBED) for 2017 was utilized. Our explanatory variable was facility type (freestanding versus hospital-based ED). Outcomes between FSED and HBED were compared. Normally distributed variables are presented as mean and standard deviation and p-values were obtained from t-tests. Non-normally distributed variables are presented as median and interquartile range and p-values from Wilcoxon rank sum tests. Outcomes were weighted based on the proportion of ED volume per facility. Outcome measures between FSED and HBED were compared both nationally and at the state level. Overall, the FSED performed better in most outcomes at the National level as compared to HBED although there are some measures that the HBED performed better than the FSED. Median length of stay (104.2 vs. 140.0), length of stay for treated and released patients (98.6 vs. 122.9), door to bed (4 vs 8), door to doctor (11 vs 16), percentage of patients admitted through the ED (4 vs 11) and percentage of patients leaving the ED without being seen (LWBS) (0.9 vs 1.5), were significantly lower in the FSED as compared to HBED, (P<0.0001). On the other hand, length of stay for admitted patients (265.9 vs 241.8), and median boarding time (96.8 vs. 71.3) were significantly lower in HBED when compared to FSED (P<0.0001). X-ray utilization per 100 patients was 24.6 at the FSED and 37.7 at the HBED (P<0.001). CT utilization per 100 patients was 10.76 at the FSED and 16.02 at the HBED (P<0.0001). EKG utilization per 100 patients was 10.32 at the FSED and 19.06 at the HBED (P<0.0001). At the state level, median length of stay, door to doctor, door to bed and percentage of LWBS were lower in FSEDs than in HBEDs while length of stay to admission, length of stay to discharge, median boarding as well as other variables varied by state. FEDs compared to HBEDs of similar size and geographic location across the country have faster length of stay, door to doctor, door to bed and lower LWBS compared to HBEDs and lower CT, EKG and x-ray utilization.

Five‐Year Incidence of Hospital‐Based Emergencies Related to Acute Recreational Intoxication in Minors

Alcohol or other drug (AOD) intoxication in minors is a public health challenge. We characterized underage patients admitted to an emergency department (ED) with acute, recreational AOD intoxication. We conducted a 5-year (2012 to 2016) analysis of minors admitted to the only hospital-based pediatric ED in an urban area. Episodes of AOD intoxication were selected using ICD-9-CM diagnostic codes. Sociodemographics, substance use and clinical characteristics, laboratory parameters, and discharge dispositions were collected through the revision of clinical charts. A total of 266 admissions related to recreational AOD intoxication in 258 patients occurred during the study period. Among the 258 patients, 127 (49.2%) were men, median age 16years [IQR: 15 to 17years], and 234 (90.7%) of episodes were alcohol-related. At admission, 202/256 (78.9%) patients had a Glasgow Coma Scale≥13 points, the median systolic and diastolic blood pressure was 109mmHg (IQR: 101 to 118mmHg) and 67mmHg (IQR: 60 to 73mmHg), respectively, and the median blood glucose level was 112mg/dl (IQR: 99 to 127mg/dl). Only 72/258 (27.9%) patients underwent urine screening (22/72 (30.5%) were positive for cannabis), and only 30/258 (11.6%) were tested for blood ethanol (median: 185mg/dl, IQR: 163 to 240mg/dl). There was a trend in admissions occurring early in the morning of weekend days, and 249 (96.5%) patients were discharged home the day of admission. Though the severity of AOD intoxication seems to be mild to moderate, assessment of substance exposure is low and may underestimate polydrug use in underage populations.

The Effects of Global Budgeting on Emergency Department Admission Rates in Maryland

In 2014, Maryland launched a population-based payment model that replaced fee-for-service payments with global budgets for all hospital-based services. This global budget revenue program gives hospitals strong incentives to tightly control patient volume and meet budget targets. We examine the effects of the global budget revenue model on rates of admission to the hospital from emergency departments (EDs). We used medical record and billing data to examine adult ED encounters from January 1, 2012, to December 31, 2015, in 25 hospital-based EDs, including 10 Maryland global budget revenue hospitals, 10 matched non-Maryland hospitals (primary control), and 5 Maryland Total Patient Revenue hospitals (secondary control). Total Patient Revenue hospitals adopted global budgeting in 2010 under a pilot Maryland program targeting rural hospitals. We conducted difference-in-differences analyses for overall ED admission rates, ED admission rates for ambulatory-care-sensitive conditions and non-ambulatory-care-sensitive conditions, and for clinical conditions that commonly lead to admission. In 3,175,210 ED encounters, the ED admission rate for Maryland global budget revenue hospitals decreased by 0.6% (95%confidence interval -0.8% to -0.4%) compared with that for non-Maryland controls after global budget revenue implementation, a 3.0% relative decline, and decreased by 1.9% (95% confidence interval -2.2% to -1.7%) compared with that for Total Patient Revenue hospitals, a 9.5% relative decline. Relative declines in ED admission rates were similar for ambulatory-care-sensitive-condition and non-ambulatory-care-sensitive-condition encounters. Admission rate declines varied across clinical conditions. Implementation of the global budget revenue model led to statistically significant although modest declines in EDadmission rates within its first 2 years, with declines in ED admissions most pronounced among certain clinical conditions.

Effects of Push-To-Web Mixed Mode Approaches on Survey Response Rates: Evidence from a Randomized Experiment in Emergency Departments

Recent work involving survey administration among emergency department (ED) patients has demonstrated very low response rates using single-mode (e.g., mail-only or web-only) approaches. In this study, the authors tested several mixed-mode protocols that focus on a push-to-web approach for survey administration in this challenging but important setting. A random sample of 26,991 ED discharged-to-community (DTC) patients discharged in January 2018–March 2018 from 16 hospital-based EDs nationwide were randomized to nine survey arms, eight of which involved a web survey with one or more of the following methods of invitation to the web survey: an emailed link to the web survey, a texted link to the web survey, and/or a mailed paper invitation with information on how to access the web survey. The reference arm was standard mixed mode (mailed survey with telephone follow-up). Invitation(s) to the web survey was followed by (1) a mailed survey, (2) telephone follow-up, or (3) both. The overall response rate across all arms was 18.6% (American Association for Public Opinion Research [AAPOR] RR1). None of the tested web-survey arms had significantly higher response rates than standard mixed mode (25.5%). Protocol comparisons demonstrated that both text outreach and including a telephone mode increased response rates. When examining response by completion mode, the arms involving text invitation had a higher percentage of completed surveys that were completed by web than arms not involving text invitation. Characteristics (e.g., age) of telephone and web respondents were more representative of the sampled population than mail respondents. Older patients and male patients were significantly less likely to be reachable by email or text. These results demonstrate that sequential multi-mode approaches involving web, mail, and telephone with multiple methods of web survey invitation show the greatest promise for obtaining higher response rates and more representative respondents from the ED population.

Differences in patient population and length of stay between freestanding and hospital-based emergency departments

BackgroundFreestanding emergency departments (FEDs) represent over 10% of emergency departments (EDs) in the United States. Little is known about differences in encounter characteristics. We compared ED length of stay (LOS) clinical demographics, method of arrival, acuity level, and patient disposition for encounters to FEDs vs. hospital-based EDs (HBEDs). MethodsA multi-center retrospective analysis was performed. Study sites included 6 FEDs and 13 HBEDs from 10/1/2017 to 9/30/2018. Data was abstracted from ED records and discharge summary within the electronic health record. Descriptive statistics were reported with prevalence (95% Confidence Interval [CI]) for categorical variables and mean (standard deviation [SD]) for continuous variables. Multivariable linear regression assessed the relationship between ED facility (FEDs vs. HBEDs) and ED length of stay (LOS). Results1,263,297 encounters were analyzed. Mean ED LOS was shorter at FEDs (146.62 min (±97.04)) vs. HBED (249.70 min (+287.50)). Nine percent of FED encounters arrived via EMS vs. 21% at the HBEDs. FEDs saw 5.47% emergency severity index (ESI) level 2 vs. 13.76% at the HBEDs. Medicaid and Medicare patients were more prevalent in HBEDs (64.2%) than in FEDs (50.6%). FEDs admitted 13% of patients and HBEDs 27%. All results were significant (p < 0.001). After adjusting for potential confounding variables, patients utilizing FEDs had 16.2% shorter ED LOS vs. HBEDs (β = −0.18 [95% CI: −0.18 to −0.17]). ConclusionOverall ED LOS was significantly less for FED vs. HBED patients. Acuity level, insurance status, method of arrival, and patient disposition were significantly different at FEDs vs. HBEDs.

Racial and Ethnic Differences in Diagnostic Imaging Utilization During Adult Emergency Department Visits in the United States, 2005 to 2014

ObjectiveTo compare the use of medical imaging (x-ray [XR], CT, ultrasound, and MRI) in the emergency department (ED) for adult patients of different racial and ethnic groups in the United States from 2005 to 2014. MethodsWe performed a multilevel stratified regression analysis of the National Hospital Ambulatory Medical Care Survey ED Subfile, a nationally representative database of hospital-based ED visits. We examined race (white, black, Asian, other) and ethnicity (Hispanic versus non-Hispanic) as the primary exposures for the outcomes of ED medical imaging use (XR, CT, ultrasound, MRI, and any imaging). We controlled for other potential patient-level and facility-level determinants of ED imaging use. ResultsApproximately half (48.8%) of the 225,037 adult patient ED visits underwent imaging; 36.1% underwent XR, 16.4% CT, 4.1% ultrasound, and 0.8% MRI. White patients received imaging during 51.3% of their encounters, black patients received imaging during 43.6% of their encounters, Asians received imaging during 50.8% of their encounters, and other races received imaging during 46% of their encounters. As compared with white patients, black patients had decreased adjusted odds of receiving imaging in the ED (odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.84-0.89). Comparatively, black patients had a lower odds of CT scan (OR = 0.80, 95% CI: 0.77-0.83) or MRI (OR = 0.74, 95% CI: 0.65-0.85). Hispanic patients and Asian patients had a higher odds of receiving ultrasound (OR = 1.36, 95% CI: 1.27-1.44 and OR = 1.25, 95% CI: 1.10-1.42), respectively. ImplicationsWe observed significant racial and ethnic differences in medical imaging use in the ED even after controlling for patient- and facility-level factors.

Freestanding emergency departments in Texas do not alleviate congestion in hospital-based emergency departments

ObjectivesEver since the passage of the Texas Freestanding Emergency Medical Care Facility Licensing Act in 2009, freestanding Emergency Departments (FrEDs) have spread throughout Texas. This study aims to determine whether the entry of FrEDs has been associated with less congestion in hospital-based EDs. MethodsThe dependent variables of interest were hospital-based ED annual visit volume, median wait time, length of visit for discharged patients and the percent of patients who left without being seen (LWBS). The explanatory variables of interest were the numbers of FrEDs within the same local market of each hospital-based ED, and an indicator variable for whether the hospital owned satellite FrEDs in outlying areas. ResultsHospital ED visits, wait times, length of visit for discharged patients, and LWBS rates were not associated with the number of competitor FrEDs in the local market. Hospitals that opened satellite FrEDs had significantly higher visit volume in general, but did not experience shorter wait times, length of visit or LWBS rates if located in large metropolitan areas. ConclusionsThe entry of FrEDs did not help relieve congestion in nearby hospitals in major metropolitan areas in Texas. By offering more treatment options to patients, FrEDs are associated with increased usage of emergency services.

Treat-and-Release Emergency Department Utilization by Patients With Gynecologic Cancers.

Seventeen percent of patients with cancer visit the emergency department (ED) annually, often with nonemergent complaints. We sought to describe the burden of treat-and-release ED utilization by patients with gynecologic cancers and to identify opportunities for improved triage. Patients with gynecologic cancer diagnoses who were treated and released were identified within the Nationwide Emergency Department Sample, a stratified sample of US hospital-based ED visits, from 2009 to 2013. Sample weights were applied to generate national estimates. Associations with visit charges were assessed with weighted multivariable linear regression. Between 2009 and 2013, there were an estimated 174,092 annual treat-and-release ED visits by patients with gynecologic cancer (95% CI, 163,480 to 184,703 visits), which corresponded to $736 million in annual charges with an average visit charge of $4,232 (95% CI, $4,099 to $4,366). Annual visits and total charges increased significantly over the 5 years under study. Visits were more frequent for patients with cervical cancer (44.1%) versus ovarian (27.8%) and uterine (24.6%) cancer. These patients were younger and more likely to be from low socioeconomic status areas. The most common primary diagnoses were similar across cancers, including abdominal pain (10.5%), chest pain (6.1%), and urinary tract infection (5.2%). The most frequent diagnostics were culture/smear, computed tomography scan, and x-ray, and the most frequent therapeutic procedures included wound care, transfusion, and paracentesis. Patients with gynecologic cancers, and cervical cancer in particular, are frequently seen in the ED with issues that could be less expensively managed in an outpatient clinic or urgent care setting. Visit frequency, but not per-visit cost, is increasing over time.

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County

BackgroundIn Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use.MethodsA population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services.ResultsThose 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12–44% for those in the lowest income groups. However, age and gender differences were observed with men 65–79 years (OR 1.75 CI: 1.51–2.03) and women 80+ years (OR 1.50, CI 1.19–1.87) in the lowest income groups having a higher odds of frequent ED use.ConclusionThis study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

Hospital-based Emergency Department Visits with Periapical Abscess: Updated Estimates from 7 Years

IntroductionThe impact of the Affordable Care Act (ACA) on the utilization of the emergency department (ED) for periapical abscess (PA) is unknown. The objectives of this study were to provide nationwide estimates of hospital-based ED visits with PA and to examine the effect of the ACA on the use of EDs for PAs. MethodsWe performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS) for 2008 to 2014. All ED visits with a diagnosis of PA were selected. The International Classification of Diseases, Ninth Revision–Clinical Modification code was used to identify PA. Patient- and hospital-level characteristics were examined. Descriptive statistics were used to summarize the data. ResultsFrom 2008 to 2014, a total of 3,505,633 ED visits for PA occurred. The proportion of ED visits with PA significantly increased over the study period (from 460,260 in 2008 to 545,693 in 2014). Medicaid was the primary payer (30.3%) and more than 40% were uninsured. Mean charge per PA-related ED visit was $1080.50 and total PA-related ED charge across the United States was $3.4 billion. Among those hospitalized following PA-related ED visits, mean hospitalization charges were $34,245 and total hospitalization charges were $5.7 billion. ConclusionOral health continues to be overlooked in health care. A large proportion of ED visits with PA were made by those covered by Medicaid and uninsured. The passing of the ACA has not reduced the number of ED visits with PA.

Epidemiology of facial fractures among older adults: A retrospective analysis of a nationwide emergency department database.

The prevalence of facial fractures among older adults has increased in recent years, and nationwide studies about the epidemiological profile and outcomes of hospital-based ED visits for facial fractures among older adults are scarce. The aim of this study was to provide USA-wide data of hospital-based Emergency Department (ED) visits for facial fractures among older adults, and to investigate the outcomes associated with these visits. The Nationwide Emergency Department Sample (NEDS) for the years 2008-2014 was used for the present study. All ED visits with a diagnosis of facial fractures in any of the diagnoses fields and only patients aged 65years and above were included. A total of 540748 ED visits matched the criteria (62.7% were females). Public insurance-Medicare-(85.2%) was the most common payer. The three most frequent facial fractures included fractures of the nasal bones (61.3%), fractures of "other" facial bones (16.7%), and fractures of the orbital floor (15.0%). Falls were the most common causes of facial fractures (81.8%). Following ED visits, 64.1% were treated and released, and 30.6% were admitted into the hospital. The mean ED charge per visit was US$5507. Total ED charges across the entire United States was US$2518289555. Among older adults, nasal bone fractures are the most common type of facial fracture. Facial fractures are mainly caused by falls. There was no significant trend in mortality rates over the study period, and there was a significant financial burden associated with the facial fracture-related ED visits.

The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement.

Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs). Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED. Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1year before and after conversion. There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828). After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.

Hospital-Based Emergency Department Visits With Pediatric Burns: Characteristics and Outcomes.

The objective of this study was to examine the characteristics and outcomes in children presenting to emergency departments (EDs) with burn injuries. The Nationwide Emergency Department Sample (NEDS) for the years 2008 to 2013 was used. All patients younger than 18 years who visited a hospital-based ED with a burn injury were selected. The study focused on (1) demographics (age, sex, insurance status), (2) characteristics of burns (types, causes), (3) disposition status after ED/hospitalization, (4) charges (ED and hospital), and (5) patient outcomes. Inclusion criteria were a visit to ED in the United States with a burn. Descriptive statistics were used to summarize the findings. During the study period, there were 746,593 ED visits due to burn injuries. Majority were insured by Medicaid (52.8%). Most frequent injuries were burns of wrists/hands (39.5%), lower limbs (24.1%), and upper limb-except wrist/hand (20.1%). The most common causes of burns were heat from electric appliances (37.1%) or hot liquids and vapors (24.8%). Following the ED visit, 89.1% were discharged routinely, and 4.3% were admitted. Mean charge per patient per ED visit was $1117. Total ED charges across the United States was $708.7 million. When admitted, mean length of stay was 5.7 days. Total hospitalization charge across the United States was $1.7 billion. Pediatric burn injuries require significant resources for stabilization and treatment by EDs. The present study highlights the burden and impact of pediatric burn injuries in the United States.

1856. Comparison of Antibiotic Susceptibility in Hospitals vs. Hospital-Based Emergency Departments

BackgroundAntibiotic susceptibility varies by hospital location (inpatient vs. emergency department (ED)) and by geographic location. Despite these differences, hospitals often have one antibiogram to determine empiric guidelines. The purpose of this study was to evaluate a large health system’s bacterial sensitivity for key organisms in the inpatient vs. the ED setting to determine whether ED-specific antibiograms are necessary based on region.MethodsA health-system, consisting of primarily large general community hospitals across 20 US states, evaluated 156 of their hospitals and hospital-based EDs. These hospitals and hospital-based EDs were divided into regions based on geographic area for assessment. Inpatient and ED susceptibilities were then compared and classified based on susceptibility differences (Minimal 0–4, Moderate 5–10, Considerable > 10). One year of susceptibility data for E. coli, P. aeruginosa and S. pneumoniae was evaluated for antibiotic sensitivity.ResultsA total of 171,556 nonduplicative isolates were evaluated including 139,562 E. coli urine isolates (inpatient 41,612, ED 97,950), 28,685 P. aeruginosa (inpatient 19,983, ED 8,702) and 3,309 S. pneumoniae (inpatient 1,565, ED 1,474). The ED was expected to have less resistance than inpatients as ED patients primarily come from a community setting. For E. coli urinary isolates, minimal differences were found for sulfamethoxazole/trimethoprim, and moderate differences were seen in cefazolin and ceftriaxone for the California/Nevada and Texas San Antonio regions. Moderate or considerable differences were seen in nearly all regions for ciprofloxacin. Considerable differences in S. pneuomoniae susceptibilities were seen between the inpatient and ED for azithromycin and penicillin G, while one region also had a considerable difference for levofloxacin. P. aeruginosa had one region with a considerable difference, with the Colorado + Central Kansas regions showing less resistance inpatient than the ED.ConclusionDifferences in inpatient vs. ED bacterial sensitives warrant justification for-specific regions to monitor and develop inpatient and ED-specific antibiograms.Disclosures All authors: No reported disclosures.

183. Alerting and Education via the Electronic Health Record (EHR) Decreases Inappropriate Fluoroquinolone prescribing in the Emergency Department of a Large Integrated Hospital Network

BackgroundEmergency department (ED) providers frequently use fluoroquinolones (FQs) as first-line therapy for common infections in discharged patients. In 2016 the FDA issued a warning against FQ use for three common conditions: cystitis, bronchitis, and sinusitis. This study evaluated the effect of an electronic health record (EHR) clinical decision support alert followed by targeted provider education on FQ prescribing in the ED.MethodsWe performed a nonrandomized, single arm, pre–post study of FQ prescribing in target indications before (November 2015–October 2016) and after (January 2017–December 2017) implementation of an EHR alert at 19 hospital-based and free-standing EDs in the Charlotte NC area. Providers were alerted when a patient was discharged from the ED on an FQ with a target diagnosis (infections identified as being inappropriate for FQ) without additional exclusions (e.g., penicillin allergy) (Figure 1). Initial provider education on appropriate FQ use accompanied EHR alert implementation at all 19 participating EDs in November 2016. Targeted follow-up education was delivered in August 2017. We compared overall FQ prescribing rates in pre- vs. post-alert intervals using chi-squared tests. We compared FQ prescription volume following alert failure by indication for high alert failure diagnoses (ICD10 codes with ≥75 alerts) in Q1 2017 vs. Q4 2017.ResultsTarget population ED discharges remained stable pre- and post-alert implementation (n = 37,975; n = 37,731). FQ prescribing decreased 53% from pre (n = 13,796, 36%) to post alert (n = 7,289, 19%; P < 0.01). While total orders avoided after alert firing remained low, the total prescriptions (i.e., alert overrides) dropped from 789 in January 2017 to 397 in December 2017 (Figure 2). The largest decrease was observed after repeat provider education in August 2017. Diagnosis categories with high volume alert failures decreased from 15 unique ICD10 diagnosis (n = 1,534 prescriptions) in Q1 2017 to 3 (diverticulitis, pneumonia, gastroenteritis/colitis; n = 419 prescriptions) in Q4 2017.ConclusionEffective EHR alert implementation combined with timely and targeted provider education on appropriate prescribing reduces inappropriate ED provider FQ prescribing by more than 50%. Disclosures L. Davidson, Duke Endowment: Grant Investigator, Grant recipient

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011–2013

Background: Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment. Objectives: This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care. Methods: The 2011–2013 Healthcare Cost and Utilization Project’s NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively. Results: A total of 492,419 ED visits for SUDs were reported through 2011–2013. Despite NY’s Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York’s EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.

Michigan Emergency Department Leader Attitudes Toward and Experiences With Clinical Pathways to Guide Admission Decisions: A Mixed-methods Study.

The objective was to characterize emergency department (ED) leader's attitudes toward potentially avoidable admissions and experiences with the use of clinical pathways to guide admission decisions, including the challenges and successes with implementation of these pathways. A mixed-methods study of Michigan ED leaders was conducted. First, a cross-sectional Web-based survey was distributed via e-mail to all 135 hospital-based EDs in the state. Descriptive statistics were calculated. Survey participants who provided contact information were considered eligible for follow-up. Semistructured interviews were conducted by telephone until thematic saturation was reached. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and thematically coded. Representative quotes were extracted for reporting. Survey responses were received from 64 ED leaders (48% eligible response rate). Semistructured interviews were conducted with a purposeful sample of 11 of the 29 representatives willing to be contacted. Eight sites implemented clinical care pathways as a strategy to reduce avoidable admissions. Pathways were developed for high-frequency conditions. Many pathways were multidisciplinary, incorporating case managers and outpatient care providers, which was thought to improve acceptability. Five models of care emerged 1) standardized care, 2) observation medicine, 3) enhanced follow-up, 4) care coordination, and 5) comprehensive programs. We identified barriers to and facilitators of discharging a patient from the ED when an admission otherwise could be avoided. Barriers included limited access to follow-up, lack of care coordination, and lack of trust in patient's ability to provide self-care or navigate the system. Facilitators included strong relationships with outpatient providers, care coordination, and shared decision making. Potential solutions to help avoid hospitalization from the ED include multidisciplinary clinical care pathways. Successful pathways emerged from bringing stakeholders from the ED, hospital, and health care community together. Additionally, emergency providers need systems and supports in place to help their patients navigate follow-up care in a timely fashion.