Hospital-based Emergency Research Articles

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.

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.

Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records.

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

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.

Depressive symptoms and health care within 30 days after discharge from a cardiac hospital unit.

To determine the association between depressive symptoms in CHD patients and in- and outpatient health care utilization during the 30 days following treatment in a cardiac hospital unit. The study sample consisted of 949 CHD patients who completed a measure of depressive symptom severity (the Patient Health Questionnaire [PHQ-9]). Cardiac disease severity and medical comorbidities were assessed by chart review. Follow-up questionnaires were mailed to patients assessing in- and outpatient health care. Among patients with elevated depressive symptoms (PHQ-9 score of ≥7), 19.9% had at least one outpatient hospital visit (hospital-based medical centers, outpatient clinics, and emergency departments) within the first 30 days after the initial hospitalization, compared to 11.8% of patients without depressive symptoms (p = 0.002). This association remained significant after adjustment for sociodemographic and medical covariates. Elevated depressive symptoms also predicted a higher number of outpatient physician visits (adjusted OR = 2.36; 95% CI 1.75 - 3.18; p < 0.001). Results were similar for the PHQ-9 continuous score. There was no association between depressive symptoms and re-hospitalizations. After hospitalization for cardiac care, patients with elevated depressive symptoms may be at higher risk for utilizing outpatient physician and outpatient hospital care. This is not explained by more severe cardiac disease or more comorbidities.

88EMF Freestanding Versus Hospital-Based Emergency Departments: Comparing Geographic Catchment Areas and Visit Characteristics

We compared the geographic catchment areas and patient visit characteristics at hospital-affiliated freestanding emergency departments (FREDs) versus hospital-based emergency departments (HEDs). We performed a retrospective observational analysis of adult patient visits to 19 hospital-affiliated FREDs and 5 HEDs in Colorado over a 1-year period. Catchment areas were defined using a straight marginal approach as Colorado zip codes that served as the zip code of residence for at least 0.5% of an emergency department’s (ED's) annual census. Catchment area characteristics were obtained from the 2016 American Community Survey, and median demographics were compared using the 2-sample Wilcoxon rank-sum test. Patient visit characteristics were abstracted from 2016-17 electronic medical record data, and Chi-squared test was used to compare visit characteristics between FREDs and HEDs. The FRED catchment area included 150 zip codes and the HED catchment area included 82 zip codes, with 70 zip codes overlapping. The catchment areas were similar in median zip code population, percent Hispanic residents, percent of residents with health insurance, educational attainment, and percent non-English speakers. Compared to HED catchment areas, FRED catchment areas had a lower proportion of non-White residents (12.4% versus 17.3%, p=0.005), higher median household incomes ($70,356 versus 58,762, p=0.008), a lower proportion of residents with public health insurance (26.1% versus 30.6%, p=0.033), and a lower proportion of residents below the federal poverty level (8.1% versus 10.8%, p=0.013). On analysis of patient visit characteristics, FREDs had a larger proportion of visits from patients between the ages of 18 and 44 (63% versus 54%, p< 0.001) and fewer visits from patients 80 years and older (3% versus 6%, p<0.001). Similar to catchment area patterns, FREDs had significantly lower proportions of non-White patient visits (24% versus 34%, p<0.001) and patient visits with public insurance (29% versus 39% Medicaid and 14% versus 23% Medicare, p<0.001). FREDs did have a larger proportion of uninsured patient visits than HEDs (12% versus 10%, p<0.001). FREDs had more visits from infrequent ED utilizers, with fewer than 4 visits to any study ED over the year (84% versus 72%, p<0.001), and they had fewer visits from super-utilizers, with 10 or more ED visits (3% versus 7%). Hospital-affiliated FREDs tend to serve communities with higher incomes, fewer minorities, and higher rates of private insurance than do HEDs. These patterns are largely reflected in patient visit characteristics as well.

Insight Into Health Care Services: A Characterization of Emergency Room Visits and Economic Hazards in the United States.

This study explores the impact of economic hazard areas on hospital-based emergency departments to determine whether economically hazardous environments, characterized by the change of population, income per capita, and unemployment rate, experience a higher number of emergency room visits than areas of lower rated economic hazard risk in the United States. A cross-sectional design was used of a nationally constructed data set of hospital-based emergency departments of over 6,000 hospitals in the United States. We identified our quality outcome measure as the emergency room visits rate within a hospital service area. We created the variable by dividing the number of emergency room visits by the population of the hospital services area in which the emergency room was located. Results indicate that there is a difference in the incident rate ratio of emergency room visits between environments considered to be experiencing greater amounts of hazard, compared to lower amounts of hazard. Hospital administrators and health policy-makers need to work in conjunction to focus efforts on public safety as a key objective in the delivery of emergency medical care. One crucial effort that hospital administrators need to focus on is improving emergency room capacity and efficiency as part of the disaster preparedness plan (Disaster Med Public Health Prep. 2019;13:470-475).

Transitioning Nurse Handoff to the Bedside: Engaging Staff and Patients.

The emergency department is a complex environment in which reliable communication is vital for safe patient care. Communication during nurse shift report can be risky without an effective report process in practice. Reliability improves with the use of a standardized, patient-centered nurse handoff process. Quality improvement methods were used to promote reliable information exchange during nurse shift handoff through the implementation of a standardized, patient-centric bedside report process. Forty-six hospital-based emergency nurses participated in the project. Outcomes were measured through observation of bedside report process, nurse, and patient surveys. Of 13 handoffs observed, 92% occurred at the bedside and 54% of patients actively participated in the report process. The offgoing nurses adopted most elements of the handoff process, while the oncoming nurses were less successful. Nurses believed that the new process influenced their ability to respond to patient needs and patients were more satisfied with nurses. A structured, patient-centered bedside handoff process can reduce safety risk and promote satisfaction with care through reliable information exchange. This implementation template for bedside handoff engages staff and patients while translating best practice.

Clinical differences between visits to adult freestanding and hospital-based emergency departments

ObjectiveCompare clinical characteristics for adult visits to freestanding emergency departments (FEDs) and a hospital-based ED (HBED). MethodsElectronic health records were collected on adult ED visits from 7/1/14 to 6/30/15 from three FEDs and one level 1 trauma tertiary care HBED. ResultsThere were 55,909 HBED visits; 44,108 FED visits. The FED population was slightly more female (61% vs 57%), younger (48 vs 46 years), white (86% vs 60%), and employed (67% vs 49%). A higher percent of FED visits had private insurance (43% vs 20%); a lower percent had Medicaid (25% vs 42%) and Medicare (23% vs 30%). The top three presenting problems were the same at the HBED and FEDs, but the order differed: gastrointestinal (HBED 19% vs FED 18%), cardiorespiratory (18% vs 16%), injury-pain-swelling of extremity (14% vs 17%). Differences were seen in primary ICD9 codes. One quarter of FED visits and only 18% of HBED visits were for injury/poisoning. A higher percent of FED visits were for respiratory diseases (12% vs 9%) but a lower percent were for circulatory system diseases (7% vs 11%) and visits for mental illness (2% vs 6%). Nearly 30% of HBED visits resulted in admission, compared to 8% of FED visits. ESI level differed significantly, with a lower percent of high acuity cases at FEDs (level 1: 0.1% vs 1.6%; level 2: 5% vs 26%). ConclusionDifferences were observed in clinical characteristics of adult HBED visits versus FEDs. Results of this study can help communities plan their emergency care system.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders

IntroductionFor ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling. MethodsWe invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders’ views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse. ResultsFrom 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%). DiscussionDespite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.Image 1

A Comparison of Care Delivered in Hospital‐based and Freestanding Emergency Departments

We compare case mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs). Data from 74 FSEDs (2013-2015) in Texas and Colorado were compared to H-ED data from the 2013-2014 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g., payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, nonambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED LOS and as well as hospital admission rates and resource utilization rates in the IPW-weighted samples. Before balancing, FSEDs saw more young adults (age 25-44) and fewer older adults (age 45-64) than H-EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H-ED patients. Hospital admission rates were 37% lower overall (95% confidence interval = -51% to -23%) in FSEDs and varied considerably by primary discharge diagnosis. X-ray and electrocardiogram use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, computed tomography scans, and laboratory tests). In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to < 65 years, privately insured, and nonambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H-ED over FSEDs.

Characteristics of Pediatric Patient Transferred From Hospital-Based General Emergency Departments to Acute-Care Facilities: An Analysis of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample.

The objective of this study was to analyze the characteristics of pediatric patients transferred from a hospital-based general emergency department (ED) to an acute care facility. Study data were abstracted from the 2010 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database. A multivariate logistic regression was constructed for pediatric patients (<18 years old) who require a transfer to an acute care facility from a general ED. Independent variables included in the model were age (<1, 1-4, 5-9, 10-14, 15-17 age in years), sex, insurance/payment method, and diseases/body systems using International Classification of Diseases, Ninth Revision, coding. In the Healthcare Cost and Utilization Project/Nationwide Emergency Department Sample, 5.5 million ED visits were for children less than 18 years. About 1.5% of visits resulted in transfer. Children younger than 1 year had higher transfer rates as compared with 15 to 17 year old group (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.089-1.146). Patients with Medicaid and self-pay compared with private insurance/health maintenance organization had 4% (OR, 0.96; 95% CI, 0.944-0.976) and 9% (OR, 0.91; 95% CI, 0.886-0.945), respectively, lower likelihood of being transferred. Patients with circulatory (OR, 8.43; 95% CI, 7.8-9.1), endocrine (OR, 5.9; 95% CI, 5.6-6.2), mental (OR, 5.44; 95% CI, 5.3-5.6), nervous system (OR, 5.2; 95% CI, 4.9-5.5), congenital anomalies (OR, 5.14; 95% CI, 4.5-5.9), hematology-oncology (OR, 4.49; 95% CI, 4.2-4.8), digestive, (OR, 1.52; 95% CI, 1.5-1.6), and other disorders (OR, 1.33; 95% CI, 1.3-1.4) had a higher odds of being transferred as compared with trauma/injury and poisoning, whereas patients with disorders related to genitourinary (OR, 0.96; 95% CI, 0.91-1.0), respiratory (OR, 0.79; 95% CI, 0.77-0.81), musculoskeletal (OR, 0.63; 95% CI, 0.58-0.68), skin (OR, 0.47; 95% CI, 0.45-0.50), infectious and parasitic (OR, 0.23; 95% CI, 0.22-0.25), and eyes/ears/nose/throat (OR, 0.09; 95% CI, 0.079-0.094) had a lower odds of being transferred as compared with trauma/injury and poisoning. Children younger than 1 year had relatively higher transfer rates. Patients covered by Medicaid and self-pay had the lowest likelihood of transfer. Transfer rates varied significantly by condition and the high-transfer diagnostic categories were related to circulatory, endocrine, nervous, hematology-oncology, and mental disorders as well as congenital anomalies, which may be related to a lack of ED or inpatient resources to care for children with problems that require more complex care.

Hospital Emergency Department Lethal Means Counseling for Suicidal Patients

Lethal means counseling of suicidal individuals in emergency departments has the potential to reduce suicide. This study examines the provision of lethal means counseling and the presence of written protocols in a region with high rates of both firearm ownership and suicide. In 2015-2016, emergency department nurse managers in hospital-based emergency departments throughout eight states were surveyed using an 80-item survey developed through qualitative interviews and pilot testing. Questions focused on discharge counseling with suicidal patients and the presence of written protocols. Using survey weights to adjust for nonresponse, relationships of protocols with counseling practices were examined. Data were obtained from 52.3% of all 363 eligible hospital emergency departments in the region. Among facilities that discharge suicidal patients, 79.7% (95% CI=75.0%, 84.4%) reported asking about access to firearms and 68.9% (95% CI=62.9%, 74.8%) counsel about safe storage when patients reported access. Forty-four percent of emergency departments reported having written protocols for lethal means counseling. Presence of written protocols was associated with a higher rate of counseling for all suicidal patients even if they were not planning to use a gun (45.0% [95% CI=33.4%, 56.7%] in hospitals with protocols vs 21.5% [95% CI=14.9%, 29.0%] in facilities without protocols). There are significant gaps in attention to lethal means counseling in emergency departments. This signals an opportunity to increase consistency and thoroughness of care for suicidal patients in the emergency department and for leadership from key professional organizations to advocate for protocols.

391 Same Physician, Different Location: Variation in Press Ganey Scores Between Freestanding and Hospital-Based Emergency Departments

391 Same Physician, Different Location: Variation in Press Ganey Scores Between Freestanding and Hospital-Based Emergency Departments

Hospital-Based Emergency Department Visits With Dental Conditions: Impact of the Medicaid Reimbursement Fee for Dental Services in New York State, 2009-2013

ObjectivesHospital-based emergency department (ED) visits for dental problems have been on the rise. The objectives of this study are to provide estimates of hospital-based ED visits with dental conditions in New York State and to examine the impact of Medicaid reimbursement fee for dental services on the utilization of EDs with dental conditions. MethodsNew York State Emergency Department Database for the year 2009-2013 and Health Resources and Services Administration's Area Health Resource File were used. All ED visits with diagnosis for dental conditions were selected for analysis. ResultsThe present study found a total of 325,354 ED visits with dental conditions. The mean age of patient was 32.4 years. A majority of ED visits were made by those aged 25-44 years (49%). Whites comprised 52.1% of ED visits. Proportion of Medicaid increased from 22% (in 2009) to 41.3% (in 2013). For Medicaid patients, the mean ED charges and aggregated ED charges were $811.4 and $88.1 million, respectively. Eleven counties had fewer than 4 dentists per 10,000 population in New York State. ConclusionHigh-risk groups identified from the study are those aged 25-44 years, uninsured, covered by Medicaid and private insurance, and residing in low-income areas. The study highlights the need for increased Medicaid reimbursement for dentists and improves access to preventive dental care especially for the vulnerable groups.

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.

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.

Investment versus Impact- Psychosocial and Metric Analysis of High Fidelity Manikin Use in Hospital-Based Emergency Response Team Training

Investment versus Impact- Psychosocial and Metric Analysis of High Fidelity Manikin Use in Hospital-Based Emergency Response Team Training

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.