Inappropriate Emergency Department Research Articles

Emergency Department Poisoning Visits in Children Younger Than 6 Years

The study purpose was to compare medical appropriateness and costs of regional poison control center (RPCC) versus non-RPCC referrals to children's hospital emergency department (ED) for acute poison exposure. This is a retrospective cross-sectional study of children (<6 years) during an 8-month period, who presented for poison exposure. Demographic and clinical patient characteristics were abstracted onto a uniform data form. Medical appropriateness was determined by presence of 1 of 4 criteria by 3 independent reviewers blinded to the patients' race, source of referral, charges, and disposition. Determination of medical appropriateness was matched by all 3 reviewers in 187 patients who make up the study population. There were 92 RPCC-referred cases and 95 non-RPCC-referred controls. Groups were comparable by age, sex, toxin, and symptoms. For RPCC referrals, 84 were self-transported, and 8 were transported by emergency medical services. For non-RPCC referrals, 60 were self-referred/transported, 26 were transported by emergency medical services, and 9 were physician referred. Regional poison control center referrals had a 39.1% higher rate of medical appropriateness than did non-RPCC referrals (odds ratio, 13.0; 95% confidence interval, 3.6-36.1). For this sample, mean charges for inappropriate ED poison exposure visits were $313.42, and the cost per RPCC call was $25, thus giving a potential return on investment of 12.54 to 1 favoring RPCC triage. When compared with other referral sources, RPCC triage results in fewer unnecessary ED visits in this age group. Increasing prehospital use of poison centers would likely decrease unnecessary ED referrals and related costs.

Healthcare providers attitudes and perceptions of ‘inappropriate attendance’ in the Emergency Department

Emergency Departments (EDs) worldwide are facing a crisis from overcrowding and a common perception exists that inappropriate use of the ED is a major contributing factor. Patients, who attend the ED with non-urgent problems, could be dealt with by a General Practitioner; such patients use time and resources that would otherwise be used for patients with more appropriate needs. Study aimTo explore attitudes and perceptions of healthcare providers regarding ‘inappropriate attendance’ in the ED. Study designUsing a survey questionnaire, this descriptive quantitative study included ED nurses, doctors and paramedics from three regional hospitals in the Republic of Ireland. ResultsA total of 163 surveys were returned (59% response rate). There was an overwhelming agreement among respondents that inappropriate attendance in Irish ED exists and poses a considerable challenge for healthcare providers. Results suggest differences of opinion on what represents inappropriate ED use.Potential solutions to address the issue of inappropriate ED attendance include General Practitioners and Advanced Nurse Practitioners practicing within the ED setting; education and greater public awareness and faster access to a specialist opinion in the Out Patient Department.

Integrating community children’s nursing in urgent and emergency care: a qualitative comparison of two teams in North West England

BackgroundDespite the policy principle that “children are best cared for at home whenever possible” children continue to have high rates of emergency department (ED) attendance and emergency hospital admission. Community Children’s Nursing Teams (CCNTs) can care for acutely ill children at home but their potential to provide an alternative to ED attendance and hospitalisation depends on effective integration with other services in the urgent care system, such as EDs and Observation and Assessment Units (OAUs). Although challenges of integrating CCNTs have been identified, there has been no comparative assessment of the factors that facilitate or hinder integration of care of acutely ill children by CCNTs with the urgent care system. The aim of this study was to identify enablers and barriers to integration of CCNTs with urgent and emergency care.MethodsComparative case studies were conducted of two CCNTs serving Primary Care Trusts in North West England. Twenty-two health professionals including CCNT managers and staff; paediatricians; nurses; children’s ward, ED and OAU staff; commissioners of children’s services; GPs and primary care staff were interviewed between June 2009 and February 2010. Qualitative data were analysed thematically using the Framework approach.ResultsBarriers to integration included paediatricians’ perceived lack of ownership of the CCNT, poor communication between consultants and community children’s nurses (CCNs), and weak personal relationships. This prevented early referral to the CCNT as an alternative to hospital care. Enablers of integration included co-location and rotation of CCNs through urgent care settings including OAUs and EDs. This enabled nurses to develop skills, make decisions about referral to home care and gain the confidence of referring clinicians.ConclusionsIntegration of CCNTs at multiple points in the urgent care system is required in order to provide an alternative to inappropriate ED attendances and emergency admission. The principal enablers and barriers are both aspects of normative integration, which involves shared understanding of the contribution of CCNTs and trusting relationships between practitioners. Co-location and rotation of CCNs through acute services can promote integration and appropriate referrals to CCNTs to support families to care for children at home.

Reducing inappropriate emergency department attendances—a review of ambulance service attendances at a regional teaching hospital in Scotland

IntroductionEmergency Departments (ED) in the UK have seen increasing attendance rates in recent years. Departments are now seeking strategies to reduce their attendances. A review of all ambulance attendances to...

Inappropriate Emergency Department Thoracotomy Is Futile

To test the hypothesis that inappropriate emergency department (ED) thoracotomy is futile, wastes resources, and poses a health risk to providers, researchers reviewed data for 123 patients who underwent ED thoracotomy at a level I trauma center in Toronto during a 17-year period. The authors defined ED thoracotomy as being inappropriate if …

Societal Costs of Inappropriate Emergency Department Thoracotomy

Emergency department (ED) thoracotomy can be lifesaving. It can also lead to resource waste and exposure to blood-borne infections. We investigated the frequency with which ED thoracotomy was performed for inappropriate indications and the resulting societal costs. This retrospective cohort study examined all trauma patients admitted directly from the scene of injury from 1992 to 2009 who underwent ED thoracotomy. The main outcomes included inappropriate ED thoracotomy. Secondary outcomes included resource use and societal costs for performing ED thoracotomy for improper indications. Specifically, we analyzed for operating room use, blood transfusions, ICU and hospital stay, needlestick injuries, survivor rate, and neurological outcomes in this group. One hundred and twenty-three patients underwent ED thoracotomy during the study period. Of those, 63 (51%) were considered inappropriate. In this group, we observed no survivors, none became organ donors, 3 cases of needlestick injuries to health care providers occurred, and 335 U of blood products were used in their care. Also, 4 patients of 63 survived to the operating room and required a total of 6 separate operating room visits. Three of these patients had an ICU stay of 1 day and 1 died on day 5. ED thoracotomy should be reserved for potentially salvageable patients, but discouraged for other indications. From the societal point of view, inappropriate use of the procedure resulted in substantial costs and waste of resources, exposure of health care providers to possible blood-borne infections, and offered no survival benefit.

Factors influencing inappropriate use of ED visits among type 2 diabetics in an evidence‐based management programme

This study analyses inappropriate use of emergency department (ED) services among type 2 diabetics under an evidence-based management programme. Using 1999-2006 databases of Louisiana Health Care Services Division (HCSD) eight public hospitals ED visits among the uninsured and other patients in Louisiana, we termed urgent ED visits appropriate and less-urgent visits inappropriate. Eliminating weekend ED visits, 17,458 urgent and 22,395 less-urgent visits by 8596 patients were analysed, using generalized estimating equation methods. Caucasians were 0.82 times (95% CI: 0.751-0.889) less likely to use the ED inappropriately compared with African Americans. Patients with commercial insurance, Medicaid and Medicare used the ED more inappropriately than uninsured, with odds ratios of 1.28, 1.32 and 1.28, respectively. Patients hospitalized the prior year were 0.84 times (95% CI: 1.08-1.31) less likely for inappropriate. Patients in larger hospitals used the ED more inappropriately, with an odds ratio of 1.44 (95% CI: 1.32-1.56). The study suggests that inappropriate use of the ED among diabetic patients in an evidence-based management programme is more likely to occur among African American, patients with insurance coverage and those seeking care in larger hospitals. Reinforcing the regular use of clinic services for diabetes management, providing clinic access in off-hours, and engaging the health plans in providing incentives for more appropriate use of the ED might reduce inappropriate ED visits. Notably, uninsured patients with diabetes from HCSD were more efficient users of the ED.

Real Healthcare Reform: Focus on Primary Care Access

Primary care coverage for the uninsured is the first necessary step to reform and can be more cost effective and tolerable than a major system reform. By providing foundational care to the uninsured, more care resources are targeted to those that most need the services, while providing benefits such as increased productivity and reduced inappropriate emergency department utilization. The authors aimed to design a primary care coverage system in the United States for the uninsured using established reimbursement, budgeting, and compliance methods. Providing four primary care visits for acute care, four associated ancillary and four fulfilled pharmaceutical–treatment prescriptions, and one preventive primary care visit per year for nearly 48,000,000 uninsured would cost $36 per month for every working American and legal alien resident. Theoretical and empirical literature was reviewed and the authors applied practical knowledge based on their experience in healthcare systems to develop the Access America Program.

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program

BackgroundThis study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD).MethodsAll ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables.ResultsPatients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect.ConclusionPatients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.

Preferences and Perceptions of Patients Attending Emergency Departments with Low Acuity Problems in Hong Kong

ObjectiveTo explore why patients in Hong Kong seek medical advice from the emergency department (ED) and to identify the methods by which patients would prefer to be updated on the likely waiting time for medical consultation in the ED.MethodsThe study recruited 249 semi‐urgent and non‐urgent patients in the ED of Prince of Wales Hospital from 26th September 2005 to 30th September 2005 inclusive. A convenience sample of subjects aged ≥15 years old in triage categories 4 or 5 were verbally consented and interviewed by research nurses using a standardized questionnaire.ResultsFrom 1715 potential patients, 249 were recruited ad hoc (mean age 44 years [SD18]; 123 females). About 63% indicated that an acceptable ED waiting time was less than or equal to two hours, and 88% felt that having individual number cards and using a number allocation screen in the ED waiting area would be useful. Perceived reasons for attending the ED rather than other health care providers such as primary health care or the general outpatient clinic (GOPC) included: a desire for more detailed investigations (56%); a perception that more professional medical advice was given in the ED (35%); patients were under the continuing care of the hospital (19%); and patients were referred to the ED by other health care professionals (11%). Notably, 26% of participants had considered attending the GOPC prior to attending the ED. Patients educated to tertiary level expected a shorter waiting time than those educated to lesser degrees (p=0.026, Kruskal‐Wallis test). Suggestions were made on how to provide a more pleasant ED environment for the wait for consultations, which included the provision of a television screen with sound in the waiting area (43%), more comfortable chairs (37%) and health care promotion programs (32%).ConclusionPatients chose ED services because they believed they would receive more detailed investigations and more professional medical advice than available alternatives. Clear notification of the likely waiting times and enhancement of comfort before consultation are considered desirable by patients. Enhanced public education about the role of the ED and making alternatives to ED care more accessible may be useful in reducing inappropriate ED attendances in Hong Kong.

Inappropriate use of emergency services: a systematic review of prevalence and associated factors

This systematic review aimed to measure the prevalence of inappropriate emergency department (ED) use by adults and associated factors. The review included 31 articles published in the last 12 years. Prevalence of inappropriate ED use varied from 20 to 40% and was associated with age and income. Female patients, those without co-morbidities, without a regular physician, without a regular source of care, and those not referred to the ED by a physician also showed more inappropriate ED use, with the relative risk varying from 1.12 to 2.42. Difficulties in accessing primary health care (difficulties in setting appointments, longer waiting periods, and short business hours at the primary health care service) were also associated with inappropriate ED use. Thus, primary care requires fully qualified patient reception and efficient triage to promptly attend cases that cannot wait. It is also necessary to orient the population on situations in which they should go to the ED and on the disadvantages of consulting the ED when the case is not really urgent.

301: What is the Frequency of Inappropriate Emergency Department Catheterization Laboratory Activation for Patients With Potential ST-Segment Elevation Myocardial Infarction?

301: What is the Frequency of Inappropriate Emergency Department Catheterization Laboratory Activation for Patients With Potential ST-Segment Elevation Myocardial Infarction?

Increased long-term mortality in patients with repeated visits to the emergency department

Revisits to the emergency department (ED) are common. It is not clear whether the number of revisits, the time between revisits or the reason for the revisits are associated with increased mortality. During 1 year, the number of visits, the reason for the visit and the time between visits were recorded in 15 607 nonsurgical ED patients and related to 1-year and 5-year mortality. Five-year mortality was dependent on the number of revisits in an inverse U-shaped manner. When compared with one-time visitors, patients with three visits showed an increased 5-year mortality (hazard ratio 1.85, 95% confidence interval 1.58-2.16, P<0.0001), whereas in patients with four or five visits mortality decreased. Patients with six or more visits had a 5-year mortality not different from one-time visitors. The impact of the number of visits was, however, dependent on the presenting complaint (P<0.0001). Furthermore, the time between two adjacent visits influenced long-term mortality in an inverse U-shaped manner. In patients not admitted to the ward, a revisit after 2-3 days was associated with increased mortality (hazard ratio 1.89, 95% confidence interval 1.06-3.35, P=0.03). In patients revisiting the ED with the same adjacent presenting complaint, mortality differed depending on the complaint (P<0.0001). In nonsurgical patients revisiting the ED, long-term mortality was dependent on both the number of revisits, as well as the time between two visits in an inverse U-shaped manner. This indicates a possibility of detecting the transition level between appropriate medical utilization and inappropriate frequent ED use.

Value of Information of a clinical prediction rule: Informing the efficient use of healthcare and health research resources

The aim of this study was to estimate the potential cost-effectiveness and expected value of perfect information of a recently derived clinical prediction rule for patients presenting to emergency departments with chest discomfort. A decision analytic model was constructed to compare the Early Disposition Prediction Rule (EDPR) with the current standard of care. Results were used to calculate the potential cost-effectiveness of the EDPR, as well as the Value of Information in conducting further research. Study subjects were adults presenting with chest discomfort to two urban emergency departments in Vancouver, British Columbia, Canada. The clinical prediction rule identifies patients who are eligible for early discharge within 3 hours of presentation to the emergency department. The outcome measure used was inappropriate emergency department discharge of patients with acute coronary syndrome (ACS). The incremental cost-effectiveness ratio of the EDPR in comparison to usual care was (negative) $2,999 per inappropriate ACS discharge prevented, indicating a potential cost-savings in introducing the intervention. The expected value of perfect information was $16.3 million in the first year of implementation, suggesting a high benefit from conducting further research to validate the decision rule. The EDPR is likely to be cost-effective; however, given the high degree of uncertainty in the estimates of costs and patient outcomes, further research is required to inform the decision to implement the intervention. The potential health and monetary benefits of this clinical prediction rule outweigh the costs of doing further research.

The emergency department for routine healthcare: Race/ethnicity, socioeconomic status, and perceptual factors

Our objective was to study the role of race/ethnicity and socioeconomic status (SES) in the use of the emergency department (ED) as a source of routine healthcare. Adult patients presenting to an urban ED were surveyed. We assessed demographics, race/ethnicity, SES, and perceptional factors related to choosing the ED for the current visit. Stepwise logistic regression analyses were used to explore whether SES accounted for racial/ethnic trends in ED use. Of 1375 patients, 936 (68%) were enrolled. After controlling for insurance status, income, employment status, and education, neither race nor ethnicity remained a strong predictor of routine ED use. Race/ethnicity-based disparities in routine ED use were due to the confounding effects of SES. Programs to reduce inappropriate ED use must be sensitive to an array of complex socioeconomic issues and may necessitate a substantial paradigm shift in how acute care is provided in low SES communities.

Effects of Social Work Intervention on Nonemergent Pediatric Emergency Department Utilization

The purpose of this study was to determine whether social work intervention would reduce nonemergent visits to the emergency department and increase scheduled pediatric visits. A high-risk repeater group of 104 pediatric patients with three or more emergency department visits was randomly selected to receive social work intervention. Control and intervention groups were compared for inappropriate emergency department utilization and scheduled primary care visits. Pre- and postintervention emergency department visits were significantly reduced in the intervention group compared with the group that received no intervention and with prior utilization. Scheduled visits declined in the control group but increased by 26 percent in the intervention group.

The impact and enforcement of prudent layperson laws

Study objective Almost every state has enacted a “prudent layperson” standard for determining insurance coverage for emergency department (ED) services. This study evaluates whether these laws are achieving their goals or causing unintended side effects. Methods Six states were selected for in-depth case studies to represent a range of market, demographic, and legal conditions. In each state, 11 to 15 interviews were conducted with insurers, regulators, providers, employers, patient advocates, and industry observers, for a total of 87 interviews. In addition, regulators in all 50 states completed a written survey about likely enforcement responses for hypothetical violations of these laws. Results Basic compliance with prudent layperson laws appears to be widespread. Regulators actively enforce these laws, and most subjects reported no systematic violations. Insurers explained that it is difficult to operationalize a coverage standard that relies on patients' experience of symptoms rather than on providers' assignment of diagnostic and procedure codes. No strong evidence was found that these laws have significantly increased insurance costs, which is due in part to various strategies insurers have adopted to reduce payments to providers for ED services and to greatly increase patients' copayments. Accordingly, few subjects believe these laws have increased inappropriate ED use. Conclusion Prudent layperson laws have helped to catalyze industry-wide changes in how health insurers review ED claims and how they manage ED costs. Whether these changes, on balance, are beneficial to patients and to society requires further study focused on outcomes and system-wide costs.

The association between care co-ordination and emergency department use in older managed care enrollees

To investigate the association between care co-ordination and use of the Emergency Department (ED) in older managed care enrollees. Nested case-control with 103 cases (used the ED) and 194 controls (did not use the ED). Older patients with multiple chronic illnesses enrolled in a care management programme of a large group-model health maintenance organisation with more than 50,000 members over the age of 64. Better care co-ordination was defined as timely follow-up after a change in treatment; fewer decision-makers involved with the care plan; and a higher patient-perceived rating of overall care co-ordination. Logistic regression was used to assess the relationship between ED use (the outcome variable) and measures of care co-ordination (the predictor variables). Self-reported care co-ordination was not significantly different between cases and controls for any of the four classifications of inappropriate ED use. Similarly, no differences were found in the number of different physicians or medication prescribers involved in the patients' care. Four-week follow-up after potentially high-risk events for subsequent ED use, including changes in chronic disease medications, missed encounters, and same day encounters, did not differ between subjects with inappropriate ED use and controls. Existing measures of care co-ordination were not associated with inappropriate ED use in this study of older adults with complex care needs. The absence of an association may, in part, be attributable to the paucity of validated measures to assess care co-ordination, as well as the methodological complexity inherent in studying this topic. Future research should focus on the development of new measures and on approaches that better isolate the role of care co-ordination from other potential variables that influence utilisation.

Inaccuracy of “Personal Best” Peak Expiratory Flow Rate Reported by Inner-City Patients with Acute Asthma

Percent predicted peak expiratory flow (PEF) is used to determine the severity of asthma exacerbation and the appropriateness of discharge from the emergency department (ED). The 1995 Global Initiative for Asthma and 1997 National Asthma Education and Prevention Program guidelines recommend using a patient's “personal best” PEF, if available, as a better measurement than the predicted PEF obtained from population-based nomograms. We evaluated the accuracy of personal best PEF as provided by inner-city ED patients with acute asthma. One hundred four patients with acute asthma agreed to return to the ED for repeat PEF measurements on days 3, 7, 12, 21, and 24 after their initial ED visits for acute asthma. At the ED visit, only 29% (30/104) of patients were able to report a personal best PEF. Over the 24 days of follow-up, 45% (10/22) of these patients had a measured PEF greater than their reported personal best. If a predicted PEF of at least 70% was used as the criterion for ED discharge, as several asthma guidelines recommend, then using patients' reported personal best PEF would have led to inappropriate ED discharge for some patients.

Predictors of Treatment Adherence Among Asthma Patients in the Emergency Department

This study examined predictors of treatment adherence among 120 adult patients with asthma at two emergency departments (EDs). Structured medical chart reviews were performed for characteristics hypothesized to be associated with treatment adherence difficulties. Sixty percent of subjects had evidence of nonadherence with asthma treatment. Several variables were associated with nonadherence including younger age, more utilization of ED services (more ED visits, using the ED for medication refills), certain treatment characteristics (receiving more medications in the ED, not being prescribed prednisone at discharge), and not keeping post-discharge follow-up appointments. Further research should be directed at enhancing self-management skills and decreasing inappropriate ED use among nonadherent patients.