Increased Emergency Department Research Articles

Social Determinants, Drug And Device Prices, And More

Social Determinants, Drug And Device Prices, And More

National Demographic and Economic Trends of Acute Diverticulitis in the United States From 2000-2015

Introduction: Acute diverticulitis (AD) remains a common health problem often requiring inpatient admission. The purpose of this study is to analyze trends in demographics, in-hospital morbidity and mortality, and costs of hospitalizations for AD. Methods: The Nationwide Inpatient Sample (NIS) database generated from the Healthcare Cost and Utilization Project was used to obtain a subset of discharge level data obtained from every 3 years from 2000 to 2015 (until Q3). All hospital discharges with ICD-9 CM primary diagnosis codes of diverticulitis (with and without hemorrhage) were identified. SPSS version 23 was used to conduct analysis on demographics, charges, morbidity and mortality. Results: 1,193,648 total discharges for AD were recorded between 2000-2015 with an overall increase in incidence from 167,249 in 2000 to 227,935 in 2012. There was a consistent predominance for female over males in all years (approximate ratio of 1.4:1). The majority of patients identified were Caucasians over the age of 45, with a regional predominance in the South. Median length of stay (LOS) remained stable at 4 days until 2015 (median 3 days). The number of AD admissions with associated surgical procedure decreased from 24.4% in 2000 to 21.1% in 2015. In-hospital mortality reduced from 1.2% to 0.5% between 2000-2012. Despite stable LOS, reduction in mortality and surgical intervention, the median charges per hospitalization increased by approximately 2.5 fold from 2000 ($9444) to 2015 ($24,472). Conclusion: This study highlights that the number of hospitalizations for acute diverticulitis continues to increase from 2000 to 2015. Despite improvements of markers for morbidity and mortality, there has been an increase in inpatient hospital costs for AD. This is consistent with prior studies showing increasing emergency department burden of AD (1). Further studies are needed to elucidate factors contributing to the increasing costs, increasing incidence, and regional variation such as the specific dietary and environmental factors that could help explain the higher incidence in the Southern U.S (2). Future strategies should focus on prevention of AD and reduction of costs per hospital stay 1. Bollom, A et al. Emergency Department Burden of Diverticulitis in the USA, 2006-2013. Digestive Diseases and Sciences. 2017. 62:2694-2703. 2. Nguyen, G et al. Epidemiological trends and geographic variation in hospital admissions for diverticulitis in the United States. 2011. World Journal of Gastroenterology, 1600-1605.183 Figure 1. Nationwide Inpatient Sample 2000-2015, every 3 years, Epidemiological Data for Acute Diverticulitis

10 Boarding Psychiatric Patients in the Emergency Department is Associated With Increased Emergency Department Violence

The national shortage of available inpatient psychiatric beds has led to many emergency departments (EDs) boarding patients on involuntary psychiatric holds for hours to days. Psychiatric holds absorb ED resources, consume beds that could be used for other acute care patients, and often delay adequate psychiatric treatment. Our study sought to determine if ED psychiatric holds also contribute to increased violence in the emergency department. A secondary objective was to determine if other variables, such as weather or proximity to the first day of the month (when financial assistance funds arrive), could predict ED violence. Staff hypothesized that more assaults occur toward the end of the month as some patients desire their holds revoked around the time of monthly financial support distributions. When an assault on staff occurs an overhead code is called and logged. We reviewed 1 year of these logs and compared them to logs showing the number of psychiatric holds in the department, the maximum temperature and occurrence of rain on a given day, whether a given day was in the first or last 10 days of a month, and the total ED census of a given day. The hospital is an urban level 2 academic trauma center and regional referral center in southern California that sees 120,000 patients per year. Between May 1, 2016 and April 30, 2017, 297 assaults resulting in an overhead code call occurred in the hospital with 57 of them in the ED. 94% of the ED assaults occurred during days with 4 or more patients on a hold, compared with 6% on days with 3 or fewer holding patients (p<0.04). A logistic regression analysis that included the number of holds (4 or greater versus less than 4), the maximum daily temperature, the total ED census, whether rain occurred on a given day, and the 10-day period of the month (early versus late) showed 2 significant associations. Having more psychiatric holds (4 or more) predicted assault, even with total ED census controlled (p=0.02), and more assaults occurred in the last 10 days of the month than the first 10 (p=0.03). Weather patterns were not associated with assaults. Increased boarding of psychiatric patients in the ED is associated with increased assaultive behavior, demonstrating another adverse impact of psychiatric patient boarding. Weather failed to predict assaults but as predicted more assaults occurred toward the end of the month.

Using the LACE Score as a Predictor of Clinical Outcomes in Patients Referred for Inpatient Palliative Care Consultation: A Single-Center Experience.

Readmissions and death for palliative care patients are common and costly outcomes for hospitals, patients, and/or caregivers. Predicting which patients are likely to be readmitted or die within 30 days would help allocate resources and aid in patient disposition planning. Few factors have been strongly correlated with predicting which patients will be readmitted or die within 30 days of hospital discharge. The LACE (Length of Stay, Acuity of admission, Charlson comorbidity index, Emergency department use) score has been validated in medical/surgical patients; however, it has not been evaluated in the palliative care population. To evaluate the LACE score in palliative care population. This study was a single-center retrospective cohort design. Patients were identified based on their consultation to an inpatient palliative care service. Thirty-day readmissions, 30-day mortality, length of stay, acuity of admission, Charlson comorbidity index, emergency department utilization, and demographic information. The LACE score was not an accurate predictor of clinical outcomes in the palliative care population. Patients who were readmitted or died within 30 days tended to be younger. Patients who were readmitted within 30 days tended to have increased emergency department use in the previous 6 months. Our study demonstrates the LACE score may not be a sensitive predictor of clinical outcomes in our institution's palliative care patients. This may be due to the complexity of the required care in this population; thus, other factors should be investigated to determine accurate predictors of patient outcomes to better allocate resources.

Constipation in Children with Autism Spectrum Disorder Associated with Increased Emergency Department Visits and Inpatient Admissions

To evaluate whether constipation in children with autism spectrum disorder (ASD) is associated with increased emergency department (ED) visits and inpatient admissions compared with constipation in children without ASD. The Nationwide Emergency Department Sample was used to retrospectively examine demographic data, clinical characteristics, and outcomes of children with ASD and children without ASD who visited the ED for constipation between 2006 and 2014. ED visits by children with ASD were more likely to be constipation-related compared with visits by children with other chronic conditions or children with no chronic conditions (1.9% vs 0.6% vs 0.9%; P < .001). Children with ASD were more likely than children with other chronic conditions or no chronic conditions to be admitted to the hospital after an ED visit for constipation (15.0% vs 10.6% vs 1.2%; P < .001). Hospital charges were higher in children with ASD than in those without chronic conditions. Constipation is responsible for a large proportion of ED visits and more inpatient admissions resulting from these ED visits. These findings suggest a need for developing more effective outpatient therapies for constipation in children with ASD.

Narcotics and Knee Arthroscopy: Trends in Use and Factors Associated With Prolonged Use and Postoperative Complications

To (1) examine trends in the prevalence of preoperative and prolonged postoperative narcotic use in patients undergoing knee arthroscopy, (2) characterize factors associated with prolonged narcotic use after knee arthroscopy, and (3) explore the association of preoperative and prolonged postoperative narcotic use with complications after knee arthroscopy. The PearlDiver database was reviewed for patients who underwent knee arthroscopy from 2007 to 2015 with a minimum of 6months' follow up. Patients with preoperative or prolonged postoperative narcotic use were identified and analyzed for trends. Predictors for prolonged postoperative use were identified, and regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). A total of 75,372 patients were included, of which 23.9% used narcotics preoperatively and 22.6% used narcotics for a prolonged period postoperatively. There was no statistically significant trend on a year-to-year basis in preoperative (P= .744) or prolonged postoperative (P= .304) narcotic use. The most significant predictor for prolonged postoperative use was preoperative use (OR 5.33, CI 5.11-5.56, P<.0001), with the odds increasing as the number of preoperative prescriptions increased. Preoperative narcotic use was associated with increased emergency department visits (OR 1.25, CI 1.15-1.36, P < .0001), hospital admission (OR 1.15, CI 1.00-1.33, P= .046), and infection (OR 1.31, CI 1.07-1.59, P= .007). Prolonged postoperative narcotic use was associated with subsequent ipsilateral knee arthroscopy (OR 1.64, CI 1.45-1.86, P < .0001) as well as subsequent knee arthroplasty (OR 1.98, CI 1.83-2.14, P < .0001). The results of this study did not show a trend in the use of narcotics, preoperatively or on a prolonged basis postoperatively, during the study period. The degree of preoperative narcotic use is correlated with prolonged narcotic use. The use of narcotics preoperatively and for a prolonged period postoperatively is associated with increased complications. Level IV, case series, therapeutic.

Role of the general practitioner in improving rural healthcare access: a case from Nepal

BackgroundThere is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital.Case presentationWe perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital’s catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.ConclusionsGPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal’s maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal’s public sector.

Emergency department presentations in early stage breast cancer patients receiving adjuvant and neoadjuvant chemotherapy.

(Neo)adjuvant chemotherapy for early stage breast cancer is associated with side-effects, resulting in increased emergency department (ED) presentations. Treatment-related toxicity can affect quality of life, compromise chemotherapy delivery and treatment outcomes, and increase healthcare use. We performed a retrospective study of ED presentations in patients receiving curative chemotherapy for early breast cancer to identify factors contributing to ED presentations. Of 102 patients, 39 (38%) presented to ED within 30 days of chemotherapy, resulting in 63 ED presentations in total. Most common reasons were non-neutropenic fever (17 presentations/27%), neutropenic fever (15/24%), pain (9/14%), drug reaction (6/10%) and infection (4/6%). Factors significantly associated with ED presentation were adjuvant chemotherapy timing compared to neoadjuvant timing (P = 0.031), prophylactic antibiotics (P = 0.045) and docetaxel-containing regimen (P = 0.018).

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: Answers to the November 2017 Journal Club Questions

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: Answers to the November 2017 Journal Club Questions

Impact of Telephone-Based Problem-Solving Treatment on the Use of Medical and Psychological Services in the Military.

To explore the impact of problem-solving treatment (PST) for mild traumatic brain injury in active duty service members on the use of medical and psychological services. Service members who had a mild traumatic brain injury during their last deployment and enrolled in the CONcussion Treatment After Combat Trauma (CONTACT) study. Secondary analysis of a randomized clinical trial. Participants were assigned to telephone-based PST, or e-mailed or mailed education only over the course of 6 months. Self-reported health service utilization from months 4 through 6 and 10 through 12 after initiation of treatment, using the Cornell Service Index. In months 4 to 6, participants receiving PST had 6.17 times the odds of an emergency department visit or hospitalization than those receiving education only (95% confidence interval = 1.92-19.8; P value = .0023). These estimates, however, were not significant using a conservative Bonferroni correction (P value threshold < .0014). There were no other significant differences for other medical or psychological services received in months 4 to 6 or 10 to 12. Telephone-based PST was designed to complement clinical care, and this study showed that it may increase emergency department utilization. Future evaluations of PST with more accurate and complete measures of health service utilization are needed.

A proactive transfer policy for critical patient flow management.

Hospital emergency departments are often overcrowded, resulting in long wait times and a public perception of poor attention. Delays in transferring patients needing further treatment increases emergency department congestion, has negative impacts on their health and may increase their mortality rates. A model built around a Markov decision process is proposed to improve the efficiency of patient flows between the emergency department and other hospital units. With each day divided into time periods, the formulation estimates bed demand for the next period as the basis for determining a proactive rather than reactive transfer decision policy. Due to the high dimensionality of the optimization problem involved, an approximate dynamic programming approach is used to derive an approximation of the optimal decision policy, which indicates that a certain number of beds should be kept free in the different units as a function of the next period demand estimate. Testing the model on two instances of different sizes demonstrates that the optimal number of patient transfers between units changes when the emergency patient arrival rate for transfer to other units changes at a single unit, but remains stable if the change is proportionally the same for all units. In a simulation using real data for a hospital in Chile, significant improvements are achieved by the model in key emergency department performance indicators such as patient wait times (reduction higher than 50%), patient capacity (21% increase) and queue abandonment (from 7% down to less than 1%).

Winter pressures and a safety checklist

Sam Foster, Chief Nurse, Oxford University Hospitals, discusses the Emergency Department Safety Checklist, some of the results after implementation and how it can help with increased emergency department admissions.

Managing Changes in Condition in the SNF with a Rectal Administration Catheter to Prevent ED and Hospital Utilization (S729)

•Verbalize understanding that rectal hydration and medication administration is an effective alternative to parenteral or hypodermoclysis therapy.•Incorporate new understanding/skills that can help drive nursing efficiency and patient outcomes.•Incorporate understanding in the use of oral medications on hand to quickly address symptoms via the rectal route. Options to treat a patient’s change in condition when the oral route is compromised in the SNF setting are limited. Parenteral or hypodermoclysis administration of fluids and medication is possible; however, these methods have limitations, and require alternate forms of medications that can be costly. Delays in obtaining orders, equipment and supplies has the potential to increase emergency department (ED) and/or hospital utilization. The aim of this QI project was to look at the feasibility of the intervention to facilitate safe, easy, comfortable and effective enteral hydration and medication delivery via the rectal route, and the ability to treat changes in a patient’s condition while decreasing the need for parenteral therapy and ED or hospital utilization. A Pretest-posttest intervention study design was used to evaluate 11 clinical use cases of a specialized rectal administration catheter to treat patient changes in condition in four SNFs over a 2-month period between November and December 2016. Ten participants (100%) completed the study with 11 total use cases. Hydration was effective in all 11 use cases, with all participants tolerating the intervention without signs of discomfort or expulsion of fluids. Nine of the 11 (81%) use cases facilitated successful management of the patients’ condition at the facility. In two use cases, participants had ‘Do Not Hospitalize’ orders on the chart. For the remaining nine use cases, ED or hospital transfer would have been necessary if unmanageable in the SNF. Of these nine use cases, seven (78%) were able to avoid ED and/or hospital utilization through successful management of the condition. The other two participants (18%) needed acute care intervention. In all use cases the catheter provided a safe, easy, and comfortable alternative to provide hydration and medication administration compared to parenteral and previous enteral delivery options. Additionally, the SNFs were able to reduce the need for ED or hospital utilization.

Association of shared decision-making on patient-reported health outcomes and healthcare utilization

BackgroundShared decision-making (SDM) is a process that respects the rights of patients to be fully involved in decisions about their care. By evaluating all available healthcare options and weighing patients' personal values and preferences against available unbiased evidence, patients and healthcare professionals can make health-related decisions together, as partners. We sought to evaluate the impact of perceived SDM on patient-reported outcomes, healthcare quality, and healthcare utilization. MethodsPatients were identified from the 2010–2014 Medical Expenditure Panel Survey (MEPS) cohort. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey was levied to create a weighted composite score of satisfaction with SDM on a 12-point scale, and then categorized as optimal, average or poor SDM based on weighted scores. Weighting and variance techniques were applied to assure results were representative of the U.S. civilian population. Chi-square analysis was used to estimate differences across SDM groupings and multivariate logistic regression was performed to generate odds ratios (OR) and confidence intervals (CI). ResultsThe study cohort included 63,931 responses to the survey tool. Results of SDM satisfaction across the three categories were skewed, with 46.6% (n = 29,807) of the respondents reporting optimal SDM, 42.1% (n = 26,887) reporting average scores and only 11.3% (n = 7237) reporting poor perceived SDM. Non-white race, lower educational level, low socioeconomic status, non-married status, and uninsured or underinsured status were all associated with higher incidence of poor perceived SDM (p < .05). Poor SDM was associated with increased odds of poor physical health scores (OR: 1.17; 95% CI 1.01–1.36) and poor mental health scores (OR: 1.53; 95% CI 1.25–1.86). Poor SDM was associated with lower use of statins (OR: 0.77; 95% CI 0.68–0.87) and aspirin (OR: 0.86; 95% CI 0.77–0.95), both of which are established quality of care metrics. Poor SDM was also associated with increased emergency department (ED) utilization, with an increased likelihood of 2 or more ED visits associated with poor SDM (OR: 1.25; 95% CI 1.06–1.49). ConclusionsPoor SDM was associated with worse patient-reported health outcomes, worse established quality indicators, and higher healthcare utilization. While increasing physician education may help optimize SDM, differences in patient-perceived SDM were also strongly driven by inherent patient characteristics.

Exclusionary Criteria for Inpatient Hospitalization: Quality Safeguards or Unnecessary Roadblocks?

For patients with mental illness who require hospitalization, the process of admission to inpatient care involves an assessment of medical status and assurance to the receiving facility that the patient is medically stable and suitable for transfer. An increasing number of facilities have developed checklists that need to be met for a patient to be accepted. Referred to as exclusionary criteria, these include a collection of physical findings, laboratory values, and medical conditions that might prevent a patient from being admitted and thus receiving the appropriate psychiatric care. Inpatient facilities have the flexibility to set their own acceptance criteria—a process that is unregulated. In parallel, emergency medicine has a differing philosophy regarding the need for medical clearance and stability of the psychiatric patient. These two requirements and workflows often conflict. Exclusionary criteria are ideally meant to protect the patients by promoting proper use of resources, and making sure medical issues are adequately addressed; however, those same criteria promote rigidity and focus on absolute laboratory values and diagnoses rather than clinical pictures, which may be contributing to the difficulty of accessing already scarce inpatient care resources and increased emergency department boarding currently sweeping the nation. Furthermore, inflexible checklists contradict the guidelines issued by several national organizations, which promote the need for customized flexible assessment of patients with severe mental illness who are awaiting inpatient placement. [ Psychiatr Ann. 2018;48(1):51–57.]

Increasing Emergency Department Visits for Anaphylaxis, 2005-2014

MS Motosue, G Bellolio, HK Van Houten, ND Shah, RL Campbell. J Allergy Clin Immunol Pract. 2017;5(1):171–175 To identify trends regarding anaphylaxis-related emergency department (ED) visits from 2005 to 2014. Population data were drawn from OptumLabs Data Warehouse, a national administrative claims database of >100 000 000 pediatric and adult patients in the United States (including those with Medicare Advantage and private insurance) and with a higher representation from the Midwest and the South. ED visits between 2005 and 2014 were included if patients had medical insurance for at least 30 days before the visit. International Classification of Diseases, Ninth Revision, …

Induction of chronic migraine phenotypes in a rat model after environmental irritant exposure.

Air pollution is linked to increased emergency department visits for headache and migraine patients frequently cite chemicals or odors as headache triggers, but the association between air pollutants and headache is not well understood. We previously reported that chronic environmental irritant exposure sensitizes the trigeminovascular system response to nasal administration of environmental irritants. Here, we examine whether chronic environmental irritant exposure induces migraine behavioral phenotypes. Male rats were exposed to acrolein, a transient receptor potential channel ankyrin-1 (TRPA1) agonist, or room air by inhalation for 4 days before meningeal blood flow measurements, periorbital cutaneous sensory testing, or other behavioral testing. Touch-induced c-Fos expression in trigeminal nucleus caudalis was compared in animals exposed to room air or acrolein. Spontaneous behavior and olfactory discrimination was examined in open-field testing. Acrolein inhalation exposure produced long-lasting potentiation of blood flow responses to a subsequent TRPA1 agonist and sensitized cutaneous responses to mechanical stimulation. C-Fos expression in response to touch was increased in trigeminal nucleus caudalis in animals exposed to acrolein compared with room air. Spontaneous activity in an open-field and scent preference behavior was different in acrolein-exposed compared with room air-exposed animals. Sumatriptan, an acute migraine treatment blocked acute blood flow changes in response to TRPA1 or transient receptor potential vanilloid receptor-1 agonists. Pretreatment with valproic acid, a prophylactic migraine treatment, attenuated the enhanced blood flow responses observed after acrolein inhalation exposures. Environmental irritant exposure yields an animal model of chronic migraine in which to study mechanisms for enhanced headache susceptibility after chemical exposure.

23 Patient and staff perspectives on the reasons for increasing emergency department attendances

Background/objectivesAn NHS England review recognised that demand for Urgent and Emergency Care is unsustainable. Health practitioners and policy makers are interested in understanding the reasons why patients with low acuity...

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: November 2017 Annals of Emergency Medicine Journal Club

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: November 2017 Annals of Emergency Medicine Journal Club

Pain Acceptance as a Predictor of Medical Utilization and School Absenteeism in Adolescents With Chronic Pain.

Identifying factors contributing to high medical utilization and productivity loss is important, given the high cost of pediatric chronic pain. The current study examined chronic pain acceptance as a predictor of medical utilization and school absenteeism in adolescents with chronic pain. In all, 122 adolescents (aged 12-21 years) with chronic pain and their parents/guardians completed questionnaires assessing medical visits (past 6 months), medication usage, and number of school absences (past month). Homebound school status was also reported. Adolescents completed the Chronic Pain Acceptance Questionnaire and pain intensity ratings, and underwent a diagnostic psychological evaluation. Multivariate generalized linear model analyses indicated lower pain acceptance predicted increased inpatient hospitalizations and higher number of opioid and nonopioid prescription medications, controlling for pain intensity, age, and sex. Pain acceptance was not associated with outpatient consultations or number of nonprescription medications. Exploratory moderation analyses indicated lower pain acceptance significantly predicted increased emergency department visits and inpatient hospitalizations for patients diagnosed with an internalizing psychological disorder. Patients in homebound schooling reported low pain acceptance and for those in school full-time, linear regression indicated lower pain acceptance significantly predicted higher number of school absences. Findings suggest that lower pain acceptance contributes to the use of higher-level medical care (especially for adolescents with internalizing disorders) and increased productivity loss owing to school absences or homebound school status. Clinical implications exist for recommending acceptance-based interventions for pain acceptance promotion and continued development of cost-effective, easily disseminated acceptance-based therapy modules to curb the economic burden of chronic pain.