Inpatient Transfer Research Articles

Predicting hospital-onset Clostridium difficile using patient mobility data: A network approach.

To examine the relationship between unit-wide Clostridium difficile infection (CDI) susceptibility and inpatient mobility and to create contagion centrality as a new predictive measure of CDI. Retrospective cohort study. A mobility network was constructed using 2 years of patient electronic health record data for a 739-bed hospital (n = 72,636 admissions). Network centrality measures were calculated for each hospital unit (node) providing clinical context for each in terms of patient transfers between units (ie, edges). Daily unit-wide CDI susceptibility scores were calculated using logistic regression and were compared to network centrality measures to determine the relationship between unit CDI susceptibility and patient mobility. Closeness centrality was a statistically significant measure associated with unit susceptibility (P < .05), highlighting the importance of incoming patient mobility in CDI prevention at the unit level. Contagion centrality (CC) was calculated using inpatient transfer rates, unit-wide susceptibility of CDI, and current hospital CDI infections. The contagion centrality measure was statistically significant (P < .05) with our outcome of hospital-onset CDI cases, and it captured the additional opportunities for transmission associated with inpatient transfers. We have used this analysis to create easily interpretable clinical tools showing this relationship as well as the risk of hospital-onset CDI in real time, and these tools can be implemented in hospital EHR systems. Quantifying and visualizing the combination of inpatient transfers, unit-wide risk, and current infections help identify hospital units at risk of developing a CDI outbreak and, thus, provide clinicians and infection prevention staff with advanced warning and specific location data to inform prevention efforts.

BOARDING TIME AND PATIENT SATISFACTION AT THE EMERGENCY DEPARTMENT

Background: Delays of inpatient transfer from the Emergency Department (ED) will affect delayed care, overcrowd at ED, and patient’s disappointment. Such patient transfer delay from the Emergency Departement (ED) also occurs at Haji General Hospital, Surabaya.Aims: This study analyzed the relationship between inpatient boarding time from Emergency Departement (ED) and patient satisfaction at Haji General Hospital, Surabaya.Methods: This was an observational research using a cross-sectional approach. The population was 980 ED patients who decided to be hospitalized. Out of 980 ED patients, the study only involved 83 respondents selected by simple random sampling. The instruments used were observational sheet and questionnaires to collect data which were then analyzed with a chi-square test.Results: Average boarding time was 142 minutes 25 seconds (minimum = 60 minutes; maximum = 290 minutes). Almost all respondents (81.3%) were satisfied about fast boarding time. Inpatient boarding time at the Emergency Departement (ED) was significantly related to patient satisfaction (p = 0.058 &lt;α = 0.1). The faster inpatients move to ED, the more satisfied they are.Conclusion: The average patient boarding time from the Emergency Departement (ED) to Inpatient Unit was slow. Respondents were satisfied with the quality of services even though patient boarding time was slow. The hospital should pay more attention to evaluate the minimal standard of boarding time, ensure the availability of beds, and improve the quality of facilities and services to enhance patient satisfaction. Keywords: Boarding time, Emergency Department, Inpatient, Satisfaction.

BOARDING TIME AND PATIENT SATISFACTION AT THE EMERGENCY DEPARTMENT

Background: Delays of inpatient transfer from the Emergency Department (ED) will affect delayed care, overcrowd at ED, and patient’s disappointment. Such patient transfer delay from the Emergency Departement (ED) also occurs at Haji General Hospital, Surabaya.Aims: This study analyzed the relationship between inpatient boarding time from Emergency Departement (ED) and patient satisfaction at Haji General Hospital, Surabaya.Methods: This was an observational research using a cross-sectional approach. The population was 980 ED patients who decided to be hospitalized. Out of 980 ED patients, the study only involved 83 respondents selected by simple random sampling. The instruments used were observational sheet and questionnaires to collect data which were then analyzed with a chi-square test.Results: Average boarding time was 142 minutes 25 seconds (minimum = 60 minutes; maximum = 290 minutes). Almost all respondents (81.3%) were satisfied about fast boarding time. Inpatient boarding time at the Emergency Departement (ED) was significantly related to patient satisfaction (p = 0.058 &lt;α = 0.1). The faster inpatients move to ED, the more satisfied they are.Conclusion: The average patient boarding time from the Emergency Departement (ED) to Inpatient Unit was slow. Respondents were satisfied with the quality of services even though patient boarding time was slow. The hospital should pay more attention to evaluate the minimal standard of boarding time, ensure the availability of beds, and improve the quality of facilities and services to enhance patient satisfaction. Keywords: Boarding time, Emergency Department, Inpatient, Satisfaction.

17. Tick-borne relapsing fever: a fever syndrome mimic

17. Tick-borne relapsing fever: a fever syndrome mimic

Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care.

Interfacility neurosurgical transfers to tertiary care centers are driven by a number of variables, including lack of on-site coverage, limited available technology, insurance factors, and patient preference. The authors sought to assess the timing and necessity of surgery and compared transfers to their institution from emergency departments (ED) and inpatient units at other hospitals. Adult neurosurgical patients who were transferred to a single tertiary care center were analyzed over 12 months. Patients with traumatic injuries or those referred from skilled nursing facilities or rehabilitation centers were excluded. A total of 504 transferred patients were included, with mean age 55 years (range 19-92 years); 53% of patients were women. Points of origin were ED in 54% cases and inpatient hospital unit in 46%, with a mean distance traveled for most patients of 119 miles. Broad diagnosis categories included brain tumors (n = 142, 28%), vascular lesions, including spontaneous and hypertensive intracerebral hemorrhage (n = 143, 28%), spinal lesions (n = 126, 25%), hydrocephalus (n = 45, 9%), wound complications (n = 29, 6%), and others (n = 19, 4%). Patients transferred from inpatient units had higher rates of surgical intervention (75% vs 57%, p < 0.001), whereas patients transferred from the ED had higher rates of urgent surgery (20% vs 8%, p < 0.001) and shorter mean time to surgery (3 vs 5 days, p < 0.001). Misdiagnosis rates were higher among ED referrals (11% vs 4%, p = 0.008). Across the same timeframe, patients undergoing elective admission (n = 1986) or admission from the authors' own ED (n = 248) had significantly shorter lengths of stay (p < 0.001) and ICU days (p < 0.001) than transferred patients, as well as a significantly lower total cost ($44,412, $46,163, and $72,175, respectively; p < 0.001). The authors present their 12-month experience from a single tertiary care center without Level I trauma designation. In this cohort, 65% of patients required surgery, but the rates were higher among inpatient referrals, and misdiagnosis rates were higher among ED transfers. These data suggest that admitting nonemergency patients to local hospitals may improve diagnostic accuracy of patients requiring urgent care, more precisely identify patients in need of transfer, and reduce costs. Referring facilities may lack necessary resources or expertise, and the Emergency Medical Treatment and Active Labor Act (EMTALA) obligates tertiary care centers to accept these patients under those circumstances. Telemedicine and integration of electronic medical records may help guide referring hospitals to pursue additional workup, which may eliminate the need for unnecessary transfer and provide additional cost savings.

Factors associated with the inter-facility transfer of inpatients in Sichuan province, China

BackgroundThe overuse of tertiary hospitals and underuse of primary care facilities has been one of the key reasons leading to fast health expenditure increase and health service utilization inequity in China. Recent health care reform in China tries to enforce a patient transfer system to make the health services utilization more efficient. This study examined the pattern and associated factors of inter-facility transfer of inpatients in Sichuan province of Western China.MethodsPatient discharge records (n = 1,490,695) from 604 general hospitals during the period of April to June 2015 in Sichuan were extracted from the front page of the medical records system with individual information on demographics, insurance coverage, diagnoses, hospitals admitted and discharge type. We calculated the percentage of inpatients transferring to other health facilities, the Inter-Facility Transfer Rate (IFTR) with adjustment for Charlson Comorbidity Index (CCI). Multi-level logistic regression models were established to identify factors associated with IFTRs.ResultsA small number of tertiary hospitals (n = 75, 12.41%) shared 51.71% (n = 770,823) of all admitted cases while a large number of primary/unrated hospitals (n = 321, 53.15%) shared only 8.15%. The overall CCI-adjusted IFTR was 2.08% with 3.73% among secondary hospitals, 1.87% among tertiary hospitals and 1.30% among primary/unrated hospitals. Uninsured patients (OR = 1.13) and those with a lower level of insurance entitlements (OR = 1.12 for the New Rural Cooperative Medical Scheme and the Basic Medical Insurance for Urban Residents) were more likely to experience inter-facility transfer than those with a higher level of insurance entitlements (the Basic Medical Insurance for Urban Employees).ConclusionThe level of IFTR in general hospitals in Sichuan is low, which is associated with the level of hospitals and insurance entitlements. Further studies are needed to better understand how patients and health care providers respond to different insurance policies and make decisions on inter-facility transfer.

PIH55 NATIONAL PATTERNS OF EMERGENCY DEPARTMENT USE FOR WOMEN WITH ENDOMETRIOSIS, 2006-2015

To characterize national trends in emergency department (ED) visits, disposition and charges for endometriosis. ED visits for endometriosis by women aged 18–49 were extracted from the Health Care Utilization Project Nationwide Emergency Department Sample into three cohorts for calendar years 2006–2007, 2010–2011 and 2014–Q3 2015. Visits with a principal diagnosis code of endometriosis (International Classification of Disease, 9th Edition, code 617.x) were included. Visits with a diagnosis of malignant neoplasm of female genital organs were excluded. Patient and hospital characteristics were compared across cohorts using analysis of variance. Trends in the proportion of ED visits ending in inpatient admission or transfer to another hospital and in mean ED charges (2015 US dollars) were assessed using generalized linear models controlling for patient and hospital characteristics. Inpatient admission/transfer was chosen as an outcome representative of potentially preventable admissions. Nationally representative estimates were generated based on survey weights. The annual number of ED visits nationally was stable at approximately 15,000 visits per year during 2006–2015. Mean age was 30 years; 41% of visits were from the South Census region; and 8% had ≥1 Charlson comorbidity. From 2006–07 to 2014–15, the composition of ED visits shifted away from private pay (42.0% vs. 35.3%) and uninsured (23.6% vs. 16.6%) to Medicaid (26.7% vs. 40.1%) and became more concentrated in metro-teaching hospitals (33.9% vs. 51.9%) (p<0.001 for all). Inpatient admission/transfer rates declined from 20.1% to 9.2% (p<0.001). Mean ED charges increased from $2458 to $4953 (p<0.001). Older and privately insured endometriosis patients who visited metro-teaching hospitals were more likely to be admitted/transferred and had higher ED charges. During 2006–2015, the number of ED visits for endometriosis remained stable, the inpatient admission/transfer rate declined by half, and mean charges per visit doubled.

Factors Influencing Compliance on Personal Protect Equipment in In-patient Transfer Staffs

Factors Influencing Compliance on Personal Protect Equipment in In-patient Transfer Staffs

Cost Burden and Mortality in Rural Emergency General Surgery Transfer Patients

BackgroundRecent articles have suggested regionalization of some emergency general surgery (EGS) problems to tertiary referral centers. We sought to characterize the clinical and cost burden of such transfers to our tertiary referral center. Materials and methodsData were collected retrospectively for nine EGS diagnoses for patients admitted to the EGS service during calendar years 2015 and 2016. Patients were grouped as inpatient transfers (IPTs), Emergency Department transfers (EDTs), or local admissions (LAs). Demographic data, length of stay at originating site, insurance status, Charlson Comorbidity Index, and all relevant financial data were obtained. ResultsSix hundred sixty-three patients were reviewed: 93 IPTs, 343 EDTs, and 227 LAs. IPTs required longer lengths of stay (7.0 d compared to 4.0 d for EDTs and 3.0 d for LAs), higher median direct costs, and higher case mix index, which produced a higher median revenue but averaged a median net loss (−$264 compared to +$2436 for EDTs and +$3125 for LAs). The IPTs had higher median comorbidities (Charlson Comorbidity Index 3.5 versus 2.9 for EDTs and 2.0 for LAs), age (62 y versus 58 for EDTs and 52 for LAs), and mortality rate (7.5% versus 2.3% for EDTs and 0.4% for LAs). ConclusionsPatients who present to a tertiary care EGS service as an IPT from another hospital have more comorbidities, higher mortality rate, and result in a financial loss. These data suggest the need for adequate risk adjustment in quality assessment of tertiary referral center outcomes and the need for increased financial reimbursement for the care of these patients.

Hyperlactatemia on ICU admission : Comparison between direct admissions and inpatient transfers.

Hyperlactatemia is associated with increased mortality. Possible differences between patients directly admitted via the emergency department to the intensive care unit (ICU) and inpatient transfers to the ICU have not yet been investigated. In this retrospective analysis, characteristics and outcomes between critically ill medical inpatient transfers and direct admissions with hyperlactatemia on ICU admission, defined as ablood lactate >2 mmol/l, were compared. Atotal of 1042 patients were included, with 424 inpatient transfers and 618 direct admissions. The median age of inpatient transfers and direct admissions was 67.0 and 70.5 years, respectively (P = 0.03). The median APACHE II score was 25 for inpatient transfers and 23 for direct admissions (P = 0.01). The median blood lactate on ICU admission for inpatient transfers and direct admissions was similar (3.6 vs. 3.5 mmol/l). Sepsis was more common among inpatient transfers than direct admissions (53.5 vs. 31.6%, P = 0.001). The ICU (39.6 vs. 28.8%, P < 0.001), hospital (56.8 vs. 38.3%, P < 0.001) and 28-day mortality (46.5 vs. 35.4%, P < 0.001) was significantly higher for inpatient transfers than direct admissions. Among the sepsis cohort, inpatient transfer, APACHEII score and elevated blood lactate were independent predictors of ICU mortality. Among medical ICU patients with admission hyperlactatemia, the median blood lactate was not significantly different between direct admissions and inpatient referrals. Inpatients with sepsis may have been referred to the ICU late.

Day case ‘treat and transfer’ ERCP service under general anaesthesia

ObjectiveGeneral anaesthesia (GA) has been increasingly used for advanced endoscopic procedures in particular endoscopic retrograde cholangiopancreatography (ERCP). Given the increasing pressure on many hospitals, the delivery of such service on...

Abstract TP286: Efficacy of Quality Improvement Protocols Across Diverse Modes of Arrival for Thrombectomy Patients With Ischemic Stroke

Background: Quality improvement protocols (QI) aim to reduce in-hospital delays that result in prolonged door-to-groin-puncture time (DGPT) for the endovascular treatment of ischemic stroke. At our institution, we implemented a comprehensive QI protocol to reduce DGPT from June 2015 to December 2016. Here we discuss the QI protocol on DGPT across diverse modes of arrival to our interventional suite. Methods: 61 patients underwent mechanical thrombectomy for ischemic stroke during our QI period. Independent samples t-tests were used to investigate differences in DGPT early in the QI protocol (July 2015 to February 2016, n=30) versus late in the QI protocol (March 2016 to December 2016, n=31) for patients that presented via emergency medical services (EMS), inpatient, and hospital transfers. Results: Each mode of arrival demonstrated reductions in DGPT (Figure 1). The greatest reduction in DGPT was for the 23 patients within the emergency medical services (EMS) group with a mean reduction of 39 minutes which approached, but didn’t achieve, statistical significance (138 vs. 99; p=0.06). Discussion: QI interventions impact DGPT across different patient arrival methods. QI protocols accounting for patient presentation allow tailored approaches to institutional measures to reduce DGPT.

The role of perceived threat during emergency department cardiac evaluation and the age-posttraumatic stress disorder link

Evaluation for acute coronary syndrome (ACS) can trigger posttraumatic stress symptoms (PSS). Research suggests that younger, versus older, individuals may be at elevated risk for PSS after ACS evaluation. It has been proposed that younger individuals may be at greater risk because they perceive the suspected ACS event as more threatening than their older counterparts; however, this has yet to be tested. We examined whether perceived threat during ACS evaluation mediated the association between age and PSS after ACS evaluation in an observational cohort study of patients presenting to the emergency department (ED) with suspected ACS. Demographics and perceived threat were assessed in the ED. PSS were measured upon inpatient transfer or by phone 3days later. The analytic sample comprised 871 adult participants. Multiple linear regression was used to examine (1) associations of age and perceived threat with PSS and (2) whether perceived threat mediated the association. Bootstrapping with percentile-based confidence intervals (CIs) was used to test the indirect effect. Each year of age was associated with lower PSS (b=-0.12, p<.001), independent of covariates. Older age was associated with lower perceived threat during ACS evaluation (b=-0.05, p<.001). Greater threat perceptions predicted greater PSS (b=0.94, p<.0001). The indirect effect (-0.04) was statistically significant (95% CI -0.07, -0.02). Younger, versus older, individuals are at risk for greater PSS after ACS evaluation, and elevated perceived threat partially mediated this association. Understanding age differences in PSS development risk and the potential impact of age on threat perceptions may help inform ED treatment.

Injection Drug Use and Infectious Disease Practice: A National Provider Survey

BackgroundThe opioid epidemic has swept across the U.S. at a staggering rate, with an estimated half million to one million persons injecting drugs annually. Rates of hospitalization for injection drug use (IDU)-related infection have risen precipitously, comprising an escalating proportion of infectious diseases provider volume in highly impacted regions.MethodsIn March 2017, the Emerging Infections Network surveyed their national network of infectious diseases (ID) physicians to evaluate perspectives relating to the care of persons who inject drugs (PWID), including the frequency of, and management strategies for, IDU-related infection, the availability of addiction services, and the evolving role of ID physicians in the management of addiction.ResultsOver half (53%; N = 672) of 1,276 members with an adult ID practice participated; 78% (n = 526) reported treating PWID. Of 526 respondents, 464 (88%) reported seeing ≥1 patient per month with an IDU-related infection; 228 (43%) reported ≥6 per month. In the past year, 79% of respondents reported the majority of IDU-related infections seen required ≥2 weeks of parenteral therapy and reported frequently encountering skin and soft-tissue infections (61%), bacteremia/fungemia (53%), and endocarditis (50%). Strategies most commonly employed for management of prolonged parenteral antibiotic therapy included: completion of entire course on inpatient unit (by 41%) and transfer to supervised facility for completion (35%). Only 35% of respondents agree/strongly agree their health system offers comprehensive treatment of substance use disorders (N = 181). Though nearly half of respondents felt that ID providers should actively manage substance use disorders (46%; N = 241), only 3% reported being waivered to prescribe buprenorphine for treatment of opioid use disorder.ConclusionThe majority of infectious diseases physicians frequently care for PWID with serious infections. There is significant diversity amongst providers with regards to the availability of comprehensive addiction services as well as perceptions regarding the role providers should play in the management of addiction. Guidelines for the management of serious infections and concurrent addiction in the midst of the escalating national opioid crisis should be considered.Disclosures All authors: No reported disclosures.

Poster 460: Medication Discrepancies During In-Patient Transfers

Poster 460: Medication Discrepancies During In-Patient Transfers

Assessment of Outreach by a Regional Burn Center: Could Referral Criteria Revision Help with Utilization of Resources?

The objectives of this study were to identify trends in preburn center care, assess needs for outreach and education efforts, and evaluate resource utilization with regard to referral criteria. We hypothesized that many transferred patients were discharged home after brief hospitalizations and without need for operation. Retrospective chart review was performed for all adult and pediatric transfers to our regional burn center from July 2012 to July 2014. Details of initial management including TBSA estimation, fluid resuscitation, and intubation status were recorded. Mode of transport, burn center length of stay, need for operation, and in-hospital mortality were analyzed. In two years, our burn center received 1004 referrals from other hospitals including 713 inpatient transfers. Within this group, 621 were included in the study. Among transferred patients, 476 (77%) had burns less than 10% TBSA, 69 (11%) had burns between 10-20% TBSA, and 76 (12%) had burns greater than 20% TBSA. Referring providers did not document TBSA for 261 (42%) of patients. Among patients with less than 10% TBSA burns, 196 (41%) received fluid boluses. Among patients with TBSA < 10%, 196 (41%) were sent home from the emergency department or discharged within 24 hours, and an additional 144 (30%) were discharged within 48 hours. Overall, 187 (30%) patients required an operation. In-hospital mortality rates were 1.5% for patients who arrived by ground transport, 14.9% for rotor wing transport, and 18.2% for fixed wing transport. Future education efforts should emphasize the importance of calculating TBSA to guide need for fluid resuscitation and restricting fluid boluses to patients that are hypotensive. Clarifying the American Burn Association burn center referral criteria to distinguish between immediate transfer vs outpatient referral may improve patient care and resource utilization.

Analysis of Origins of Admission for Solid Tumor Oncology Inpatients: Disease Severity and Outcomes.

Hospital transfers may affect clinical outcomes. Evaluation of admission by source of transfer, time of admission, and provider type may identify opportunities to improve inpatient outcomes. We reviewed charts of patients admitted to the solid tumor oncology service between July and December 2014 from the Cleveland Clinic Foundation (CCF) Main Campus emergency department (ED), CCF Regional EDs, outside hospital (OSH) ED, OSH inpatient services, and CCF outpatient clinics. Data collected included time of admission, mortality and severity risk scores, and provider type. Risk factors were assessed for clinical outcomes, including activations of the Adult Medical Emergency Team, intensive care unit transfers, in-hospital mortality, and length of stay (LOS). Five hundred admissions were included. OSH inpatient transfers had significantly higher disease severity compared with all other origins of admission. OSH inpatient transfers demonstrated significantly longer LOS compared with all other origins of admission, and higher mortality rates compared with the outpatient direct admits and CCF Main Campus ED admits. After adjusting for disease severity and risk of mortality, OSH ED patients remained at higher risk for Adult Medical Emergency Team activation, OSH inpatient transfers had the longest LOS, and CCF Main Campus ED patients had the lowest risk of mortality. Time of admission and provider type were not associated with any of the outcomes. Oncology inpatients transferred from an outside health care facility are at higher risk for adverse outcomes. The magnitude of difference is lessened, but still significant, after adjustment for disease severity and risk of mortality.

Influence of a patient transfer network of US inpatient facilities on the incidence of nosocomial infections

Antibiotic-resistant bacterial infections are a substantial source of morbidity and mortality and have a common reservoir in inpatient settings. Transferring patients between facilities could be a mechanism for the spread of these infections. We wanted to assess whether a network of hospitals, linked by inpatient transfers, contributes to the spread of nosocomial infections and investigate how network structure may be leveraged to design efficient surveillance systems. We construct a network defined by the transfer of Medicare patients across US inpatient facilities using a 100% sample of inpatient discharge claims from 2006–2007. We show the association between network structure and C. difficile incidence, with a 1% increase in a facility’s C. difficile incidence being associated with a 0.53% increase in C. difficile incidence of neighboring facilities. Finally, we used network science methods to determine the facilities to monitor to maximize surveillance efficiency. An optimal surveillance strategy for selecting “sensor” hospitals, based on their network position, detects 80% of the C. difficile infections using only 2% of hospitals as sensors. Selecting a small fraction of facilities as “sensors” could be a cost-effective mechanism to monitor emerging nosocomial infections.

Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital.

Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource-limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low-resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncología Pediátrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes. A modified PEWS was implemented at UNOP with systems to track errors, transfers to a higher level of care, and high scores. A retrospective cohort study was used to evaluate clinical deterioration events in the year before and after PEWS implementation. After PEWS implementation at UNOP, there was 100% compliance with PEWS documentation and an error rate of <10%. Implementation resulted in 5 high PEWS per week, with 30% of patients transferring to a higher level of care. Among patients requiring transfer to the pediatric intensive care unit (PICU), 93% had an abnormal PEWS before transfer. The rate of clinical deterioration events decreased after PEWS implementation (9.3 vs 6.5 per 1000-hospitalpatient-days, p = .003). Despite an 18% increase in total hospital patient-days, PICU utilization for inpatient transfers decreased from 1376 to 1088 PICU patient-days per year (21% decrease; P<.001). This study describes the successful implementation of PEWS in a pediatric oncology hospital in Guatemala, resulting in decreased inpatient clinical deterioration events and PICU utilization. This work demonstrates that PEWS is a feasible and effective quality improvement measure to improve hospital care for children with cancer in hospitals with limited resources. Cancer 2017;123:2965-74. © 2017 American Cancer Society.

The relative contribution of provider and ED-level factors to variation among the top 15 reasons for ED admission

Study objectiveWe examine adult emergency department (ED) admission rates for the top 15 most frequently admitted conditions, and assess the relative contribution in admission rate variation attributable to the provider and hospital. MethodsThis was a retrospective, cross-sectional study of ED encounters (≥18years) from 19 EDs and 603 providers (January 2012–December 2013), linked to the Area Health Resources File for county-level information on healthcare resources. “Hospital admission” was the outcome, a composite of inpatient, observation, or intra-hospital transfer. We studied the 15 most commonly admitted conditions, and calculated condition-specific risk-standardized hospital admission rates (RSARs) using multi-level hierarchical generalized linear models. We then decomposed the relative contribution of provider-level and hospital-level variation for each condition. ResultsThe top 15 conditions made up 34% of encounters and 49% of admissions. After adjustment, the eight conditions with the highest hospital-level variation were: 1) injuries, 2) extremity fracture (except hip fracture), 3) skin infection, 4) lower respiratory disease, 5) asthma/chronic obstructive pulmonary disease (A&C), 6) abdominal pain, 7) fluid/electrolyte disorders, and 8) chest pain. Hospital-level intra-class correlation coefficients (ICC) ranged from 0.042 for A&C to 0.167 for extremity fractures. Provider-level ICCs ranged from 0.026 for abdominal pain to 0.104 for chest pain. Several patient, hospital, and community factors were associated with admission rates, but these varied across conditions. ConclusionFor different conditions, there were different contributions to variation at the hospital- and provider-level. These findings deserve consideration when designing interventions to optimize admission decisions and in value-based payment programs.