Lower Emergency Department Research Articles

Outpatient Total Hip Arthroplasty Performed at an Ambulatory Surgery Center vs Hospital Outpatient Setting: Complications, Revisions, and Readmissions

BackgroundOutpatient total hip arthroplasty (THA) utilization continues to grow. Literature suggests outpatient THA may result in low rates of complications and readmission. There are no studies comparing safety profiles of THA performed at ambulatory surgery centers (ASC) vs hospital outpatient (HOP) settings. MethodsProspectively collected data were reviewed on all patients who underwent THA from 2013 to 2018. ASC and HOP subgroups were compared, investigating difference in demographics, comorbidities, American Society of Anesthesiologists subgroups, all complications, revisions, emergency department (ED) visits, and readmissions within the first 90 days of surgery. An additional subgroup analysis of patients younger than 65 years was performed. ResultsTwo surgeons performed 3063 THAs during the study period, including 965 outpatient cases (ASC = 335; HOP = 630). Thirty-seven (3.8%) complications occurred within 90 days. No differences were found between groups for 90-day complication rates (ASC = 13, 3.9%; HOP = 24, 3.8%; P = .48), revision rates (ASC = 0, 0%; HOP = 2, .3%; P = .30), all-cause reoperation rates (ASC = 1, 0.3%; HOP = 5, 0.8%; P = .35), ED visits (ASC = 3, 0.9%; HOP = 2, 0.3%; P = .23), or readmission rates (ASC = 2, 0.6%; HOP = 9, 1.4%; P = .25). ConclusionTHA can be safely performed in both ASC and HOP settings with low 90-day postoperative complication, revision, reoperation, ED visit, and readmission rates. Based on the populations studied, we identified no statistically significant differences in rates of complications between ASC and HOP groups.

Impact of an oncology urgent care clinic on emergency department rates.

6615 Background: Oncology-specific urgent care clinics (UCC) may play a key role in reducing unscheduled emergency department (ED) visits among patients with cancer. We sought to determine if establishment of an Oncology UCC was associated with lower ED utilization among patients receiving cancer care at Yale’s Smilow Cancer Hospital (SCH) and two nearby, integrated community practices. Methods: SCH opened its UCC in April 2017 to provide supportive care and symptom management for patients with cancer who need acute medical attention outside of regular clinic visits. We identified patients who had at least one visit with an oncology provider during the Pre-UCC period (9/1/16 – 12/31/16) or Post-UCC period (9/1/17 – 12/31/17) and received chemotherapy within a year preceding their provider visit. For each patient, we captured all ED visits in a four-month window starting from their last provider visit in each study period. The ED visit rate for both periods was defined as the total number of ED visits divided by the total number of unique patients in the period. To determine the impact of the UCC on ED utilization, we evaluated the absolute difference in the ED visit rate between the Pre- and Post-UCC period using a two-sample t test. Results: There were 3,754 patients in the Pre-UCC period and 4,734 patients in the Post-UCC period. In the full study sample, the mean age was 62.9 and most common cancer types were Hematologic, Gastrointestinal, and Breast. Prior to opening the UCC, the ED visit rate was 0.27 per unique patient. After opening the UCC, we found a 13.9% relative decrease in the overall ED visit rate from 0.27 to 0.23 (p = 0.02). The SCH patient ED visit rate declined by 12.5% (p = 0.03) and the community practice rate declined by 37.1%; however, the latter decline was not statistically significant, potentially due to a small sample size (p = 0.19). Conclusions: Our study found a decrease in the ED visit rate after the opening of an Oncology UCC. An urgent care strategy for cancer centers may serve as an efficient way to manage patients while minimizing ED use. [Table: see text]

Emergency department utilization and monetary charges in adolescents with autism spectrum disorder, intellectual disability, and a population comparison group.

Adolescents with autism spectrum disorder (ASD) and/or intellectual disability (ID) may utilize the emergency department (ED) more frequently than individuals in the general population. This study compared ED utilization and charges during adolescence among four groups of individuals: ASD-only, ASD + ID, ID-only, and a population comparison (PC) group. ED visits occurring during age 12-17 years were examined to identify non, low, and high utilizers. Logistic regression was used to compare groups on the odds of having at least one ED visit during adolescence. Generalized linear models were used to compare groups on number of ED visits and total charges, stratified by low and high ED utilization. Descriptive examination of presenting diagnoses was performed. Individuals with ID, with or without co-occurring ASD, were significantly more likely to have at least one ED visit during adolescence. Among high ED utilizers, the ID-only group had the most frequent ED visits but had significantly lower charges than the ASD-only group. Individuals with ASD-only and ASD + ID differed from the ID-only and PC groups in presenting diagnoses. No differences between groups in number of ED visits or charges were observed among low utilizers. ID, with or without ASD, increased the odds of visiting the ED during adolescence. Adolescents with ID-only had the most frequent ED visits, but individuals with ASD-only had the highest ED charges and tended to be seen for psychiatric concerns. Further research is warranted to better characterize and meet the healthcare needs of individuals with ASD and/or ID during adolescence. Autism Res 2019, 12: 1129-1138. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Frequent emergency department (ED) visits strain medical resources and are costlier than primary and urgent care. Our findings show that adolescents with intellectual disability (ID) may use the ED frequently for nonurgent conditions. Adolescents with autism spectrum disorder, without ID, use the ED less frequently but incur higher charges. Further research is needed to understand how to meet the unique needs of these populations in primary care to prevent overuse of the ED.

LO13: Characteristics of emergency department visits by community-dwelling older adults who screened positive for elder abuse during home care assessments

Introduction: Elder abuse is infrequently detected in the emergency department (ED) and less than 2% are reported to proper law authorities by ED physicians. This study aims to examine the characteristics of community-dwelling older adults who screened positive for elder abuse during home care assessments and the epidemiology of ED visits by these patients relative to other home care patients. Methods: This study utilized a population-based retrospective cohort study of home care patients in Canada between April 1, 2007 and March 31, 2015. Standardized, comprehensive home care assessments were extracted from the Home Care Reporting System. A positive screen for elder abuse was defined as at least one these criteria: fearful of a caregiver; unusually poor hygiene; unexplained injuries; or neglected, abused, or mistreated. Home care assessments were linked to the National Ambulatory Care Reporting System in the regions and time periods in which population-based estimates could be obtained to identify all ED visits within 6 months of the home care assessment. Results: A total of 30,413 from the 2,401,492 patients (1.3%) screened positive for elder abuse during a home care assessment. They were more likely to be male (40.5% versus 35.3%, p < 0.001), to have a cognitive impairment (82.9% versus 65.3%, p < 0.001), a higher frailty index (0.27 versus 0.22, p < 0.001) and to exhibit more depressive symptoms (depression rating scale 1 or more: 68.7% versus 42.7%, p < 0.001). Patient who screened positive for elder abuse were less likely to be independent in activities of daily living (41.9% versus 52.7%, p < 0.001) and reported having fallen more frequently (44.2% versus 35.5%, p < 0.001). Caregiver expressing distress was associated with elder abuse (35.3% versus 18.3%, p < 0.001) but not a higher number of hours caring for the patient. Victims of elder abuse were more likely to attend the ED for low acuity conditions (Canadian triage and acuity scale (CTAS) 4 or 5). Diagnosis at discharge from ED were similar with the exception of acute intoxication that was more frequent in patients who are victims of abuse. Conclusion: Elder abuse is infrequently detected during home care assessments in community-dwelling older adults. Higher frailty index, cognitive impairment, depressive symptoms were associated with elder abuse during homecare assessments. Patients who are victims of elder abuse are attending EDs more frequently for low acuity conditions but ED diagnosis at discharge, except for acute intoxication, are similar.

P069: Does specialist referral influence emergency department return rate for patients with renal colic? A retrospective cohort study

Introduction: Renal colic is a common presentation which exerts a significant burden on healthcare infrastructure. A significant proportion of patients managed with observation may return to the Emergency Department (ED) prior to spontaneous passage due to inadequate analgesia. It is unclear whether early urologist consultation would limit the burden of renal stones by reducing returns to the ED. We wished to determine whether urologist referral from the ED department is associated with fewer returns to the ED with renal colic. Methods: We conducted a retrospective chart review using RECORD methodology of consecutive patients diagnosed with CT-confirmed, ureteric or renal calculi in our ED over a two-year period. Disposition was categorized as either hospital admission, outpatient urologist referral, follow up with primary care, or no follow up. The primary outcome was the 30-day ED re-presentation for renal colic. Multivariate logistic regression was used to identify predictors for ED-return. Results: In total, 232 patients met our inclusion criteria. Urgent or outpatient urologist referral was not associated with a significantly lower ED return rate when compared to patients with no follow-up. Surprisingly, urologic intervention and stent placement were both independent predictors for ED return (OR: 2.03; 95% CI: (1.06-3.88); p:0.03) and (OR:2.08; 95% CI: (1.07-4.05). Conclusion: A significant proportion of patients who underwent urologist-led intervention returned to the ED with renal colic. Further study may help clarify the role of early urologist referral for renal calculi, as this may not reduce ED return rates when compared to conservative management.

The Association of Nurse Practitioner Scope-of-Practice Laws With Emergency Department Use

Overuse and inappropriate use of emergency departments (EDs) remains an important issue in health policy. After implementation of Medicaid expansion, many states experienced an increase in ED use, but the magnitude varied. Differential access to primary care might explain such variation. To determine whether the increase in ED use among Medicaid enrollees following Medicaid expansion was smaller in states that allowed greater access to primary care providers by permitting nurse practitioners (NPs) to practice without physician oversight. Examining data on ED use by Medicaid beneficiaries, we estimated random effects models to examine changes in ED visits. Models for 8 different clinical conditions were estimated, with each model including a linear time trend, indicators for Medicaid expansion and for the absence of physician oversight requirements, and an interaction between these 2 indicators. States requiring physician oversight of NPs had a 28% increase in ED visits relative to the preexpansion period, while states allowing NP practice without physician oversight had only a 7% increase. The increase in the share of visits covered by Medicaid in no-oversight states was 40% of the size of the increase in oversight states. Allowing NPs to practice without physician oversight was associated with a reduction in the magnitude of increase in ED use following Medicaid expansion. States that restrict NP practice should weigh the costs of maintaining these restrictions against the potential benefits of lower ED use. States considering Medicaid expansion should also consider relaxing NP scope-of-practice laws.

What Are We Measuring? Evaluating Physician-Specific Satisfaction Scores Between Emergency Departments.

IntroductionMost emergency departments (ED) use patient experience surveys (i.e., Press Ganey) that include specific physician assessment fields. Our ED group currently staffs two EDs – one at a large, tertiary-care hospital, and the other at a small, affiliated, community site. Both are staffed by the same physicians. The goals of this study were to determine whether Press Ganey ED satisfaction scores for emergency physicians working at two different sites were consistent between sites, and to identify factors contributing to any variation.MethodsWe conducted a retrospective study of patients seen at either ED between September 2015 and March 2016 who returned a Press Ganey satisfaction survey. We compiled a database linking the patient visit with his or her responses on a 1–5 scale to questions that included “overall rating of emergency room care” and five physician-specific questions. Operational metrics including time to room, time to physician, overall length of stay, labs received, prescriptions received, demographic data, and the attending physician were also linked. We averaged scores for physicians staffing both EDs and compared them between sites using t-tests. Multiple logistic regression was used to determine the impact of visit-specific metrics on survey scores.ResultsA total of 1,012 ED patients met the inclusion criteria (site 1=457; site 2=555). The overall rating-of-care metric was significantly lower at the tertiary-care hospital ED compared to our lower volume ED (4.30 vs 4.65). The same trend was observed when the five doctor-specific metrics were summed (22.06 vs 23.32). Factors that correlated with higher scores included arrival-to-first-attending time (p=0.013) and arrival-to-ED-departure time (p=0.038), both of which were longer at the tertiary-care hospital ED.ConclusionPress Ganey satisfaction scores for the same group of emergency physicians varied significantly between sites. This suggests that these scores are more dependent on site-specific factors, such as wait times, than a true representation of the quality of care provided by the physician.

Ambulance diversions following public hospital emergency department closures.

To examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs private. Ambulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California's Office of Statewide Health Planning and Development and the American Hospital Association (2007). We match public and private (nonprofit or for-profit) hospitals by distance and size. We use random-effects models examining diversion probability and timing of private hospitals following diversions by neighboring public vs matched private hospitals. N/A. Hospitals are 3.6 percent more likely to declare diversions if neighboring diverting hospitals are public vs private (P<0.001). Hospitals declaring diversions have lower ED occupancy (P<0.001) after neighboring public (vs private) hospitals divert. Hospitals have 4.2 percent shorter diversions if neighboring diverting hospitals are public vs private (P<0.001). When the neighboring hospital ends its diversion first, hospitals terminate diversions 4.2 percent sooner if the neighboring hospital is public vs private (P=0.022). Sample hospitals respond differently to diversions by neighboring public (vs private) hospitals, suggesting that these hospitals might be strategically declaring ambulance diversions to avoid treating low-paying patients served by public hospitals.

088 Predictors of Hospital Transfer for Patients Presenting with Priapism in Emergency Departments in the United States

Priapism is a urologic emergency which requires prompt management. There is no study in the literature that assesses the characteristics of those patients with priapism presenting to the emergency room which are transferred to another hospital for further care. We examine the patient and emergency department (ED) attributes associated with an increased likelihood of being transferred to another institution for further management. ED visits with a primary diagnosis of priapism (ICD-9 code:607.3) between 2010 and 2014 were abstracted from the Nationwide Emergency Department Sample (NEDS) (Healthcare Cost and Utilization Project, the U.S. most comprehensive source of hospital care data). Univariate and multivariate analyses were performed of patient and hospital characteristics leading to a transfer to another institution. Between 2010 and 2014 we identified a weighted estimate of 68,328 visits to the emergency department for priapism in the United States, which represents a national incidence of 4.5 cases per 100,000 male subjects per year (+/- 0.3 SE). Over the study period there was significant increasing trend towards more ED visits (EAPC=6.4%, p<0.05) and more transfers (EAPC=7.8%, p<0.05). Although, the majority of the patients were treated in the presenting hospital (94.6%), 5.4% (an estimated 3692 visits) resulted in a transfer to another institution. Patients most commonly presented in the South region (45.7%), and during weekend (32.4%) and summer months (28.1%). On multivariable analyses independent predictors of transfer to another institution included presentation to a nonteaching institution (OR 2.08, P < 0.001), non-trauma hospital (OR 1.81, p < 0.001), rural hospital (OR 1.51, p < 0.001), low ED volume (OR 1.81, p < 0.001) and very low-income level (OR 1.21, p < 0.001). Presentation in the Southern region, during the winter months, and being older than 45 years old were predictors of non-transfer.

Access to Federally Qualified Health Centers and Emergency Department Use Among Uninsured and Medicaid-insured Adults: California, 2005 to 2013.

While improved access to safety net primary care providers, like federally qualified health centers (FQHCs), is often cited as a route to alleviate potentially preventable emergency department (ED) visits, no studies have longitudinally established the impact of improving access to FQHCs on ED use among Medicaid-insured and uninsured adults. We aimed to determine whether improved access to FQHCs was associated with lower ED use by uninsured and Medicaid-insured adults. Using data from the Uniform Data System, U.S. Census Bureau, and California Office of Statewide Health Planning & Development, we conducted a longitudinal analysis of 58 California counties from 2005 to 2013. For each county-year observation, we employed three measures of FQHC access: geographic density of FQHCs (delivery sites per 100 square miles), FQHCs per county resident (delivery sites per 100,000 county residents), and the proportion of Medicaid-insured or uninsured residents ages 19 to 64 years that utilized FQHCs. We then used a fixed-effects model to examine the impact of changes in the measures of FQHC access on ED visit rates by Medicaid-insured or uninsured adults in each county. Increasing geographic density of FQHCs was associated with a 26% to 35% decrease in ED use by uninsured but not Medicaid-insured patients. Increasing numbers of clinics per county resident and higher percentages of Medicaid-insured and uninsured adults seen at FQHCs were not associated with reduced rates of ED use among either uninsured or Medicaid-insured adults. We were unable to detect a consistent association between our measures of FQHC access and ED use by Medicaid-insured and uninsured nonelderly California adults, underscoring the importance of investigating additional drivers to reduce ED use among these vulnerable patient populations.

New approaches to measuring the comprehensiveness of primary care physicians.

To develop claims-based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost. A total of 5359 PCPs caring for over 1 million Medicare fee-for-service beneficiaries from 1404 practices. We developed Medicare claims-based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs' comprehensiveness in 2013 with their beneficiaries' emergency department, hospitalizations rates, and ambulatory care-sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering. Each measure varied across PCPs and had low correlation with the other measures-as intended, they capture different aspects of comprehensiveness. For patients whose PCPs' comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P<0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, -$17.4 (-2.2 percent); hospitalizations, -5.5 (-1.9 percent); emergency department (ED) visits, -16.3 (-2.4 percent); new problem management: total Medicare expenditures, -$13.3 (-1.7 percent); hospitalizations, -7.0 (-2.4 percent); ED visits, -19.7 (-2.9 percent); range of services: ED visits, -17.1 (-2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates. These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.

Determinants of emergency department utilization for non-traumatic dental conditions in Massachusetts.

To study the determinants of emergency department (ED) utilization for non-traumatic dental conditions (NTDCs) by adults in Massachusetts. We analyzed patient-level factors associated with ED utilization for NTDCs in Massachusetts during 2013, using the Massachusetts All Payer Claims Dataset. The primary independent variables of interest were use of preventive dental service in the year preceding the ED visit and dental insurance coverage. Key covariates included age, gender, income, day of the ED visit, payer type, and residing in a geographically designated dental health professional shortage area (DHPSA). A multilevel logistic regression model was used to estimate the odds of NTDC ED visits as compared to two other categories of ED visits. 1.1 percent of all ED visits in Massachusetts were for NTDCs in 2013. Preventive dental service use in the preceding year decreased the odds (OR = 0.72) of a NTDC ED visit, whereas having dental insurance coverage increased the odds (OR = 1.1) of a NTDC ED visit. Other patient-level characteristics that significantly increased odds of a NTDC ED visit included being between 26 and 35 years of age (OR = 1.2), male (OR = 1.3), uninsured (OR = 1.7) or enrolled in Medicaid (OR = 1.2), and visiting on a weekend (OR = 1.3). Increased access to preventive dental services may lower likelihood of ED use for NTDCs. Interventions that target younger adults, Medicaid enrollees, and the uninsured, may be the most efficient way to lower NTDC ED use.

Outcome of Pediatric Emergency Point-of-Care Ultrasound (POCUS) for Management of Skin and Soft Tissue Infection Prior to Ultrasound Program Implementation

Background and Hypothesis: Point-of-care ultrasound (POCUS) is underutilized for evaluation of skin and soft tissue infections (SSTI) in the pediatric emergency department (ED). This study seeks to determine the utilization of POCUS compared to formal radiology ultrasound for SSTI in the pediatric ED prior to an ultrasound program implementation. We hypothesize that POCUS utilization will be low but can lead to a decreased length of stay (LOS) and cost for patients with SSTI. &#x0D; Experimental Design or Project Methods: This is a retrospective EMR chart review covering pre-implementation (July 2016-June 2017) and post-implementation (July 2018-June 2019) of a POCUS program curriculum. Patients (&lt;18 years old) were included based on screening for diagnoses via the international classification of diseases 9th and 10th revision codes for abscesses and cellulitis. We excluded patients who required admission and subspecialty consult or had other non-SSTI evaluation. &#x0D; Results: Pre-Implementation period included 160 patients who met inclusion and exclusion criteria. Of these, 16 (10%) received POCUS evaluation and 8 (5%) received a radiology image evaluation. The majority of patients had cellulitis (80%) when compared to abscess (20%). The average LOS for POCUS ultrasound was 173 minutes compared to 304 minutes for radiology evaluation. The total cost for visit was $3,503 for patients evaluated by POCUS compared to $8,875.56 for patients who received radiology imaging. &#x0D; Conclusion and Potential Impact: Taken together, the pre-implementation assessment of POCUS utilization in the pediatric emergency department was low but associated with decreased LOS and lower total ED cost when applied to SSTI management.

Facilitators and Barriers to Reducing Emergency Department Admissions for Chest Pain: A Qualitative Study.

Chest pain of possible cardiac etiology is a leading reason for emergency department (ED) visits and hospitalizations nationwide. Evidence suggests outpatient management is safe and effective for low-risk patients; however, ED admission rates for chest pain vary widely. To identify barriers and facilitators to outpatient management after ED visits, we performed a multicenter qualitative study of key stakeholders. We identified Massachusetts hospitals with below-average admission rates for adult ED chest pain visits from 2010 to 2011. We performed a qualitative case study of 27 stakeholders across 4 hospitals to identify barriers and facilitators to outpatient management. Clinicians cited ability to coordinate follow-up care, including stress testing and cardiology consultation, as key facilitators of ED discharge. When these services are unavailable, or inconsistently available, they present a barrier to outpatient management. Clinicians identified pressure to maintain throughput and the lack of observation units as barriers to ED discharge. At 3 of 4 hospitals without observation units, clinicians did not use clinical protocols to guide the admission decision. At the site with a dedicated ED observation unit, low ED admission rates were attributed to clinician adherence to clinical protocols. In conclusion, most participants have not adopted protocols focused on reducing variation in ED chest pain admissions. Robust systems to ensure follow-up care after ED visits may reduce admission rates by mitigating the perceived risk of discharging ED patients with chest pain. Greater use of observation protocols may promote adoption of clinical guidelines and reduce admission rates.

Age Affects the Impact of Important Predictors on Mental Health Emergency Department Visits.

Visits to emergency departments (EDs) for pediatric mental health care have increased over the years. The likelihood of ED re-visit is greatest for older children; however, little is known about age-varying effects on ED visits/re-visits. This study used population-based administrative databases from Alberta, Canada, to investigate the association of predictors on mental health ED visit frequency by age for 27,947 children who presented at least once for mental health care from April 2002 to March 2011. A marginal regression model with age-varying effects for sex, geographic area, and socio-demographic group was fit. The impact of predictors depended on a child's age. Notably, older males had lower ED visit frequencies compared to females (age 15 adjusted hazard ratio [aHR] = 0.70, 95% confidence interval [CI] [0.65, 0.76]) than younger males (age 10 aHR = 1.83, 95% CI [1.50, 2.24]). Children with particular ages for some socio-demographic groups also showed higher ED frequencies than children from the non-subsidized group. The analysis revealed important age-varying effects on predictors of mental health ED visit frequency.

Factors associated with older people's emergency department attendance towards the end of life: a systematic review.

BackgroundEmergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people’s ED attendance towards the end of life. MethodsSystematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged ≥65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. ResultsOf 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1–0.94); non-white ethnicity (1.03–2.16); male gender (1.04–1.83, except 0.70 in one sub-sample) and rural areas (0.98–1.79). The final model included socio-demographic, illness and service factors, with largest effect sizes for service factors. ConclusionsIn this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research.

Outcomes of Patients Presenting with Primary or Secondary Atrial Fibrillation with Rapid Ventricular Rate to the Emergency Department

Atrial fibrillation (AF) with rapid ventricular rate (RVR) is a common diagnosis in the Emergency Department (ED) requiring evaluation and treatment. We present the characteristics and outcomes of patients presenting with primary or secondary AF in a tertiary hospital ED. This retrospective cohort study included consecutive patients ≥21 years old, with a primary or secondary diagnosis of AF with RVR in the ED over a 1-year period from 1 January 2016 to 31 December 2016. Primary AF is defined as AF with no precipitating cause and secondary AF as AF secondary to a precipitating cause. A total of 464 patients presented to the ED from 1 January to 31 December 2016 with primary and secondary diagnosis of AF with RVR; 44.8% had primary diagnosis of AF whereas 55.2% had secondary AF. Overall admission rate from ED was high at 91.8% (primary 84.6% vs secondary 97.7%). Patients with primary AF were younger (68 vs 74 years, P <0.001), had lower rates of cardiovascular risk factors, and shorter length of stay (median 4 vs 5 days). Within 30 days of discharge, they had lower ED reattendance (16.3% vs 25.8%, P <0.001) and lower readmission (16.3% vs 25.8%, P <0.001). There was no mortality in the primary AF group (0% vs 9.8%, P <0.001). Currently, majority of patients with AF with RVR are admitted from the ED. Other study suggests patients with uncomplicated primary AF have lower adverse outcomes and some could potentially be treated as outpatients.

Overall Emergency Department Rating: Identifying the Factors That Matter Most to Patient Experience.

Patient experience is becoming an area of interest in Emergency Medicine as more is understood about its impact on outcomes and the expectation that it will soon be tied to reimbursement. No study has investigated the predictors of emergency department (ED) patient satisfaction in over a decade. As the care environment, access to information, and consumer interests change, determinants of satisfaction have likely evolved. Our objective was to examine the factors that were most predictive of ED satisfaction. A retrospective cohort study at an urban, university-affiliated ED. The relationship between overall satisfaction and patients' responses to individual questions was assessed using a chi-square test and a multivariable logistic regression model. During the study period, 7,872 patients participated in a telephone interview. Logistic regression found 13 questions predictive of high overall ED rating and 9 questions predictive of low overall ED rating. Six questions appeared in both analyses, related to timeliness, cleanliness, the physician's ability to listen carefully, teamwork, and the perception of being helped by the care. There are strong predictors of overall ED satisfaction related to communication, wait time, environment, and perception that care was helpful. Further efforts should focus on identifying interventions in each of these domains.

66 Comparison of Patient Demographics, Disposition, and Outcomes Using a Chief-Complaint-Based Denominator versus Administrative Claims-Based Denominator for Emergency Department Patients With Chest Pain

International Classification of Diseases (ICD) codes are used by many quality measures to identify cohorts of patients with disease positive states. Because emergency department (ED) patients are evaluated and managed in real-time according to their chief complaint, we hypothesize that quality measures utilizing a chief complaint-based denominator may be a more accurately reflect care delivered in the ED. In this study, we sought to compare patient demographics, disposition, and outcomes using 2 unique yet overlapping denominators using medical record data from a large health care network. Using electronic medical record data between 1/1/2017 - 4/13/2018 from 16 different emergency departments in Western Pennsylvania, we included all patients ≥ 18 years old, afebrile (temp ≤ 38°C), for whom an ECG and troponin were ordered in the ED. We excluded any patient not evaluated in an in-network outpatient office within 365 days before the index ED visit in order to allow reliable estimation of patient comorbidities in our patient cohort. We then identified ED patients with chest pain using 2 different methods. In our chief complaint cohort, patients were selected using a text string matching algorithm. In our ICD cohort, patients were selected using a predefined set of ICD-10 diagnostic codes for chest pain which matched the denominator of a quality measure currently used by the Emergency Quality Network (E-QUAL). Patient outcomes, including 30-day rates of acute myocardial infarction and mortality were determined from subsequent medical records, including office visits, and the national death index. We compared patient demographics, ED disposition, and outcomes between our 2 patient cohorts using a Pearson’s Chi-square test with alpha error rate of 0.05. Of 78,619 patients meeting our initial inclusion and exclusion criteria, 22,092 patients were identified using the chief-complaint algorithm while 21,800 patients were identified using the ICD coding method. Although there was no difference in overall admission rates between the chief complaint cohort and the ICD cohort, more patients in the ICD cohort were admitted to observation status (46.7 versus 41.4, p<0.001). In terms of 30-day outcomes, there was a higher rate of acute myocardial infarction and mortality in the chief complaint cohort relative to the ICD cohort (AMI: 2.0 versus 1.1, p<0.001; mortality: 0.8 versus 0.7, p=0.027). Similarly, there was a higher rate of diabetes mellitus and underlying coronary artery disease in the chief complaint cohort relative to the ICD cohort (diabetes: 20.6 versus 19.6, p=0.008; coronary artery disease: 18.7 versus 16.9, p<0.001). In comparison to a chief-complaint-based denominator, an ICD-based denominator may select for a lower risk ED population with a lower incidence of short-term morbidity and mortality.

196 Checkpoint Inhibitor Complications in the Emergency Department: Methods to Improve Awareness and Outcomes

Immune checkpoint inhibitors (ICPIs) are a novel class of cancer therapeutics that serve to recruit patients’ native immune systems to combat cancer. Given initial successes, we have recently seen the release of several new ICPIs, along with expanding ICPI indications. Unfortunately, we have also seen a parallel rise in ICPI-related adverse events presenting to the emergency department. These complications have the potential to escalate into life-threatening autoimmune inflammatory conditions if they are not identified and treated in an expedited fashion. We designed this study to evaluate whether an electronic medical record (EMR)-based ICPI alert tool and educational intervention could improve the outcomes of patients on ICPIs presenting to the emergency department (ED). We conducted a retrospective cohort study at 2 academic EDs between April 20, 2015 and April 30, 2018 to evaluate the effectiveness of an EMR-based ICPI educational best practice advisory (BPA) alert. This BPA fired every time the treating provider would initially open the chart of a patient who was receiving an ICPI. The BPA included a link to educational content on the potential side effects of ICPIs. For our study, we evaluated several outcomes based on whether the ED provider utilized the educational content link provided in the BPA (Link+ versus Link-). These outcomes included ED disposition, admission level of care, ED revisits within 7 days, and 30-day hospital readmission rates. Descriptive statistics are reported. During our study period there were 912 ED visits associated with an ICPI BPA alert. Among these encounters, there were 63 visits when the ED provider accessed the BPA educational link (Link+). There were no significant differences in age, sex, race, or ethnicity among the patient populations. Link+ visits were much more likely to result in an admission than Link- visits (79.4% versus 47.6%), though the admitted patients from the Link- group were more likely to require a higher level of care (ICU or stepdown unit) than the Link+ group (27.4% versus 11%). Among those patients who were discharged, the Link- group was more likely to require a 7-day ED return visit (20.7% versus 16.7%) and was more likely to require a 30-day hospital readmission (23% versus 14%, p<.05). The most common cancers encountered in our cohort were melanoma, lung, breast, and colon. The results of our study suggest that an EMR-based BPA educational tool has the ability to improve the outcomes of patients on ICPIs. Although we observed a higher initial admission rate for Link+ patients, we also observed lower ED return visits and 30-day readmissions. This may suggest that ICPI complications are being more appropriately diagnosed and treated on the initial visit due to the educational content, leading to improved downstream outcomes. This may also be reflected in the admission level of care difference between the groups. The Link- group was more likely to require a higher level of care, suggesting that the Link+ group may have received more appropriate, aggressive care, targeting the ICPI complications that sometimes mimic other disease processes. As we encounter more ICPIs in the emergency department, an EMR-based educational tool may be helpful in minimizing the potential harms from these novel cancer therapies.