Low-volume Emergency Departments Research Articles

The hospital costs of high emergency department pediatric readiness.

We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS)≥88 (0-100 scale) across EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness. We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day-to-day ED operations (ie, direct clinical care and routine ED supplies). The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719-100,694) for low volume EDs to $279,134 (95% CI 196,487-362,179) for very high volume EDs; equipment costs accounted for 0.9-5.0% of expenses. The total annual cost-per-patient ranged from $3/child (95% CI 2-4/child) to $222/child (95% CI 156-288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child. Annual hospital costs for HPR are modest, particularly when considered per child.

Emergency Department Volume and Delayed Diagnosis of Serious Pediatric Conditions

Diagnostic delays are common in the emergency department (ED) and may predispose to worse outcomes. To evaluate the association of annual pediatric volume in the ED with delayed diagnosis. This retrospective cohort study included all children younger than 18 years treated at 954 EDs in 8 states with a first-time diagnosis of any of 23 acute, serious conditions: bacterial meningitis, compartment syndrome, complicated pneumonia, craniospinal abscess, deep neck infection, ectopic pregnancy, encephalitis, intussusception, Kawasaki disease, mastoiditis, myocarditis, necrotizing fasciitis, nontraumatic intracranial hemorrhage, orbital cellulitis, osteomyelitis, ovarian torsion, pulmonary embolism, pyloric stenosis, septic arthritis, sinus venous thrombosis, slipped capital femoral epiphysis, stroke, or testicular torsion. Patients were identified using the Healthcare Cost and Utilization Project State ED and Inpatient Databases. Data were collected from January 2015 to December 2019, and data were analyzed from July to December 2023. Annual volume of children at the first ED visited. Possible delayed diagnosis, defined as a patient with an ED discharge within 7 days prior to diagnosis. A secondary outcome was condition-specific complications. Rates of possible delayed diagnosis and complications were determined. The association of volume with delayed diagnosis across conditions was evaluated using conditional logistic regression matching on condition, age, and medical complexity. Condition-specific volume-delay associations were tested using hierarchical logistic models with log volume as the exposure, adjusting for age, sex, payer, medical complexity, and hospital urbanicity. The association of delayed diagnosis with complications by condition was then examined using logistic regressions. Of 58 998 included children, 37 211 (63.1%) were male, and the mean (SD) age was 7.1 (5.8) years. A total of 6709 (11.4%) had a complex chronic condition. Delayed diagnosis occurred in 9296 (15.8%; 95% CI, 15.5-16.1). Each 2-fold increase in annual pediatric volume was associated with a 26.7% (95% CI, 22.5-30.7) decrease in possible delayed diagnosis. For 21 of 23 conditions (all except ectopic pregnancy and sinus venous thrombosis), there were decreased rates of possible delayed diagnosis with increasing ED volume. Condition-specific complications were 11.2% (95% CI, 3.1-20.0) more likely among patients with a possible delayed diagnosis compared with those without. EDs with fewer pediatric encounters had more possible delayed diagnoses across 23 serious conditions. Tools to support timely diagnosis in low-volume EDs are needed.

Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge

Pediatric readiness is essential for all emergency departments (EDs). Children's experience of care may differ according to operational challenges in children's hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges. To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022. This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children's hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs. Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022. Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours). A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children's hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites. In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.

Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic.

Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic.

Yield of whole-body computed tomography at a low-volume emergency department: A 5-year experience.

ABSTRACTObjectives:To share our experience with immediate whole-body computed tomography (WBCT) imaging for trauma patients and to determine its association with surgical intervention and hospital admission.Methods:This retrospective observational study included 208 trauma patients who presented to the emergency department and underwent WBCT at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2014 and November 2018. We excluded pregnant patients and those who went into traumatic cardiac arrest or died before imaging.Results:Of all included patients, 48.6% were adults and 72.1% had positive findings; of these, 36.7% of patients were admitted for observation and 27.3% underwent operative interventions.Conclusion:Whole-body computed tomography is a useful tool to detect significant traumatic injuries in patients presenting to the emergency department. Moreover, it may assist physicians in determining the disposition of these patients. A clear set of criteria should be established to determine which trauma patients require WBCT imaging during initial resuscitation.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong

BackgroundDespite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting.MethodThis was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics.ResultsIn total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1–86.1%); specificity, 99.2% (95% CI 95.8–100%); positive predictive value, 93.8% (95% CI 67.6–99.1%); and negative predictive value, 94.8% (95% CI 90.8–97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60–0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65–0.97, p < 0.001).ConclusionsThe 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments

Introduction Sepsis is a life-threatening emergency. Together, early recognition and intervention decreases mortality. Protocol-based resuscitation in the emergency department (ED) has improved survival in sepsis patients, but guideline-adherent care is less common in low-volume EDs. This study examined the association between provider-to-provider telemedicine and adherence with sepsis bundle components in rural community hospitals. Methods This is a prospective cohort study of adults presenting with sepsis or septic shock in community EDs participating in rural telemedicine networks. The primary outcome was adherence to four sepsis bundle requirements: lactate measurement within 3 hours, blood culture before antibiotics, broad-spectrum antibiotics, and adequate fluid resuscitation. Multivariable generalized estimating equations estimated the association between telemedicine and adherence. Results In this cohort (n = 655), 5.6% of subjects received ED telemedicine consults. The telemedicine group was more likely to be male and have a higher severity of illness. After adjusting for severity and chief complaint, total sepsis bundle adherence was higher in the telemedicine group compared with the non-telemedicine group (aOR 17.27 [95%CI 6.64–44.90], p < 0.001). Telemedicine consultation was associated with higher adherence with three of the individual bundle components: lactate, antibiotics, and fluid resuscitation. Discussion Telemedicine patients were more likely to receive initial blood lactate measurement, timely broad-spectrum antibiotics, and adequate fluid resuscitation. In rural, community EDs, telemedicine may improve sepsis care and potentially reduce disparities in sepsis outcomes at low-volume facilities. Future work should identify specific components of telemedicine-augmented care that improve performance with sepsis quality indicators.

Do Financial Incentives Change Length-of-stay Performance in Emergency Departments? A Retrospective Study of the Pay-for-performance Program in Metro Vancouver.

Pay-for-performance (P4P) programs have been implemented in various forms to reduce emergency department (ED) patient length of stay (LOS). This retrospective study investigated to what extent the timing of patient disposition in Metro Vancouver EDs was influenced by a LOS-based P4P program. We analyzed ED visit records of four major hospitals in Metro Vancouver, Canada. For each ED, we individually tested whether LOS was distributed discontinuously at the LOS target before and after the P4P program was terminated. For the P4P effective period, we examined whether patients discharged just prior to the LOS target had a higher 7-day return-and-admission (RA) rate-the probability that a patient, after being discharged home, returned to any ED within 7 days and was admitted to an inpatient unit-than patients discharged just after the target. Prior to the termination of the P4P program, in all four EDs, the LOS density of admitted patients was discontinuous and had a significant drop at the P4P 10-hours admission LOS target; a similar phenomenon was observed among discharged patients at the 4-hours discharge LOS target, but only in the two lower-volume EDs. Furthermore, in a lower-volume ED, patients who were discharged right before the 4-hours P4P LOS target had a higher 7-day RA rate than patients discharged right after the LOS target. After the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, but patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program. The LOS-based financial incentive scheme appears to have influenced the timing of ED patient dispositions. The results suggest mixed consequences of the P4P program-it can reduce access block for admitted patients but may also lead to discharges associated with return visits and admissions.

Interhospital transfer in low-volume and high-volume emergency departments and survival outcomes after out-of-hospital cardiac arrest: A nationwide observational study and propensity score–matched analysis

IntroductionPost-resuscitation care of out-of-hospital cardiac arrest (OHCA) patients often involves inter-hospital transfer (IHT). We aimed to determine the association between IHT and outcomes of OHCA. MethodsThis cross-sectional study used data from the nationwide emergency medical services (EMS)–based OHCA registry in Korea. All cases of adult patients with OHCA with a presumed cardiac aetiology and a sustained return of spontaneous circulation (ROSC) at hospitals between 2015 and 2016 were analysed. The primary outcome was a good neurological recovery at discharge, defined as cerebral performance in categories 1 or 2. We compared the primary outcome between a non-IHT group and an IHT group, using a propensity score–matching analysis. All analyses were performed separately by mean annual volume of patients with OHCA initially visiting high-volume emergency departments (HVEDs; >100 OCHA patients) and low-volume emergency departments (LVEDs; ≤100 OHCA patients). ResultsOf 54,779 OHCA patients, 11,632 were included. Of 4477 patients who visited LVEDs initially, 1360 (30%) patients were transferred. Of 7155 patients who visited HVEDs initially, 604 (8%) patients were transferred. In the propensity score–matching analysis, the IHT group was more likely to have good neurological recovery than was the non-IHT group [adjusted odds ratio (OR): 1.34; 95% confidence interval (CI): 1.07–1.67] in LVED visitors, but there was no significant difference of good neurological recovery between the non-IHT group and the IHT group (adjusted OR: 0.84; 95% CI: 0.63–1.13) in HVED visitors. ConclusionIHT should be considered when treating OHCA patients in LVEDs.

Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study.

Pediatric out-of-hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher-volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an insitu simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5-year-old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14-item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital-level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low<1,800/year; medium 1,800-4,999; medium-high 5,000-9,999; high>10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital-level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800-4,999/year), 24 medium-high (5,000-9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range= 50.0-78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium-high-volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest-volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ=0.47 and pediatric volume (low and medium vs. medium-high and high) γ=0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium-high-volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower-volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient.

A different crowd, a different crowding level? The predefined thresholds of crowding scales may not be optimal for all emergency departments

IntroductionPrevious studies indicate that crowding scales may not perform well in low-volume emergency departments (EDs). In this study, face-validity of the Modified National ED OverCrowding Score (mNEDOCS) was assessed in a high-volume ED as well as in a low-volume ED. MethodsA prospective observational cohort study was performed in the Netherlands. The correlation of the mNEDOCS with ED staff perceptions of crowding were assessed, using weighted Kappa (κ) and Pearson correlation. Subsequently, ED process measures (elapsed target times to triage, elapsed target times to treatment and patients’ LOS) were described under different levels of ED crowding. ResultsCorrelation between the categorized crowding scores was low (weighted κ 0.34 resp. 0.26). However, good correlations of 0.73 and 0.82 were found between the uncategorized mNEDOCS and ED staff’s perception of crowding. Percentages of patients with elapsed target times to treatment increased simultaneously with increasingly busy periods when measured with mNEDOCS. ConclusionsThe uncategorized mNEDOCS correlates well with perceived crowding, even at a low-volume ED. Determining a cut-off level at which a specific ED can be identified as crowded is important, because the predefined mNEDOCS categories may not be optimal for all EDs.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BackgroundThe emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children. ObjectivesTo describe the trends of emergency care for children in the United States from 2006–2014 in EDs across different pediatric volumes. MethodsWe analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006–2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics. ResultsFrom 2006–2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (−3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%). ConclusionsOverall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

Interfacility transfers for US ischemic stroke and TIA, 2006–2014

To investigate changes in emergency department (ED) transfers for ischemic stroke (IS) and TIA. We performed a retrospective observational study using the US Nationwide Emergency Department Sample to identify changes in interfacility ED transfers for IS and TIA from the perspective of the transferring ED (2006-2014). We calculated nationwide transfer rates and individual ED transfer rates for IS/TIA by diagnosis and hospital characteristics. Hospital-level fractional logistic regression examined changes in transfer rates over time. The population-estimated number of transfers for IS/TIA increased from 22,576 patient visits in 2006 to 54,485 patient visits in 2014 (p trend < 0.001). The rate of IS/TIA transfer increased from 3.4 (95% confidence interval [CI] 3.0-3.8) in 2006 to 7.6 (95% CI 7.2-7.9) in 2014 per 100 ED visits. Among individual EDs, mean transfer rates for IS/TIA increased from 8.2 per 100 ED visits (median 2.0, interquartile range [IQR] 0-10.2) to 19.4 per 100 ED visits (median 8.1, IQR 1.1-33.3) (2006-2014) (p trend < 0.001). Transfers were more common among IS. Transfer rates were greatest among rural (adjusted odds ratio [AOR] 3.05, 95% CI 2.56-3.64) vs urban/teaching and low-volume EDs (AOR 7.49, 95% CI 6.58-8.53, 1st vs 4th quartile). The adjusted odds of transfer for IS/TIA increased threefold (2006-2014). Interfacility ED transfers for IS/TIA more than doubled from 2006 to 2014. Further work should determine the necessity of IS/TIA transfers and seek to optimize the US stroke care system.

Factors associated with availability of anticoagulation reversal agents in rural and community emergency departments.

Results of a study of anticoagulation reversal agent availability in rural and community hospital emergency departments (EDs) are reported. A cross-sectional telephone survey was conducted to test the hypothesis that anticoagulation reversal agents are not commonly stocked in low-volume EDs. In phase 1 of the study, a physician, pharmacist, or nurse manager at a sample of EDs in 1 state was surveyed to characterize anticoagulation reversal agent availability and the presence or absence of reversal protocols; in phase 2, follow-up qualitative interviews were conducted with hospital pharmacists selected by purposive sampling to identify barriers to availability. Among the 103 EDs represented in the survey, 87 (84%) stocked fresh frozen plasma, 14 (14%) stocked 4-factor prothrombin complex concentrate (4F-PCC), and 2 (2%) stocked activated 4F-PCC. Forty-one EDs (40%) had a warfarin reversal protocol, but only 2 (2%) EDs had a protocol for direct oral anticoagulant reversal. ED volume and neurology coverage were significantly associated with reversal agent availability (p = 0.014) and warfarin protocol availability (p < 0.001). Identified factors contributing to reversal agent nonavailability were product cost, lack of knowledge of drug availability, and concerns about shelf life. An investigation of rural and community hospitals in 1 state revealed that the institutions rarely have specialized anticoagulation reversal drugs available. Cost and infrequency of utilization were 2 commonly cited reasons for reversal agent nonavailability.

Characterizing New England Emergency Departments by Telemedicine Use.

IntroductionTelemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use.MethodsWe analyzed data from the National Emergency Department Inventory-New England survey, which assessed basic ED characteristics in 2014. The survey queried directors of every ED (n=195) in the six New England states (excluding federal hospitals and college infirmaries). Descriptive statistics characterized ED telemedicine use; multivariable logistic regression identified independent predictors of use.ResultsOf the 169 responding EDs (87% response rate), 82 (49%) reported using telemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of non-users, p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); and less likely to have 24/7 access to neurology (p<0.001), neurosurgery (p<0.001), orthopedics (p=0.01), plastic surgery (p=0.01), psychiatry (p<0.001), and hand surgery (p<0.001) consultants. Neuro/stroke (68%), pediatrics (11%), psychiatry (11%), and trauma (10%) were the most commonly reported applications. On multivariable analysis, telemedicine was more likely in rural EDs (odds ratio [OR] 4.39, 95% confidence interval [CI] 1.30–14.86), and less likely in EDs with 24/7 neurologist availability (OR 0.21, 95% CI [0.09–0.49]), and annual volume <20,000 (OR 0.24, 95% CI [0.08–0.68]).ConclusionTelemedicine is commonly used in New England EDs. In 2014, use was more common among rural EDs and EDs with limited neurology consultant availability. In contrast, telemedicine use was less common among very low-volume EDs.

188 Lower Pediatric Patient Volume is Associated With Higher Mortality in US Emergency Departments

Children account for over 25% of emergency department (ED) visits in the United States. Almost ninety percent of pediatric ED visits occur in general community EDs, many of which have low pediatric volumes and sporadic exposure to critically ill children. The goal of this study was to assess the association between ED pediatric volume and mortality with the hypothesis that EDs with lower annual pediatric volumes will have higher mortality for similar life-threatening conditions. We performed a secondary analysis of the 2012 Nationwide Emergency Department Sample (NEDS) dataset, the largest all-payer ED database in the United States. We included all patients ages 0-17 years. Using ICD-9 codes, the dataset was restricted to all patients with respiratory failure or cardiac arrest to identify critically ill children at high risk for mortality. Annual pediatric ED volume was divided into quartiles: low (<6373), medium (6374-12117), medium-high (12118-25376), and high (>25376). Descriptive statistics were performed and hierarchical multivariable logistic regression used to estimate associations between pediatric ED volume and mortality, adjusting for patient-level (comorbidity count, age, insurance, household income, sex) and hospital-level factors (urban-rural classification, teaching status, trauma designation, inpatient capacity, children’s hospital designation) that may offer competing explanations for this association. Of the 6.4 million pediatric patient visits in the 2012 NEDS dataset, 2,629 had a primary ICD-9 diagnosis of respiratory failure or cardiac arrest and were included in the cohort. The mean age was 4.1 years (SD 5.4), 40% were female, and the mean comorbidity count was 1.6 (SD 1.77), with 83% having at least one comorbidity. Thirty-nine percent of the cohort died in the ED. The majority of patients had Medicaid insurance (60%), 26% were privately insured, 10% were self-pay, and 49% lived in an urban area. Eleven percent were seen at children’s hospitals, 42% at trauma centers, and 56% at teaching hospitals. Almost 19% of patients were treated at a low-volume (1st quartile) ED, 24% at a low-medium volume ED, 27% at a medium-high volume ED, and 31% at a high-volume ED. High-volume EDs were associated with decreased mortality (OR 0.40 95% CI 0.17-0.94) when compared to low-volume EDs. There was a trend toward incrementally lower odds of mortality in low-medium, medium-high, and high-volume EDs when compared to low-volume EDs, but only high-volume ED mortality reached significance. Using predicted probabilities to convert odds ratios to risk difference, children who present in cardiac arrest or with respiratory failure are 17% less likely to die in a high-volume ED than a low-volume ED, adjusting for patient- and hospital-level covariates available in the NEDS dataset. In a population-based pediatric ED sample of respiratory failure or cardiac arrest, higher volume EDs were significantly associated with decreased mortality after adjusting for patient- and hospital-level confounders.

Volume Matters: Improved Outcomes for Patients Presenting to High-Volume Emergency Departments with Atrial Flutter and Fibrillation.

ObjectivesClinical familiarity plays a role in health outcomes; the relationship between emergency department (ED) volume and outcomes for atrial fibrillation and flutter (AFF) are not clear. We compared ED presentation outcomes for AFF between high (HV) and low volume (LV) EDs in Alberta, Canada.Methods45,372 AFF presentations for patients aged ≥ 35 years from all 104 EDs in Alberta during 1999 to 2011 using administrative health databases formed a retrospective cohort. EDs were grouped by annual AFF volume: 11 high (>100 presentations) or 93 low (≤100 presentations). Outcomes included hospital admission rate, return to ED for AFF within 30 and 90 days, and death within 30 and 90 days. Analyses included statistical tests and mixed effects modeling.ResultsMean age at ED presentation was 69.8 years (52% male). HV ED presentations were associated with lower admissions (adjusted odds ratio [aOR] = 0.68, 95% confidence interval [CI] 0.64, 0.72; p-value [p]<0.001), ED returns at 90 (aOR = 0.81, 95% CI 0.73, 0.90; p<0.001) days, and a higher likelihood of specialist visits at 30 (aOR = 1.81, 95% CI 1.68, 1.94; p<0.001) and 90 (aOR = 1.82, 95% CI 1.76, 2.03; p<0.001) days. For admitted patients, there were fewer returns to HV EDs at 30 (aOR = 0.37, 95% CI 0.15, 0.87; p = 0.02) and 90 (aOR = 0.48, 95% CI 0.26, 0.89; p = 0.02) days after hospital discharge. There was no difference in death between the two groups.ConclusionsAFF patients presenting to HV EDs experienced fewer admissions and AFF ED revisit and higher specialist referrals compared to LV EDs.

LO005: Association between emergency department chest pain volume and outcomes among patients presenting with chest pain

Introduction: Chest pain is one of the most common reasons for emergency department (ED) visits in developed countries. Patients discharged after ED assessment remain at risk for adverse cardiac events. Although a volume-outcome relationship has been shown for myocardial infarction, it is uncertain whether a similar relationship exists with ED chest pain volume. Accordingly, we aimed to determine whether ED chest pain volume influences outcomes of patients presenting to the ED with chest pain who were discharged home. Methods: This was a retrospective cohort study using population-based data from Ontario, Canada. Patients who were discharged home from an ED in Ontario with a primary diagnosis of chest pain from April 1, 2004 to March 31, 2010 were included. High-risk patients were defined as the presence of diabetes or pre-existing cardiovascular disease, while low-risk patients were defined as the absence of these conditions. ED volume was categorized as low, medium, or high, based on tertiles of annual chest pain patient volume. The primary outcome of this study was all-cause mortality one year after the index ED visit. Mantel-Haenszel Chi-Square was used to compare crude outcome rates. Results: There were 56,767 high-risk patients. The average age was 66 years and 53% were male. All-cause mortality rates were 6.8%, 6.3%, and 6.0% (p=0.028), and rates of hospitalization for acute coronary syndrome were 5.8%, 4.6%, and 4.0% (p&lt;0.001) among low, medium, and high volume EDs respectively. There were 216,527 low-risk patients. The average age was 64 years and 42% were male. All-cause mortality rates were 2.0%, 1.9%, and 1.6% (p&lt;0.001), and rates of hospitalization for acute coronary syndrome were 1.5%, 1.4%, and 1.0% (p&lt;0.001) among low, medium, and high volume EDs respectively. Conclusion: Higher volume EDs were associated with decreased rates of all-cause mortality and admission for acute coronary syndrome among chest pain patients who were discharged home. Future research should study the reasons for this finding and attempt to improve outcomes in lower volume EDs.

A Challenging Penetrating Trauma Case

We present the prehospital management of a 23-year-old Australian Aboriginal man with an isolated knife stab wound to the posterior right chest. The lead author attended to the prehospital management of this young man during tenure as a registrar in retrieval medicine for CareFlight Medical Services (CMS) in North Queensland, Australia. The case is noteworthy because it involved a combination of a life-threatening injury with a superimposed iatrogenic injury. The case will be of interest to physicians and clinicians in prehospital medicine as well as those in low-volume emergency departments or facilities in which major trauma may present infrequently.

Emergency Department Hospitalization Volume and Mortality in the United States

Although numerous studies have demonstrated a relationship between higher volume and improved outcomes in the delivery of health services, it has not been extensively explored in the emergency department (ED) setting. Therefore, we seek to examine the association between ED hospitalization volume and mortality for common high-risk conditions. Using data from the Nationwide Inpatient Sample, a national sample of hospital discharges, we evaluated mortality overall and for 8 different diagnoses between 2005 and 2009 (total admissions 17.55 million). These conditions were chosen because they are frequent (in the top 25 of all ED hospitalizations) and high risk (> 3% observed mortality). EDs were excluded from analysis if they did not have at least 1,000 total annual admissions and 30 disease-specific cases. EDs were then placed into quintiles based on hospitalized volume. Regression techniques were used to describe the relationship between volume (number of hospitalized ED patients per year) and both subsequent early inpatient mortality (within 2 days of admission) and overall mortality, adjusted for patient and hospital characteristics. Mortality decreased as volume increased overall and for all diagnoses, but the relative importance of volume varied, depending on the condition. Absolute differences in adjusted mortality rates between very high-volume EDs and very low-volume EDs ranged from -5.6% for sepsis (95% confidence interval [CI] -6.5% to -4.7%) to -0.2% for pneumonia (95% CI -0.6% to 0.1%). Overall, this difference was -0.4% (95% CI -0.6% to -0.3%). A similar pattern was observed when early hospital deaths were evaluated. Patients have a lower likelihood of inhospital death if admitted through high-volume EDs.