Multiple Emergency Department Visits Research Articles

386 Improved Identification and Visualization of Emergency Department Patient Visits

386 Improved Identification and Visualization of Emergency Department Patient Visits

Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain

A spinal epidural abscess (SEA) is rare but potentially devastating if not diagnosed early. Unfortunately, diagnostic delays and associated neurological deficits are common. The objectives of this analysis were to explore the use of a novel clinical decision guideline to screen patients who present to the emergency department (ED) with spine pain for SEA and to determine the diagnostic test characteristics of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level in patients at risk for SEA. This was a prospective, cohort analysis comparing the incidence of diagnostic delays and presence of motor deficits at the time of diagnosis before and after implementation of a novel decision guideline using risk factor assessment followed by ESR and CRP testing prior to definitive imaging. A delay was defined as either multiple ED visits or admission to a nonsurgical service without a diagnosis of SEA. A 9-month substudy was performed in all patients who presented to the ED with spine pain so that the diagnostic test characteristics of the ESR and CRP level could be defined. A total of 55 patients with an SEA in the 9-year control period and 31 patients with an SEA in the 5-year study period were identified. Diagnostic delays were observed in 46 (83.6%) of 55 patients before guideline implementation versus 3 (9.7%) of 31 after guideline implementation (p < 0.001). Motor deficits were present at the time of diagnosis in 45 (81.8%) of 55 patients before guideline implementation versus 6 (19.4%) of 31 after guideline implementation (p < 0.001). The sensitivity and specificity of ESR in patients with an SEA risk factor were 100% and 67%, respectively. The receiver operating characteristic curve analysis revealed better test characteristics for ESR (area under curve 0.96) than for CRP (area under curve 0.81). A treatment guideline incorporating risk factor assessment followed by ESR and CRP testing was highly sensitive and moderately specific in identifying ED patients with SEA. A decrease in diagnostic delays and a lower incidence of motor deficits at the time of diagnosis was observed.

Does Poorer Familiarity with Medicare Translate into Worse Access to Health Care?

To examine the relationship between a global measure of Medicare program familiarity and a broad set of measures of actual and perceived healthcare access. Mailed survey in fall of 2004 (2,997 completed surveys; 53% response rate). Metropolitan and nonmetropolitan areas across the United States. White, black, and Hispanic Medicare beneficiaries. Familiarity with Medicare and self-reported measures of health status, healthcare use, and perceived access to care. Reported poorer familiarity with Medicare is associated with a greater likelihood of delayed care due to cost, multiple emergency department visits, lack of prescription medication use, poorer perceived access to care, poorer overall health, and a greater reported decline in health from the prior year. Black and Hispanic respondents were more likely to be unfamiliar than whites, although the relationship between familiarity and healthcare access persisted after adjusting for race or ethnicity, Medicare health plan enrollment status, supplemental insurance status, age, sex, income level, education, geographic area, and general healthcare use. Poorer familiarity with Medicare may affect beneficiaries' ability to access needed care effectively, may lead them to delay or avoid seeking care, and ultimately may have negatively affect the quality of the health care that they receive and their outcomes.

103: Why Do Some Patients With Sickle Cell Disease Have Multiple Emergency Department Visits and What Do They Expect?

103: Why Do Some Patients With Sickle Cell Disease Have Multiple Emergency Department Visits and What Do They Expect?

Medical Emergency Department Utilization Patterns Among Uninsured Patients With Psychiatric Disorders

This study examined medical emergency department utilization for patterns among uninsured patients with psychiatric disorders. Billing records of 15,672 uninsured adult patients treated in the emergency department of an academic medical center in southeast Texas over a 12-month period were analyzed for information on demographic characteristics, diagnosis, number of emergency department visits, and hospitalization. Overall, 11.8% of the population was diagnosed as having at least one psychiatric disorder during an emergency department visit. Patients with psychiatric disorders had an increased risk of having multiple emergency department visits and hospitalization compared with patients without psychiatric disorders. The risk of multiple emergency department visits was particularly high for patients with either bipolar disorder or psychotic disorders. Uninsured patients with psychiatric disorders appear to be heavy users of medical emergency department services. These findings may be helpful in developing more efficient strategies to serve the mental health needs of the uninsured.

Emergency Department Usage by Uninsured Patients in Galveston County, Texas

The number of uninsured Texas residents who rely on the medical emergency department as their primary health care provider continues to increase. Unfortunately, little information about the characteristics of this group of emergency department users is available. Using an administrative billing database, we conducted a descriptive study to examine the demographic and clinical features of 17,110 consecutive patients without medical insurance who presented to the emergency department of the University of Texas Medical Branch in Galveston over a 12-month period. We also analyzed the risk of multiple emergency department visits or hospitalization according to demographic characteristics. Twenty percent of the study population made two or more emergency department visits during the study period; 19% of the population was admitted to the hospital via the emergency department. The risk of multiple emergency department visits was significantly elevated among African Americans and increased in a stepwise fashion according to age. The risk of being hospitalized was significantly reduced among females, African Americans, and Hispanics. There was an age-related monotonic increase in the risk of hospitalization. Abdominal pain, cellulitis, and spinal disorders were the most common primary diagnoses in patients who made multiple emergency department visits. Hospitalization occurred most frequently in patients with a primary diagnosis of chest pain, nonischemic heart disease, or an affective disorder. Additional studies of emergency department usage by uninsured patients from other regions of Texas are warranted. Such data may prove helpful in developing effective community-based alternatives to the emergency department for this growing segment of our population. Local policymakers who are responsible for the development of safety net programs throughout the state should find this information particularly useful.

A Validation of Self-Reported Substance Use with Biochemical Testing Among Patients Presenting to the Emergency Department Seeking Treatment for Backache, Headache, and Toothache

Purpose: This study tests the validity of self-reported illicit substance use against biochemical testing among Emergency Department (ED) patients seeking treatment with narcotics for backache, headache, and toothache and to characterize patients who provide false reports. Methods: Retrospective chart review comparing the self-reported drug use history obtained during an ED visit during a six-year period (1995–2001) with the results of a biochemical drug screen obtained the same day. Results: 248 patients met screening criteria, 79 (32%) of whom tested positive for unclaimed “drugs of abuse.” Patients with a history of “drug abuse” and chronic pain were significantly more likely to test positive for unclaimed drugs than were their counterparts (p =. 05 and p <. 0001, respectively). No significant difference was found in comparing those with and without multiple ED visits or those requesting a specific narcotic. Conclusion: Self-reported drug use is unreliable in this ED subpopulation. When this knowledge is critical for patient care, biochemical testing may be indicated.

Predictors of readmission after elective coronary artery bypass graft surgery

We sought to examine potential predictors of readmission after coronary artery bypass graft (CABG) surgery. We analysed routinely collected data of CABG patients who have used the public hospital system of Victoria, Australia from July 1998 to June 2003. In total, 6,627 patients were selected by linking records of elective surgery waiting time data (Elective Surgery Information System), emergency department data (Victorian Emergency Minimum Dataset) and hospital discharge data (Victorian Admitted Episodes Dataset). The outcome measures were 7-day, 30-day and 6-month readmissions. Possible predictors included were age, gender, Charlson comorbidity index, waiting times, length of stay in the hospital, and frequency of emergency department (ED) visits before CABG surgery. 7.1%, 15.2%, and 32.3% of the study population were readmitted at 7 days, 30 days and 6 months respectively. In a multivariable regression model Charlson comorbidity index was associated with 30-day (OR = 1.18; 95% CI 1.11-1.24; P < 0.01) and 6-month readmission (OR = 1.20; 95% CI 1.15-1.26; P < 0.01). Multiple ED visits were associated with 7 day (OR = 1.75; 95% CI 1.28-2.38; P < 0.01), 30 day (OR = 1.53; 95% CI 1.22-1.93; P < 0.01) and 6 month (OR = 1.80; 95% CI 1.49-2.18; P < 0.01) readmission. Waiting time was not a statistically significant predictor of readmission.

The Effect of Alcohol Consumption on Emergency Department Services Use Among Injured Patients: A Cross-National Emergency Room Study

Although injured patients in the emergency department (ED) report more frequent use of the ED compared with the general population, and alcohol-related admissions and chronic alcohol misuse have been found to be predictive of future ED admissions, these data are based on only a few U.S. studies. The purpose of this article was to explore the association of alcohol use and ED services use among injured patients cross-nationally. Binary and multinomial logistic regression were used to analyze the association of alcohol consumption with prior ED visits among 9,743 injured patients surveyed in 37 EDs in 14 countries and reported in 23 studies from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and World Health Organization Collaborative Study of Alcohol and Injuries. Drinking within 6 hours before injury was associated with prior ED visits during the last 12 months (odds ratio = 1.25, p < .05), with a positive dose-response relationship. Heavy drinkers and those drinkers who were alcohol-dependent were also significantly more likely to report multiple prior ED visits, reflecting an elevated burden of services use. At the ED level, stigmatization of alcohol use was the only significant contextual variable that consistently predicted cross-ED variation in the relationship between drinking and ED use, in which the association was weaker in areas where alcohol use is less accepted. This study lends additional support to the potential effectiveness of screening for acute and chronic alcohol use among ED injured patients to reduce ED services use and associated costs.

Pediatric asthma revisits to the ED and the role of primary care physicians versus asthma specialists

Rationale Stressful and costly revisits to an emergency department (ED) for asthma exacerbation occur often. This study examines the frequency with which asthmatic children require multiple ED visits and explores the effect of age and specialty care on this phenomenon. Methods We conducted a systematic chart review of all pediatric patients treated for asthma in the ED of the AI duPont Hospital for Children between 1/1/00 to 3/1/03. Results There were 3565 ED encounters for asthma involving 2603 children. In 602/2603 (23%) there were multiple visits with 388/2603 (14.9%) having one revisit and 214/2603 (8.2%) >1 revisit; 83/2603 (3.2%) had revisits within 5 days of the first visit and 149/2603 (5.7%) within 30 days. Mean age increased significantly with number of revisits (p<0.05) possibly showing progression from transient wheezing to true bronchial asthma. Of the 602 patients with multiple visits to the ED, 199 (33%) were managed by an asthma specialist (12% by allergists and 21% by pulmonologists) and 403/602 (67%) were managed by a primary care physician. Conclusions We conclude that: 1. Repeat ED visits are commonplace for asthmatic children. 2. The number of revisits is a function of the age of the patient. 3. Almost 6% of patients had revisits in close proximity to initial contact which may reflect insufficient initial treatment or inadequate follow-up. 4. Consistent with earlier studies, asthma patients managed by specialists, particularly allergists, may fare better as judged by frequency of ED revisits.

The emergency department presentation of patients with active pulmonary tuberculosis.

To determine the clinical presentation of emergency department (ED) patients with active pulmonary tuberculosis (TB). This was a retrospective medical record review of adult patients, identified through infection control records, diagnosed as having active pulmonary TB by sputum culture over a 30-month period at an urban teaching hospital. The ED visits by these patients from one year before to one year after the initial positive sputum culture were categorized as contagious or noncontagious, using defined clinical and radiographic criteria. The medical records of patients with contagious visits to the ED were reviewed to determine chief complaint, presence of TB risk factors and symptoms, and physical examination and chest radiograph findings. During the study period, 44 patients with active pulmonary TB made 66 contagious ED visits. Multiple contagious ED visits were made by 12 patients (27%; 95% CI = 15% to 43%). Chief complaints were pulmonary 33% (95% CI = 22% to 46%), medical but nonpulmonary 41% (95% CI = 29% to 54%), infectious but nonpulmonary 14% (95% CI = 6% to 24%), and traumatic/orthopedic 12% (95% CI = 5% to 22%). At least one TB risk factor was identified in 57 (86%; 95% CI% = 76 to 94%) patient visits and at least one TB symptom in 51 (77%; 95% CI = 65% to 87%) patient visits. Cough was present during only 64% (95% CI = 51% to 75%) of the patient visits and hemoptysis during 8% (95% CI = 3% to 17%). Risk factors and symptoms that, if present, were likely to be detected at triage were foreign birth, homelessness, HIV positivity, hemoptysis, and chest pain. Patients with active pulmonary TB may have multiple ED visits, and often have nonpulmonary complaints. Tuberculosis risk factors and symptoms are usually present in these patients but often missed at ED triage. The diversity of clinical presentations among ED patients with pulmonary TB will likely make it difficult to develop and implement high-yield triage screening criteria.

The effect of continuity of care on emergency department use.

To examine whether continuity of care with an individual health care provider is associated with the number of hospital emergency department (ED) visits in a statewide Medicaid population. A cross-sectional study based on a 100% sample of Delaware Medicaid claims for 1 year (July 1, 1993, to June 30, 1994). Continuity with a single provider during the year was computed for each participant. The state of Delaware. Continuously enrolled Medicaid clients aged 0 to 64 years who had made at least 3 physician office visits during the study year (N = 11,474). None. Likelihood of making a single ED visit or multiple ED visits during the study year. In multivariate analysis, continuity is associated with a significantly lower likelihood of making a single ED visit (odds ratio, 0.82; 95% confidence interval, 0.70-0.95), and is even more strongly associated with a lower likelihood of making multiple ED visits (odds ratio, 0.65; 95% confidence interval, 0.56-0.76). This study demonstrates that high provider continuity is associated with lower ED use for the Medicaid population. This suggests that strategies to improve continuity of care may result in lower ED use and possibly reduced health care costs. Such strategies may be more acceptable than current managed care policies that attempt to control costs by denying access to emergency care.

An evaluation of the role of the ED in the management of migraine headaches

The objective of this study was to describe the characteristics and clinical course of patients who receive emergency department (ED) migraine treatment and their association with frequent ED visits. All migraine patient records during a 42-month period were reviewed retrospectively at an urban teaching hospital ED. One hundred eighty-five migraine patients had 339 total visits; 133 had a single visit; 31 had two visits; and 21 patients had three or more ED visits (range, 3 to 26 visits). Patients with three or more visits accounted for 42.5% of all ED migraine visits. Drugs were administered in 82.3%, and efficacy was documented in 49% of ED visits. Complete or considerable relief was noted in 64.5% of visits. Drug abuse was infrequently identified in migraine patients. Most migraine patients seem to use the ED appropriately. A small group (11.4%) of patients accounted for 42.5% of all ED visits. Given the nature of severe, frequent migraines and the current lack of consistently effective therapy, this may be a common ED phenomenon. More effective management strategies and therapy that will enable patients to reduce their dependence on the ED for treatment would be useful for patients with multiple ED visits.

Malaria in an urban emergency department: Epidemiology and diagnostic features of 25 cases

This article presents a retrospective study of 25 patients diagnosed with malaria in an urban emergency department (ED) between June 1986 and June 1989. The mean annual case rate of malaria in this study group was more than three times the national rate. This may be ascribed to the notable ethnic diversity of the population. A history of travel to an area endemic for malaria was eventually elicited from all patients. The most common chief complaint was fever (56%) followed by abdominal pain (12%). Temperatures were elevated in 70% of the patients, with a mean temperature of 102.9°F (39°C). Gender was found to play a role in delaying diagnosis, with women accounting for 83% of a group of patients requiring multiple ED visits before diagnosis. The authors conclude that malaria must be considered when diagnosing patients in ethnically diverse populations. Gender may be associated with a delay in diagnosis. A careful travel history and a peripheral smear are aids in rapid diagnosis.