National Hospital Ambulatory Medical Care Survey Research Articles

The Burden of Burns: An Analysis of Public Health Measures.

Accurate analysis of injuries is paramount when allocating resources for prevention, research, education, and legislation. As burn mortality has improved over recent decades, the societal burden of burn injuries has grown ambiguous to the public while a scarcity of investigational funding for survivors has led to a gap in understanding lifelong sequela. We aim to compare national references reporting the incidence of burn injuries in the United States. The American Burn Association Burn Injury Summary Report (ABA-BISR), American Burn Association Fact Sheet, Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting (WISQARS) database, the CDC National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey (NHAMCS), National Inpatient Sample (NIS), National Emergency Department Sample (NEDS), and commercially available claims databases were queried for 2020 or the most recent data available. The BISR estimated 30,135 burn admissions in 2022. The 2016 ABA Fact Sheet reported 486,000 burns presented to US emergency departments (ED). In 2020, CDC's WISQARS database reported 3,529 fatal, and 287,926 non-fatal, burn injuries. The 2020 NEDS reported 438,185 ED visits while the 2020 NIS estimated 103,235 inpatients. The NHAMCS reported 359,000 ED visits for burn injuries in the same period, and an analysis of ICD-10 burn codes demonstrated over 698,555 claims. Our study demonstrates a large variability in the reported incidence of burn injury by the ABA, CDC, national samples, and claims databases. Per our analyses, we estimate that 600,000 individuals annually suffer a burn injury which merits emergent care in the United States.

Emergency department resource utilization among nursing home residents, a National Cross-Sectional Study

ObjectivesPersons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs. MethodsOlder persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs. ResultsFrom 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5–82.9] vs 76.1 [95%CI 75.8–76.4]), underwent more imaging (82.8% [95%CI 79.5–86.1] vs 71.6% [95%CI 69.9–73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2–2.7] vs 17.1% [95%CI 15.8–18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95% CI 38.2–49.9] vs 26.0% [95%CI 23.3, 28.7]). ConclusionsOlder NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population.

Abstract 14494: National Trends in Emergency Department Discharges for Acute Pulmonary Embolism, 2006-2015

Introduction: Outpatient management for selected low-risk patients with acute pulmonary embolism (PE) has emerged as a safe and feasible approach that is currently supported by clinical practice guidelines. However, recent evidence suggests that many patients are still managed with hospital admission. Few studies have assessed recent real-world, national trends in discharge rates for acute PE from the emergency department (ED). Methods: We conducted an observational study leveraging data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between the years 2006-2020. NHAMCS is a nationally representative probability sample which reflects ED visits within the US. All patients with a primary diagnosis of acute PE were included. Subgroup analysis was performed on patients who were hemodynamically stable (heart rate<110 and systolic blood pressure>100) and those with a PESI risk class I or II. Results: Between 2006-2020, there were an estimated 2,519,606 ED visits for acute PE. Among the whole cohort, the mean age was 58.2 (SE: 1.53) and 59.1% were female. Overall, 22.1% of patients with acute PE were discharged from the ED, which increased from 7.8% between 2006-2008 to 32.1% between 2018-2020. A total of 67.9% of patients were hospitalized, which decreased from 83.7% between 2006-2008 to 61.9% between 2018-2020. When stratified by hemodynamic stability or low PESI risk class, similar trends were observed (Figure). Since 2012, 33.0% of patients with PESI class I or II were discharged and 57.8% were hospitalized. Conclusion: In a representative nationwide sample, rates of discharge from the ED for acute PE have increased over the past fifteen years with the largest increase occurring between 2009-2014. However, since 2012, only one-third of low-risk patients presenting to the ED were discharged for outpatient management and rates appear to have stabilized. We speculate that outpatient management for low-risk acute PE is still underutilized in the US.

Age Distribution of Epistaxis in Outpatient Pediatric Patients.

Objectives: Little is known about the prevalence of epistaxis in children. Existing reports focus on hospitalized children or those presenting to an emergency department. To better understand pediatric epistaxis in clinical practice, we sought out a searchable, representative outpatient database and examined the incidence of epistaxis in children of different ages. Methods: A cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the years 2007 to 2011 was performed. The NHAMCS is a Centers for Disease Control and Prevention-curated national sample of data from visits to non-federally employed office-based physicians and health centers. We queried the NHAMCS to determine the cumulative incidence of epistaxis in children of different age groups. The International Classification of Diseases Ninth Revision code 784.7 was chosen to identify epistaxis. Comparisons of rates were performed using the chi-squared test. A P-value of <.05 was considered statistically significant. Results: In total, 55,435,691 children [27,816,237 (50.2%) males, 55,435,691 (77.2%) white] were included. The overall cumulative incidence rate of epistaxis was 2.4/1000 children. Children in the 3- to 5-year range had the highest cumulative incidence of epistaxis (5.0/1000), followed by those in the 6 to 8 (3.0/1000), 9 to 11 (2.0/1000), 0 to 2 (1.9/1000), 12 to 14 (1.6/1000), and 15 to 17 (0.5/1000) year ranges (P < .001). Conclusion: Pediatric epistaxis is common in the office setting (2.4 per 1000 children)-and well above emergency department estimates (1.7 per 1000 people). Children between the ages of 3 to 5 years have the highest cumulative incidence. Epistaxis is sufficiently unusual in infants and the late teens that alternative causes for nasal bleeding should be included in the differential diagnosis.

Estimates of HIV testing at visits to United States emergency departments.

Emergency department-based HIV testing rates are historically low, but recent testing trends surrounding the COVID-19 pandemic and launch of the Ending the HIV Epidemic (EHE) initiative are unknown. The objective of the study is to estimate recent trends in the proportion of emergency department visits that included HIV testing. We performed a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a weighted nationally representative survey of US emergency departments, from 2014 to 2020. Given EHE's focus on several rural Southern jurisdictions as well as populations disproportionately affected by HIV, we stratified by characteristics including US region and visit-listed race and ethnicity. The proportion of emergency department visits that included HIV testing increased from 2014 (0.6%) to 2018 (1.1%) but was lower in 2019 and 2020 (0.8%). Compared with other regions, the South had the lowest rates of testing in both 2019 (0.6%) and 2020 (0.5%); testing rates in the nonmetropolitan South remained 0.1% or less across all years. Testing rates for emergency department visits by persons who identified as Hispanic/Latino were highest in 2018 (2.2%) but were sharply lower in 2019 and 2020 (0.8%). After a small but insufficient increase in emergency department-based HIV testing since 2014, rates decreased between 2018 and 2019 and were stable between 2019 and 2020. Overall, very few emergency department visits during our entire study period included an HIV test, and there were persistently low rates of HIV testing for populations prioritized in national efforts and during visits in rural jurisdictions in the South.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018.

The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs). Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval. There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P=0.03). The overall trend showed a significant decrease in the mean WT (P value<0.001). In 2009, AA waited 69 minutes longer than NHW (P value<0.001), while in 2018, this gap was erased with no statistically significant difference (P value=0.26). Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

An analysis of racial inequities in emergency department triage among patients with stroke-like symptoms in the United States

BackgroundRacial inequities exist in treatment and outcomes in patients with acute stroke.ObjectivesOur objective was to determine if racial inequities exist in the time-lapse between patient presentation and provider assessment in patients with stroke-like symptoms in Emergency Departments (ED) across the U.S.MethodsThis study is a retrospective, observational study of the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2014–2018. We identified visits with stroke-like symptoms and stratified the proportion of door-to-provider (DTP) times by racial groups. We used broad and narrow definitions of stroke-like symptoms. We performed bivariate and multivariate analyses using race and clinical and demographic characteristics as covariates.ResultsBetween 2014–2018, there were an average of 138.58 million annual ED visits. Of the total ED visits, 0.36% to 7.39% of the ED visits presented with stroke-like symptoms, and the average DTP time ranged from 39 to 49 min. The proportion of the visits with a triage level of 1 (immediate) or 2 (emergent) ranged from 16.03% to 23.27% for stroke-like symptoms. We did not find statistically significant racial inequities in DTP or ED triage level. We found significantly longer DTP times in non-Hispanic blacks (15.88 min, 95% CI: 4.29–27.48) and Hispanics (by 14.77 min, 95% CI: 3.37–26.16) than non-Hispanic whites that presented with atypical stroke-like symptoms. We observed that non-Hispanic whites were significantly more diagnosed with a stroke/TIA than other racial minority groups (p = 0.045) for atypical stroke-like symptoms.ConclusionIn our population-based analysis, we did not identify systemic racial inequities in the DTP times or ED triage level at ED triage for stroke-like symptoms.

Emergency department course of patients with asthma receiving initial emergency medical services care-Perspectives From the National Hospital Ambulatory Medical Care Survey.

Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Of 435million adult ED visits during 2016-2019, there were ≈5.3million related to asthma (1.3million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of β-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients. Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.

Acute exacerbation of chronic obstructive pulmonary disease in United States emergency departments, 2010–2018

ObjectivesLittle is known about the recent status of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the U.S. emergency department (ED). This study aimed to describe the disease burden (visit and hospitalization rate) of AECOPD in the ED and to investigate factors associated with the disease burden of AECOPD.MethodsData were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010–2018. Adult ED visits (aged 40 years or above) with AECOPD were identified using International Classification of Diseases codes. Analysis used descriptive statistics and multivariable logistic regression accounting for NHAMCS’s complex survey design.ResultsThere were 1,366 adult AECOPD ED visits in the unweighted sample. Over the 9-year study period, there were an estimated 7,508,000 ED visits for AECOPD, and the proportion of AECOPD visits in the entire ED population remained stable at approximately 14 per 1,000 visits. The mean age of these AECOPD visits was 66 years, and 42% were men. Medicare or Medicaid insurance, presentation in non-summer seasons, the Midwest and South regions (vs. Northeast), and arrival by ambulance were independently associated with a higher visit rate of AECOPD, whereas non-Hispanic black or Hispanic race/ethnicity (vs. non-Hispanic white) was associated with a lower visit rate of AECOPD. The proportion of AECOPD visits that were hospitalized decreased from 51% to 2010 to 31% in 2018 (p = 0.002). Arrival by ambulance was independently associated with a higher hospitalization rate, whereas the South and West regions (vs. Northeast) were independently associated with a lower hospitalization rate. The use of antibiotics appeared to be stable over time, but the use of systemic corticosteroids appeared to increase with near statistical significance (p = 0.07).ConclusionsThe number of ED visits for AECOPD remained high; however, hospitalizations for AECOPD appeared to decrease over time. Some patients were disproportionately affected by AECOPD, and certain patient and ED factors were associated with hospitalizations. The reasons for decreased ED admissions for AECOPD deserve further investigation.

Pulmonary embolism in United States emergency departments, 2010–2018

Little is known about pulmonary embolism (PE) in the United States emergency department (ED). This study aimed to describe the disease burden (visit rate and hospitalization) of PE in the ED and to investigate factors associated with its burden. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2018. Adult ED visits with PE were identified using the International Classification of Diseases codes. Analyses used descriptive statistics and multivariable logistic regression accounting for the NHAMCS’s complex survey design. Over the 9-year study period, there were an estimated 1,500,000 ED visits for PE, and the proportion of PE visits in the entire ED population increased from 0.1% in 2010–2012 to 0.2% in 2017–2018 (P for trend = 0.002). The mean age was 57 years, and 40% were men. Older age, obesity, history of cancer, and history of venous thromboembolism were independently associated with a higher proportion of PE, whereas the Midwest region was associated with a lower proportion of PE. The utilization of chest computed tomography (CT) scan appeared stable, which was performed in approximately 43% of the visits. About 66% of PE visits were hospitalized, and the trend remained stable. Male sex, arrival during the morning shift, and higher triage levels were independently associated with a higher hospitalization rate, whereas the fall and winter months were independently associated with a lower hospitalization rate. Approximately 8.8% of PE patients were discharged with direct-acting oral anticoagulants. The ED visits for PE continued to increase despite the stable trend in CT use, suggesting a combination of prevalent and incident PE cases in the ED. Hospitalization for PE remains common practice. Some patients are disproportionately affected by PE, and certain patient and hospital factors are associated with hospitalization decisions.

Assessment of National Trauma Trends for Motor Vehicle Accidents

Background: The aim of this study was to determine if emergency department (ED) visits due to motor vehicle accidents (MVA) are affected by patient demographics, national holidays, and days of the week. Methodology: This was a retrospective, secondary database analysis research exploring the motor vehicle accident patterns in 2018 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), which is a secondary database of the utilization of ambulatory care services in hospital EDs. The incidence of ED visits due to MVA were assessed as it relates to various patient demographics, which included age, sex, race, in addition to geographic region, national holidays, and days of the week. Results: The study found that the incidence of MVA varies significantly by the time of the year, the days of the week, patient characteristics, and various holidays. Christmas (31.8%), Fridays (30.5%), Sundays (24.8%), Northeast region (36.2%), and the White population (48.9%) had the greatest number of MVA versus their comparable demographics. Males were affected in the majority of the cases (52.2%). One-third (34%) of the MVA were fatal. Conclusions: Strict enforcement of roadside checks for impairment and speeding must be enforced during the periods and days of the week as identified in this study. MVA can be reduced by law enforcement during holidays that have high-risk of crashes. High-risk groups identified in this study should be encouraged to take defensive driving training. There should be more signs, lighting and enforcement during bad weather to enforce road safety. Adherence to driving rules, and promoting awareness amongst the vulnerable groups would reduce the MVA significantly resulting in reduced morbidity, mortality, and societal cost.

A national analysis of ED presentations for early pregnancy and complications: Implications for post-Roe America

BackgroundMost obstetric emergencies are initially managed in the emergency department (ED). The Supreme Court decision of Dobbs v. Jackson Women's Health Organization, overturning Roe v. Wade, in June 2022, eliminated constitutional protection of abortion rights, allowing states to swiftly enact laws that can greatly change reproductive medicine. In this post-Roe landscape, the ambiguity and uncertainty being imposed on clinicians regarding the legality of certain interventions may have catastrophic effects. To understand and plan for the changes that will come and attempt to mitigate adverse outcomes, the authors first assessed the current state of pregnancy-related complication care in the ED setting. This study utilized data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to evaluate trends in pregnancy-related ED visits from 2016 to 2020 that could be impacted by restricted abortion access and trigger laws. The authors subsequently analyzed the legislative changes and translated the pertinent ones to dispel misunderstandings and provide a framework for appropriate medical practice. MethodsThe retrospective study utilized data from the NHAMCS database from 2016 to 2020, encompassing an estimated total of 4,556,778 pregnancy-related ED visits. NHAMCS is a multi-stage probabilistic sample collected by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention (CDC) using an annual survey of EDs in the United States. All data were summarized using descriptive statistics such as proportions and 95% confidence intervals Furthermore, the supreme court decision was analyzed in addition to multiple state laws and legal texts. The findings were summarized and discussed. ResultsThe majority (79.4%) of all studied visits were for patients between the ages of 18–34 years, capturing those in peak reproductive years. This age group also comprised of the bulk (76.4%) of visits for pathologic pregnancies, including ectopic and molar pregnancies, and 79.8% of visits for a spontaneous miscarriage or threatened miscarriage in early pregnancy. Black patients accounted for 25.7%, white patients 70.1%. Regarding ethnicity, patients were separated into Hispanic and non-Hispanic, with Hispanic patients comprising 27% of all ED visits for included diagnoses between 2016 and 2020. Most visits for complications following an induced abortion occurred in the south (70.8%) and were nearly twice as likely to occur in non-metropolitan areas. Approximately 18% patients presenting with a pathologic pregnancy required admission to the hospital and approximately 50% of those visits for pathologic pregnancies and visits for bleeding in pregnancy had a procedure in the ED (49.8% and 49.5%). There were 111,264 estimated visits in which methotrexate was administered, amounting to approximately 1 in 7 visits for ectopic or molar pregnancy. In this data set, approximately 14,000 miscarriage and early bleeding patients received misoprostol. ConclusionPregnancy-related ED visits comprise of a significant proportion of emergency care. As it relates to many of the trends previously elucidated on, the true extent of the burden cannot be predicted. It must be emphasized that contrary to popular belief, Dobbs v. Jackson does not prohibit termination of pregnancy in the setting of life-threatening conditions to the mother, including ectopic pregnancy, preeclampsia, and others, but the resultant uncertainty and ambiguity surrounding the constitutional change is leading to an over-compliance of the law, necessarily obstructing reproductive health care. The authors recommend that physicians be mindful of the rapidly-evolving laws in their particular state, and to also practice in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA). Patient safety must be prioritized.

DEVELOPMENT OF A MACHINE-LEARNING ALGORITHM FOR PREDICTING THE ARRIVAL TIME AND ASSESSING FACTORS INFLUENCING PATIENT ARRIVAL AT HOSPITAL EMERGENCY DEPARTMENT – PRELIMINARY STUDY

Abstract: Healthcare is one of the most important topics affecting society. Emergency Departments (ED) play an important role in the patient treatment cycle, providing immediate and primary health care as well as access to services offered by hospitals. From a hospital's perspective, it is crucial that emergency departments are well organized in each hospital sector. One of the most important yet overlooked problems in the medical industry is emergency department congestion. An attempt was made to estimate and predict, using predictive models and machine learning algorithm techniques, the impact of factors on the arrival time of patients at hospital emergency department and to verify the effectiveness of teaching the models, along with a comparison which one is the best in predicting the phenomena. Research materials were source data from the 2018 National Hospital Ambulatory Medical Care Survey (NHAMCS) – Emergency Department. In this paper, a study was conducted to search for factors that could affect the frequent arrival of patients at emergency departments. A tool for predicting the expected arrival time, taking into account the current arduous conditions/factors in the ED, has the potential to improve situational awareness and contribute to mitigating problems related to congestion. It appears that the model can be used to enhance decision support systems by determining patient arrival times. The results obtained in the random forest regression algorithm are estimated at R2 of 86% and RMSE of 5.45. For research purposes, when attempting to analyze on a sample and reliable hospital department database, the random forest regressor method identified the most relevant factors such as initial vital signs. The results obtained allow for a broader view in the context of assessing the prevailing situation in the emergency department. In this case – examining the most relevant factors influencing patient arrival times. With the results of high effectiveness, an algorithm can be designed to assist emergency departments in proper monitoring of existing problems.

Guest Editorial: Nurse Practitioners in Emergency Care: The Evidence.

The central tenet of any professional field of study is its well-established body of research, its ethics, and general public benefit. The role of the nurse practitioner (NP) in emergency care is supported by consistent research that underscores the excellent care quality provided by these professionals. Decades of scholarly literature attests to the safety, efficacy, patient-centricity, efficiency, equity, and evidence-based nature of NPs working in emergency care, with several studies showing that the outcomes achieved by NPs are similar to those achieved by their physician counterparts. It is clear that NPs provide comprehensive emergency care that is not only safe and effective but also patient-centered, timely, and based on the latest evidence-based practices. The evidence for nurse practitioners in emergency care may be found among several exemplars of empirical and peer-reviewed works as outlined in the following text, organized as an annotated bibliography: Carter, A., & Chochinov, A. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.Canadian Journal of Emergency Medicine, 9(4), 286–295. doi:10.1017/s1481803500015189 This comprehensive 36-article review evaluated the impact of NPs in the emergency department (ED) on wait times, patient satisfaction, and delivery of cost-effective, high-quality care. Hiring and utilizing NPs were associated with shorter waiting times, leading to greater patient satisfaction. Carter and Chochinov found that NPs possess an equal level of expertise to physicians in interpreting radiographs but proved to be more proficient at patient follow-up, conducting physical assessments, and making appropriate referrals. Fowler, L. H., Landry, J., & Nunn, M. F. (2019). Nurse practitioners improving emergency department quality and patient outcomes.Critical Care Nursing Clinics of North America, 31(2), 237–247. doi:10.1016/j.cnc.2019.02.010 The authors performed a literature search using the EBSCOhost and CINAHL databases with key words related to ED NP outcomes. Six hundred nineteen articles met the inclusion criteria, eight of which were selected for content review, including four systematic reviews, one randomized controlled trial, one qualitative study, one descriptive study, and one longitudinal cohort study. This analysis revealed that NPs provided enhanced patient satisfaction, reduced wait times, provided care similar to physicians, spent more face-to-face time with each patient, adhered to evidence-based guidelines, and collaborated effectively as a team. Jennings, N., Gardner, G., O'Reilly, G., & Mitra, B. (2015). Evaluating emergency nurse practitioner service effectiveness on achieving timely analgesia: A pragmatic randomized controlled trial.Academic Emergency Medicine, 22(6), 676–684. doi:10.1111/acem.12687 “A randomized controlled trial was conducted” to investigate the efficacy of NP-led emergency care as opposed to the standard medical care provided in the ED of a major referral hospital. “Patients presenting with pain were randomly assigned to receive either standard ED care or NP care.” The NP service proved far more effective in quickly providing analgesia to ED patients. Mafi, J. N., Chen, A., Guo, R., Choi, K., Smulowitz, P., Tseng, C. H., ... & Landon, B. E. (2022). US emergency care patterns among nurse practitioners and physician assistants compared with physicians: A cross-sectional analysis.BMJ Open, 12(4), e055138. doi:10.1136/bmjopen-2021-055138 Using 8 “years of data from the National Hospital Ambulatory Medical Care Survey,” a retrospective cohort study of adult patients compared three provider groups: NP/PA (physician assistant) alone, NP/PA with physician, and physician alone. After adjusting the data to account for observable patient characteristics, this study found the NP/PA-only group used fewer medications, diagnostic tests, procedures, hospitalizations, and low-value CT/MRI studies than physicians. Roche, T. E., Gardner, G., & Jack, L. (2017). The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: A multisite prospective longitudinal nested cohort study.BMC Health Services Research, 17(1), 445. doi:10.1186/s12913-017-2395-9 This study recruited 61 adult patients with chest pain, with a nested cohort of 41 participants suspected or confirmed to have an acute coronary syndrome. Outcomes included adherence to guidelines, diagnostic accuracy, service indicators, “satisfaction with care, quality of life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.” The emergency nurse practitioner service model demonstrated high adherence to clinical guidelines and diagnostic accuracy and was as effective as the standard care model in evaluating service indicators and patient-reported outcomes. Woo, B. F. Y., Lee, J. X. Y., & Tam, W. W. S. (2017). The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review.Human Resources for Health, 15(1), 63. doi:10.1186/s12960-017-0237-9 This review was composed of randomized controlled trials, “quasi-experimental studies, prospective and retrospective cohort studies,” and excluded “cross-sectional studies” and those “without comparison groups.” This investigation incorporated 15 studies, covering 23,681 participants “from five countries—Australia, Canada, New Zealand, the United Kingdom, and the United States.” Based on the narrative synthesis of the accessible data, NPs demonstrate “outcomes comparable to those of physicians in emergency settings,” indicating that the implementation of NPs in emergency care settings may result in improved patient outcomes. Wu, F., & Darracq, M. A. (2021). Comparing physician assistant and nurse practitioner practice in U.S. emergency departments, 2010-2017.The Western Journal of Emergency Medicine, 22(5), 1150–1155. doi:10.5811/westjem.2021.5.51988 This study examined the comparison between PA and NP practice in EDs in the United States, utilizing the data collected from ED visits reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). From 2010 to 2017, there has been a considerable rise in the number of visits attended to by PAs and NPs in the US EDs. Although emergency medicine has traditionally been a specialty of PAs, NPs have grown over the last few years. This increase is highlighted by the “greater than twofold increase in the number of visits” conducted by NPs during the same period. These visits bear a striking resemblance in many ways, “such as patient age, gender, insurance status, arrival by ambulance, diagnostic screening, procedures performed, imaging ordered, admission rate, and ED length of stay.” CONCLUSION Although clinical research and evidence are used daily by medical professionals to make informed decisions, the repercussions of poorly informed or executed studies can be far-reaching and dangerous. Violations of scientific integrity and publication ethics are especially problematic when results not only negatively impact the practice of advanced practice nurses but also carry the potential to remove patient access to quality care in areas where it is most needed. The practice environment and care provided by NPs in emergency care are unique. There is significant variation among practice standards, training, and clinical expertise between NPs in emergency care and those caring for different patient populations. Furthermore, the specialty of emergency medicine and the role of the NP in emergency care are rapidly evolving. Therefore, scientific inquiry into the discipline should be led by those with current expertise in the field. Although understanding emergency nurse practitioner (ENP) practice and how it affects health outcomes requires a broad range of content and methods experts, ENPs are uniquely positioned to lead research that is relevant to their complex practice settings. As clinicians educated in graduate-level research and scholarly methods, we must promote a critical approach to evidence appraisal. For educators, researchers and NPs in clinical emergency care, additional studies demonstrating NP outcomes are needed. Just as nurses have done for centuries, our ability to offer and implement evidence-based solutions in care delivery may well be what keeps our health care system intact. —Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP, FAEN Family and Emergency Nurse Practitioner Program Coordinator and Assistant Professor, College of Nursing University of South Alabama Mobile, Alabama —Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP, FAAN Emergency Nurse Practitioner Program Director and Professor Vanderbilt University College of Nursing Nashville, Tennessee

Racial and Ethnic Differences in Emergency Department Wait Times for Patients with Substance Use Disorder

BackgroundSubstance use-related morbidity and mortality rates are at an all-time high in the United States, yet there remains significant stigma and discrimination in emergency medicine about patients with this condition. ObjectivesThe purpose of this study was to determine whether there are racial and ethnic differences in emergency department (ED) wait times among patients with substance use disorder. MethodsThe study uses pooled data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2018. The dependent variable is length of time the patient with a diagnosis of substance use disorder waited in the ED before being admitted for care. The independent variable is patient race and ethnicity. Adjusted analyses were conducted using a generalized linear model. ResultsThere were a total of 3995 reported ED events among patients reporting a substance use disorder in the NHAMCS sample between 2016 and 2018. After adjusting for covariates, Black patients with substance use disorder were significantly more likely to wait longer in the ED (35% longer) than White patients with substance use disorder (p < 0.01). ConclusionsThe findings showed that Black patients with substance use disorder are waiting 35% longer, on average, than White patients with the same condition. This is concerning, given that emergency medicine is a critical frontline of care, and often the only source of care, for these patients. Furthermore, longer wait times can increase the likelihood of leaving the ED without being seen. Programs and policies should address potential stigma and discrimination among providers, and EDs should consider adding people with lived experiences to the staff to serve as peer recovery specialists and bridge the gap for care.

Cyclobenzaprine utilization for musculoskeletal back pain: Analysis of 2007–2019 National Hospital Ambulatory Medical Care Survey Data

BackgroundWith musculoskeletal back pain being one of the most common presentations in the emergency department, evidence-based management strategies are needed to address such complaints. Along with other medications, cyclobenzaprine is a muscle relaxant commonly prescribed for patients complaining of musculoskeletal pain, in particular, pain associated with muscle spasms. However, with recent literature questioning its efficacy, the role of cyclobenzaprine use in patients with musculoskeletal back pain remains unclear. ObjectivesThe objective of the study is to investigate trends of cyclobenzaprine utilization among patients presenting to the emergency department (ED) in the United States. MethodsThis is a retrospective cohort review of data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2007 and 2019. We analyzed ED visits of patients 18 years and older. Visits during which cyclobenzaprine was administered in the ED or prescribed at discharge were identified. Trends were described using a time series analysis of patients' visits who received administration and prescriptions of cyclobenzaprine. ResultsBetween 2007 and 2019, we identified an estimated 1.35 billion ED visits, 57.2% (772.6 million) were female. From that sample, 2.4% (32.7 million) of all visits received cyclobenzaprine prescription in the ED only, and 0.5% (6.6 million) of total visits were both given the drug in the ED and were prescribed the drug at discharge). Overall trend analysis shows a slight decrease in annual percentages of cyclobenzaprine administration and prescriptions during the study period. Visits of certain subgroups: 26–44 years, white showed relatively higher percentages of administration and prescription of cyclobenzaprine. ConclusionsAlthough there was a slight decrease, our study still shows significant cyclobenzaprine utilization in the ED, despite conflicting evidence demonstrating efficacy for patients with musculoskeletal complaints and the concern for adverse effects. Additional studies are needed to examine its overall effectiveness and risk-benefit analysis in treating patients with such conditions.

Trends in amphetamine prescriptions given at discharge in emergency departments: A national analysis (2012–2019)

ObjectivesIn parallel with the opioid epidemic, there has been a resurgence in abuse, medical complications, and deaths related to amphetamines. The opioid epidemic began with increasing rates of prescription products that evolved overtime to include heroin and more recently, fentanyl analogues. Current trends in amphetamine prescriptions are less well described. We sought to determine if there has been a change in amphetamine prescriptions given at discharge in U.S. emergency departments (EDs) in recent years. MethodsWe conducted a retrospective review of data provided by the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2012 to 2019. We computed total number of visits that were given amphetamine prescriptions (amphetamine salts, methylphenidate derivatives, and dexmethylphenidate) at discharge for each year. We computed the total number and rate of visits (of all ED visits) that had both amphetamines and opioids prescribed at discharge over the years. We computed data normality using Shapiro Wilke's test and used descriptive statistics such as mean to describe the data distribution as applicable. We used spearman's rho (SR) or pearson's correlation (PC) as applicable to describe trends in data. All p-values were one-tailed and were reported at a 0.05 significance level. All analyses were conducted in IBM SPSS version 28. Results/findingsFrom 2012 to 2019, there were an estimated 817,895 ED visits where an amphetamine prescription was given at discharge, with an overall strong increase in rate over time (SR = 0.71, p = 0.02). At the beginning of the study period (2012) there were 83,503 (0.06%) visits and in 2019 there were 186,539 (0.12%) visits (123% absolute increase). On average, there were 102,237 (SD: 52,725) visits with discharge amphetamine prescriptions per year. There was a strong, linear increase in number of visits that involved a discharge amphetamine salt prescription (PC = 0.92, p = 0.001). In 2012, there were a total of 23,676 visits and in 2019, a total of 124,773 visits (427% increase). There was no trend in visits where both an amphetamine and opioid were prescribed (PC: 0.61, p = 0.06). ConclusionThere have been increases in discharge prescriptions for amphetamines in the ED over time. This was largely driven by prescriptions for amphetamine salts. Future research initiatives should continue to monitor this trend and in prescriptions and associated abuse in the setting of rising amphetamine abuse.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits.

Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

Online Self-Triage of Ear or Hearing Concerns in a Patient Portal: Comparison of Subsequent Diagnoses and Hospitalizations to National Emergency Department and National Ambulatory Ear or Hearing Visits.

Although online self-triage is easily accessible, little is known about the patients who use self-triage or their subsequent diagnoses. We compared ear/hearing self-triage subsequent diagnoses to ear/hearing visit diagnoses in emergency departments (ED) and ambulatory clinics across the United States. We compared International Classification of Diseases version 10 (ICD10) coded diagnoses following online self-triage for ear/hearing concerns with those from national ED and ambulatory clinic samples. We used data from the Centers for Disease Control (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) and National Ambulatory Medical Care Survey (NAMCS) for comparison. Using matched ear/hearing diagnostic categories for those aged 1 and over, we compared self-triage diagnosis frequencies with national ED and ambulatory diagnosis frequencies. Following ear/hearing self-triage, there were 1092 subsequent office visits with a primary diagnosis code. For five frequently diagnosed ear/hearing conditions (i.e., suppurative and nonsuppurative otitis media [OM], otalgia, otitis externa, and cerumen impaction), there was a strong correlation between diagnosis counts made following self-triage and estimated counts of national ED visit diagnoses (r = 0.94; CI 95% [0.37 to 0.99]; p = .016, adjusted r2 = 0.85). Seven diagnoses were available to compare with the national ambulatory sample; correlation was r = 0.79; CI 95% [0.08 to 0.97]; p = .037, adjusted r2 = 0.54. For ages 1 and over, estimated hospital admissions from the national ED visits for ear/hearing were 0.76%, CI 95% [0.28-2.1%]; estimated total national ear/hearing ED visits were 7.5 million (for 4 years, 2016 through 2019). The strong correlation of ear-related self-triage diagnoses with national ED diagnoses and the low hospitalization risk for these diagnoses suggests that there is an opportunity for self-triage of ear/hearing concerns to decrease ED visits for these symptoms.

Racial and insurance status disparities in imaging modality among pediatric patients diagnosed with appendicitis

BackgroundStudies have assessed the type of diagnostic imaging used in the treatment of appendicitis in children. Few studies investigated racial/ethnic and insurance disparities in imaging modalities used in pediatric patients diagnosed with appendicitis. Our study seeks to determine whether race/ethnicity and insurance status are associated with imaging modality chosen for pediatric patients diagnosed with appendicitis in the emergency department. MethodsThis was a retrospective cohort study utilizing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2019. We included children <18 years old with a ICD-9-CM and ICD-10-CM diagnosis of appendicitis. Exposures were patient race/ethnicity and insurance status. Outcome of interest was imaging modality. We conducted adjusted survey logistic regression to evaluate the patient characteristics and receipt each of the imaging modalities among those with a diagnosis of appendicitis. ResultsOf 308,140,115 emergency department (ED) visits, 1,126,865 (0.37%) had a diagnosis of appendicitis. Overall, male patients were more likely to receive CAT scan in comparison to female children (OR=2.52, 95% CI= 1.16–5.49). Additionally, Hispanic children who had significantly greater odds of obtaining ultrasound (OR= 4.56, 95% CI=1.09–19.12). Hispanic children were also less likely to receive x-ray (OR= 0.31, 95% CI=0.11–0.89) or computed tomography (CT) scans (OR= 0.23, 95% CI=0.07–0.76). Children diagnosed with appendicitis who had insurance other than private, Medicare, Medicaid, or self-pay were significantly more likely to receive x-ray studies (OR=4.39, 95% CI= 1.23–15.69). Conclusions and global health implicationsThis study demonstrated the presence of racial/ethnic and insurance status disparities in the imaging modality chosen to assist in diagnosing appendicitis in pediatric patients.