Proportion Of Emergency Department Research Articles

Estimating the size and scope of the academic emergency physician workforce.

Academic emergency medicine (EM) is foundational to the EM specialty through the development of new knowledge and clinical training of resident physicians. Despite recent increased attention to the future of the EM workforce, no evaluations have specifically characterized the U.S. academic EM workforce. We sought to estimate the national proportion of emergency physicians (EPs) identified as academic and the proportion of emergency department (ED) visits that take place at academic sites. We performed a cross-sectional analysis of EPs and EDs using data from the American Hospital Association, the Centers for Medicare & Medicaid Services, and Doximity's Residency Navigator. EPs were identified as "academic" if they were affiliated with at least one facility determined to be academic, defined as EDs officially designated by the Accreditation Council for Graduate Medical Education (ACGME) as clinical training sites at accredited EM residency programs. Our primary outcomes were to estimate the national proportion of EPs identified as academic and the proportion of ED visits performed at academic sites. Our analytic sample included 26,937 EPs practicing clinically across 4920 EDs and providing care during 130,471,386 ED visits. Among EPs, 11,720 (43.5%) were identified as academic, and among EDs, 635 (12.9%) were identified as academic sites, including 585 adult/general sites, 45 pediatric-specific sites, and 10 sites affiliated with the Department of Veterans Affairs. In 2021, academic EDs provided care for 42,794,106 ED visits or 32.8% of all ED visits nationally. Approximately four in 10 EPs practice in at least one clinical training site affiliated with an ACGME-accredited EM residency program, and approximately one in three ED visits nationally occur in these academic EDs. We encourage further work using alternative definitions of an academic EPs and EDs, along with longitudinal research to identify trends in the workforce's composition.

Pulmonary hypertension survival and hospitalisations in people living with HIV: a systematic review and meta-analysis

IntroductionPeople living with HIV (PLHIV) have a higher risk of developing pulmonary hypertension (PH) with subsequent poorer prognosis. This review aimed to determine the (1) survival outcomes and (2) proportion...

Pediatric Emergency Department Sepsis Screening Tool Accuracy During the COVID-19 Pandemic.

Automated sepsis alerts in pediatric emergency departments (EDs) can identify patients at risk for sepsis, allowing for earlier intervention with appropriate therapies. The impact of the COVID-19 pandemic on the performance of pediatric sepsis alerts is unknown. We performed a retrospective cohort study of 59 335 ED visits before the pandemic and 51 990 ED visits during the pandemic in an ED with an automated sepsis alert based on systemic inflammatory response syndrome criteria. The sensitivity, specificity, negative predictive value, and positive predictive value of the sepsis algorithm were compared between the prepandemic and pandemic phases and between COVID-19-negative and COVID-19-positive patients during the pandemic phase. The proportion of ED visits triggering a sepsis alert was 7.0% (n = 4180) before and 6.1% (n = 3199) during the pandemic. The number of sepsis alerts triggered per diagnosed case of hypotensive septic shock was 24 in both periods. There was no difference in the sensitivity (74.1% vs 72.5%), specificity (93.2% vs 94.0%), positive predictive value (4.1% vs 4.1%), or negative predictive value (99.9% vs 99.9%) of the sepsis alerts between these periods. The alerts had a lower sensitivity (60% vs 73.3%) and specificity (87.3% vs 94.2%) for COVID-19-positive versus COVID-19-negative patients. The sepsis alert algorithm evaluated in this study did not result in excess notifications and maintained adequate performance during the COVID-19 pandemic in the pediatric ED setting.

Abstract 10975: National Study of In-Hospital Cardiac Arrest in the Emergency Department, 2010-2018

Introduction: Little is known about in-hospital cardiac arrest (IHCA) in the U.S. emergency department (ED). This study aimed to describe the incidence and mortality of ED-based IHCA visits and to investigate factors associated with higher incidence and poor outcome of IHCA. Hypothesis: We hypothesized that ED-based IHCA contributes to a stable proportion of ED visits and remains a higher mortality rate after the event. Methods: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) during 2010 to 2018. Adult ED visits with IHCA were identified using the cardiopulmonary resuscitation code, excluding those with out-of-hospital cardiac arrest. Analysis used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design. Results: Over the 9-year study period, there was an estimated 1,114,000 ED visits with IHCA and the proportion of IHCA visits in the entire ED population (1.8 per 1,000 ED visits) appeared stable. The mean age of the IHCA visits was 60 years, and 65% were men. Older age, male sex, arrival by ambulance, and being uninsured independently predicted a higher incidence of ED-based IHCA. About 51% of ED-based IHCA died in the ED, and the trend remained stable. Arrival by ambulance, nighttime or weekend arrival, and being in the non-Northeast location were independently associated with a higher mortality rate after IHCA. Conclusions: The high burden of ED visits with IHCA persisted and the outcome remained poor. Some patients were disproportionately affected and certain contextual factors were associated with a poorer outcome.

New DAWN data shows rise of methamphetamine

For the first time since 2011, the field has seen Drug Abuse Warning Network (DAWN) data. It's not complete, the way it used to be when it was when it was fully funded, but it's something. The Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality released the first report and drug profiles from its reinstated Drug Abuse Warning Network. It abstracted data from 49 hospitals and shows, via unweighted data, trends in methamphetamine, marijuana, alcohol, heroin and nonmedical use of prescription opioids. “Among the 49 currently participating DAWN hospitals, the proportion of emergency department [ED] visits attributable to substance use, illicit or otherwise, was 4.6% during the period April 1, 2019 to October 15, 2020,” the report noted. “This proportion was somewhat higher, at 5.3%, in the DAWN hospitals in urban areas,” it continued, adding that “preliminary results also suggest that public health interventions may need to focus on methamphetamine since it appears to be the illicit substance most commonly associated with substance use‐related DAWN ED visits (16,446 of the 49,773 or 33.0% of ED visits involving illicit substances and/or alcohol).” Methamphetamine, whether by itself or as part of polysubstance use, prompted the most ED visits to a DAWN hospital, the results found. For the report, go to https://www.samhsa.gov/data/report/preliminary‐dawn‐data‐review.

Underutilization of the Emergency Department During the COVID-19 Pandemic.

IntroductionThe novel coronavirus 2019 (COVID-19) pandemic in the United States (US) prompted widespread containment measures such as shelter-in-place (SIP) orders. The goal of our study was to determine whether there was a significant change in overall volume and proportion of emergency department (ED) encounters since SIP measures began.MethodsThis was a retrospective, observational, cross-sectional study using billing data from January 1, 2017–April 20, 2020. We received data from 141 EDs across 16 states, encompassing a convenience sample of 26,223,438 ED encounters. We used a generalized least squares regression approach to ascertain changes for overall ED encounters, hospital admissions, and New York University ED visit algorithm categories.ResultsED encounters decreased significantly in the post-SIP period. Overall, there was a 39.6% decrease in ED encounters compared to expected volume in the pre-SIP period. Emergent encounters decreased by 35.8%, while non-emergent encounters decreased by 52.1%. Psychiatric encounters decreased by 30.2%. Encounters related to drugs and alcohol decreased the least, by 9.3% and 27.5%, respectively.ConclusionThere was a significant overall reduction in ED utilization in the post-SIP period. There was a greater reduction in lower acuity encounters than higher acuity encounters. Of all subtypes of ED encounters, substance abuse- and alcohol-related encounters reduced the least, and injury-related encounters reduced the most.

Access and Barriers to Take-Home Naloxone Use among Emergency Department Patients with Opioid Misuse in Baltimore, Maryland, USA

Background The opioid epidemic has prompted the expansion of take-home naloxone (THN) distribution programs. The proportion of emergency department (ED) patients with opioid misuse who have access to a naloxone kit (NK) and barriers to using it are unclear. Objective: Characterizing the access and barrier to NK use among at-risk ED patients. Methods: We enrolled a convenience sample of ED patients with active opioid misuse from May 21–July 31, 2018. We administered a survey to collect patients’ demographic data, substance use history, and access to and use of NK. The primary outcome was NK access (prior receipt of a kit or prescription); secondary outcomes were knowledge and use of NK, and barriers to obtaining and using it. Results: Of 165 respondents, 71.5% knew of THN programs and 57.6% (n = 95) had access to THN by either having received a NK (n = 90) or a prescription (n = 5); 34 respondents received both. Among 39 (23.6%) who received a naloxone prescription, 25 (64.1%) filled it. 60.0% (n = 99) reported knowing how to administer naloxone; lack of training was the primary reason (n = 63/66, 96.9%) for their unfamiliarity. Patients who presented after an opioid overdose (25.5%; n = 42) were less likely to have knowledge of THN programs (57.1% vs. 76.4%), and to have received a NK (35.7% vs. 61.0%). Conclusion: Awareness of THN programs was high among our cohort. But approximately 60% the respondents received a NK or knew how to use it. Despite efforts to expand THN access, gaps in knowledge, access, and use exist.

Emergency department utilization by people living with HIV released from jail in the US South

BackgroundIncarceration is disruptive to HIV care, often resulting in poor retention in care for people living with HIV (PLWH) after jail release. This gap in HIV care might result in potentially preventable emergency department (ED) utilization. We analyzed demographic, incarceration, socioeconomic and clinical data for PLWH released from the Dallas County Jail to the community (1450 incarcerations, 1155 unique individuals) between January 2011 and November 2013.ResultsThe study population consisted of predominantly men (77%), with a mean age of 39 years, 67% were black and 14% were Hispanic; half of the releasees visited the ED at least once during the first-year post-jail. In adjusted analyses, female gender, family awareness of HIV status, serious mental illness, and late engagement to HIV care were significantly associated with higher ED utilization. Compared to the general Dallas population, PLWH released from jail had a 5-fold higher proportion of ED visits classified as related to substance use or mental health.ConclusionsFurther efforts are needed to improve the transition from incarceration to community-based HIV care, substance use disorder treatment and mental health services, and to directly address re-engagement in HIV care for out-of-care PLWH who visit the ED.

289EMF Are State Telemedicine Parity Laws Associated With Greater Uptake of Telemedicine in the Emergency Department?

Telemedicine may improve access to specialists and clinical outcomes. In an effort to increase use of telemedicine, almost half of all states have passed telemedicine parity laws which require insurers to reimburse for telemedicine visits. Our objective was to determine if there is an association between such laws and use of telemedicine in the emergency department (ED). Building on prior research, we determined each states’ telemedicine policy environment as of January 2016. States were divided into those with any form of telemedicine parity law (conditional mandate, non-conditional mandate, or requirement for full parity in payment by private payers) and those without. As part of the 2016 National ED Inventory (NEDI)-USA survey, we surveyed the directors of all 5,381 EDs on the use of telemedicine with the question, “Does your ED receive telemedicine services for patient evaluation? Yes/No.” We assessed the association between a telemedicine parity law and use of telemedicine with a hierarchical logistic regression model controlling for a number of ED characteristics (annual total and pediatric visit volumes, academic status, freestanding ED, U.S. region, and rural/urban location); state was included as a random intercept. In 2016, among the 50 states and the District of Columbia (DC), 21 (41%) had a telemedicine parity law while 30 (59%) did not. Among the 4,419 respondents to the telemedicine question, (82% response rate), 2,125 (48%) used telemedicine. The proportion of EDs using telemedicine varied widely across the states and DC ranging from 13% in DC to 89% in Maine. In unadjusted analyses, there was no difference between the use of telemedicine in EDs in states with and without telemedicine parity laws (55% vs. 53%, p=0.17). After accounting for baseline ED characteristics, there was also no association between state policy environment and ED use of telemedicine, though telemedicine use did vary significantly by state (Table). Many states have adopted parity laws to encourage use of telemedicine. Surprisingly, we found no association between the presence of these laws and use of telemedicine in the ED. These results suggest that other factors are driving the wide variation in ED adoption of telemedicine across states.TableEmergency Department (ED) Characteristics Associated with Receipt of TelemedicineOdds Ratio95% Confidence IntervalAnnual ED volume(per 10,000patient increase)0.980.95-1.02Annual pediatric volume(reference: <3,000)Annual pediatric volume>3,0001.661.40-1.98Annual pediatric volume unknown1.461.18-1.81Academic0.360.25-0.53Freestanding ED0.480.38-0.61Region (Reference: Northeast)Region Midwest0.690.36-1.35Region South0.610.32-1.16Region West0.810.41-1.58Rural1.200.99-1.44Telemedicine parity law1.040.67-1.62Random intercept: state0.690.55-0.88 Open table in a new tab

US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation of the Affordable Care Act

The US Patient Protection and Affordable Care Act of 2010 (ACA) was enacted in 2010 with several provisions that targeted reducing numbers of uninsured Americans. To assess the numbers and proportion of emergency department (ED) visits (2006-2016) and hospital discharges (2006-2016) by uninsured patients, focusing on the 2014 ACA insurance reforms (Medicaid expansion, individual mandate, and private insurance exchanges). Cross-sectional study of visitors to US EDs and patients discharged from US hospitals using National Hospital Ambulatory Care Survey data and Healthcare Cost and Utilization Project data, respectively, from 2006 to 2016. Data analysis took place in February 2019. Numbers and proportions of total and uninsured ED visits and hospital discharges. Simple descriptive statistics and interrupted time-series analysis were used to assess changes in uninsured visits over time and after the implementation of insurance provisions in 2014. There were an estimated 1.4 billion US ED visits from 2006 to 2016 and 405 million hospital discharges from 2006 to 2016. Over the study period, ED visits increased by 2.3 million per year, while hospital discharges decreased from approximately 38 million per year prior to 2009 to approximately 36 million per year after, with no clear decrease after 2013. Proportions of uninsured ED visits were largely unchanged from 2006 (16%) until 2013 (14%) (-0.2 percentage point per year; 95% CI, -0.46 to -0.01 percentage point; P = .11) but then decreased by 2.1 percentage points per year from 2014 to 2016 (95% CI, -4.3 to -1.8 percentage points; P = .003), with uninsured visits composing 8% of the total in 2016. For patients aged 18 to 64 years, uninsured ED visits declined from approximately 20% from 2006 through 2013 to 11% in 2016 (3.1% decrease per year after 2013; 95% CI, -4.3 to -1.8 percentage points; P = .003). The proportion of hospital discharges by uninsured patients remained steady at approximately 6% from 2006 to 2013, then declined to 5% in 2014 and 4% in 2016. Similar changes were seen for patients aged 18 to 64 years, with a decrease in hospital discharges from 10% to 7% over the study period. Proportions of ED visits and hospital discharges by uninsured patients decreased considerably after the implementation of the 2014 ACA insurance provisions. Despite these changes, approximately 1 in 10 ED visits and 1 in 20 hospital discharges were made by uninsured individuals in 2014 to 2016. This suggests that continued attention is needed to address the lack of insurance in US hospital visits, particularly among people aged 18 to 64 years who have less access to government-sponsored insurance.

Can a continuous quality improvement program create culturally safe emergency departments for Aboriginal people in Australia? A multiple baseline study

BackgroundProviding culturally safe health care can contribute to improved health among Aboriginal people. However, little is known about how to make hospitals culturally safe for Aboriginal people. This study assessed the impact of an emergency department (ED)-based continuous quality improvement program on: the accuracy of recording of Aboriginal status in ED information systems; incomplete ED visits among Aboriginal patients; and the cultural appropriateness of ED systems and environments.MethodsBetween 2012 and 2014, the Aboriginal Identification in Hospitals Quality Improvement Program (AIHQIP) was implemented in eight EDs in NSW, Australia. A multiple baseline design and analysis of linked administrative data were used to assess program impact on the proportion of Aboriginal patients correctly identified as Aboriginal in ED information systems and incomplete ED visits in Aboriginal patients. Key informant interviews and document review were used to explore organisational changes.ResultsIn all EDs combined, the AIHQIP was not associated with a reduction in incomplete ED visits in Aboriginal people, nor did it influence the proportion of ED visits made by Aboriginal people that had an accurate recording of Aboriginal status. However, in two EDs it was associated with an increase in the trend of accurate recording of Aboriginality from baseline to the intervention period (odds ratio (OR) 1.31, p < 0.001 in ED 4 and OR 1.15, p = 0.020 in ED 5). In other words, the accuracy of recording of Aboriginality increased from 61.4 to 70% in ED 4 and from 72.6 to 73.9% in ED 5. If the program were not implemented, only a marginal increase would have occurred in ED 4 (from 61.4 to 64%) and, in ED 5, the accuracy of reporting would have decreased (from 72.6 to 71.1%). Organisational changes were achieved across EDs, including modifications to waiting areas and improved processes for identifying Aboriginal patients and managing incomplete visits.ConclusionsThe AIHQIP did not have an overall effect on the accuracy of recording of Aboriginal status or on levels of incomplete ED visits in Aboriginal patients. However, important organisational changes were achieved. Further research investigating the effectiveness of interventions to improve Aboriginal cultural safety is warranted.

Understanding the Impact of Chronic Pain in the Emergency Department: Prevalence and Characteristics of Patients Visiting the Emergency Department for Chronic Pain at an Urban Academic Health Sciences Centre

ABSTRACT Background Canadians make approximately 16 million visits to the emergency department (ED) each year. ED visits for non-urgent reasons contribute to suboptimal patient care and ineffective resource use. Aims To estimate the proportion of ED visits related to chronic pain at our institution. Methods. We conducted a retrospective review of 1000 randomly selected ED visits at TOH during the 2012–2013 fiscal year (April 1, 2012 to March 31, 2013). Visits for chronic pain were identified using pre-defined criteria. Demographic and medical data were extracted from medical charts. Results 104 visits during this time period were related to chronic pain (10.4%; 95% CI: 8.2–12.6). All visits were from unique patients (i.e., no patients contributed more than 1 visit). Patients were predominantly women (71%), with a mean age of 45.9 years. Seventy-eight percent of patients had a primary care provider. The most common location of pain included the abdomen (24%), the head or face (21%), and the low back (21%). Only 5% of patients had consultation with a pain medicine specialist while 78% were awaiting a consultation. More than 2/3 of patients (71%) reported using opioids for their pain. Conclusion Presenting to the ED for chronic pain was found to occur among a sample of ED visits reviewed. This can result in ineffective care for patients with chronic pain. Cost-effective solutions to improve clinical outcomes and reduce ED use for chronic pain may yield significant improvements in health outcomes of patients and benefits for the health care system.

Emergency department and inpatient clinical decision tools for the management of febrile young infants among tertiary paediatric centres across Canada.

With no nationally-endorsed guidelines and the emergence of newer diagnostic tools, there exists significant variation in the management of febrile infants <90 days. We sought to evaluate the prevalence and content of clinical decision tools (CDTs) for the emergency department (ED) and inpatient management of febrile young infants across Canada. We undertook a cross-sectional analysis of febrile young infant CDTs from ED and inpatient units at all 16 Canadian tertiary paediatric hospitals. Additional data were collected using an electronic survey of ED and inpatient representatives, characterizing their clinical settings and diagnostic test availability. Content of all existent CDTs was independently reviewed using list items determined a priori. The primary outcome was the proportion of EDs and inpatient units with CDTs. Information regarding CDTs was gathered from all 16 EDs and 16 inpatient units. CDTs were infrequently available (9/32, 28%), and were more common in the ED than inpatient setting (8/16 versus 1/16, P=0.02). Review of existing CDTs revealed inter-centre differences for inclusion ages, treatment regimens, lumbar puncture recommendations, diagnostic testing and normal laboratory values. Despite availability reported at nearly all centres, C-reactive protein and respiratory virus testing were recommended in 3/9 and 5/9 CDTs, respectively. Procalcitonin testing was available at only 2/16 (13%) centres, and not incorporated into any CDTs. CDTs for the management of febrile young infants are infrequently available among Canadian tertiary paediatric centres, and rarely incorporate newer diagnostic tests. Heterogeneity among existent CDTs highlights the need for evidence-based unified ED and inpatient national guidelines.

LO11: Improving patient access, care and transportation by paramedics (IMPACT): a novel curriculum toward redefining paramedic services in Ontario

Introduction: A proportion of Emergency Department (ED) visits may be treated in out-of-hospital settings. The objective of this curriculum was to expand paramedic competencies to safely risk stratify patients and divert low risk, low acuity patients from EDs with and without physician oversight. Methods: We followed Kerns 6-step Curriculum Development Framework . (a) We identified a problem, and (b) completed a needs assessment by retrospectively reviewing the clinical pathways of 3000 patients were cared for and transported by paramedics and received care at an EDs. We used this data to identify competencies (e.g., diagnostics, interventions, reasoning needs) and targeted patient types that would result in the most significant advancements to paramedic services. These were translated to (c) goals and objectives. Results: Our (d) educational strategies involved a 14-week intensive patient-type and case-based curriculum. (e) Implementation involved 3 days/wk of clinical rotations supplemented with 2 days/wk of a mixed curriculum (i.e., fixed instruction using blended didactic small and large group sessions; flexible/individualized curriculum based on identified needs; formative assessments; self and peer-directed learning; simulations). (f) Assessment involved knowledge and application tests, clinical placement and simulation assessments; case development, assignments, and OSCE. Evaluation outcomes included student performance scores across 7-dimensions, clinical placement and student feedback. Thirteen Advanced Care Paramedics from York Region Paramedic Services completed the program. Challenges included provincial stakeholder consensus, and formally addressing clinical suspicion in a protocol based field within a limited time frame. Conclusion: A curriculum for expanded paramedic practice to risk stratify and divert targeted low risk patients from EDs resulted in new paramedic competencies and scope of practice. It received high evaluations from clinical staff and students. Successful candidates will undergo a 1-year study for validation and safety.

Evaluation of the use of health care services for non-communicable disease and prevention by children and adolescents in south Italy

BackgroundThe objectives of this investigation are to evaluate the use of health care services for non-communicable disease and prevention by children and adolescents and to identify the factors linked to the use of health care services.MethodsThis cross-sectional survey was conducted between December 2014 and January 2015 among 1198 parents of students aged between 5 and 18 years attending 12 selected schools in the geographic area of Salerno and Naples, Italy, using a self-administered questionnarie.Results68.2% of parents stated that had visited their general practitioner (GP) or family pediatrician (FP) with their child in the last year. 66.2% of children had had at least one visit to a specialist and more than half (54.8%) had had preventive care visits in the last year. The use of preventive care visits within last year was significantly higher amongst female, among those who had visited their GP or FP and among those who had a parent with a college degree or higher. The proportion of emergency department visits and hospital admissions reported were 12.8% and 4.7% respectively.ConclusionThis results highlights the need of educational interventions for parents and adolescents in order to increase the utilization of preventive health services.

LO53: Resuscitation status documentation availability among emergency patients with advanced disease

Introduction: Patients with advanced malignant and non-malignant disease (advanced disease—AD) who do not want or benefit from aggressive resuscitation may unfortunately receive such treatments if unable to communicate in an emergency. Timely access to patients’ resuscitation wishes is imperative for treating physicians and for medical information systems. Our aim was to determine what proportion of emergency department (ED) patients with AD have accurate, readily accessible resuscitation status documentation. Methods: This cross-sectional, prospective study was conducted at a tertiary care ED during purposefully sampled random accrual times in summer 2016. We enrolled all patients with: 1) palliative care consultation, 2) metastatic malignancy, 3) COPD or CHF on home oxygen, 4) hemodialysis, or 5) advanced neurodegenerative disease/dementia. The primary outcome was the retrieval of any existing resuscitation status documents. Documentation was obtained from a standardized review of forms accompanying the patient (“arrival documents”) and electronic medical record (“EMR”). We measured the time to retrieve this documentation, and interviewed consenting patients to corroborate documentation with their current wishes. Results: Of 85 enrolled patients, only 33 (39%) had any documentation of resuscitation status: 28 (33%) had goals of care retrieved from the hospital EMR, and 11 (15%) from arrival documents (some had both). Patients from long-term care facilities were more likely to have documentation available (odds ratio 13 [95% CI 2.5-65] vs community-living). Of 32 patients who were able to be interviewed, 20 (63%) expressed “do not resuscitate” wishes. Ten of these 20 lacked any documents to support their expressed resuscitation wishes. Previously expressed resuscitation wishes took more than 5 minutes to be retrieved in 3 cases when not filed “one click deep” in our EMR. Conclusion: The majority of patients with AD, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have goals of care documents readily available upon arrival to the ED. Patients living in the community with AD appear to be at high risk for unwanted resuscitative treatments should they present to hospital in extremis. Having documentation of their goals of care that is easily retrievable from the EMR shows promise, though issues of retrieval, accuracy, and validity remain important considerations.

GD05: Careful Anticoagulation Review in Emergency Medicine (CARe-EM)

Background: The number of patients prescribed anticoagulation for stroke prevention is increasing, along with the proportion of emergency department (ED) patients who are anticoagulant users. Bleeding is the most common side effect. Inappropriate dosing, co-prescription of anti-inflammatories or aspirin, and renal impairment all increase the bleeding risk. An ED visit is an opportunity to review anticoagulant bleeding risks and intervene to prevent bleeding in patients at high risk. Objectives: To establish the 12-month incidence of bleeding in anticoagulated patients visiting the ED, to develop an ED specific anticoagulant-associated bleeding prediction score, to evaluate the ED utility of existing prediction scores. Methods: Research ethics board approval has been granted. Patients will be identified in Hamilton General and Juravinski EDs. Each patient will be followed forward in time for 12 months to document bleeding events. Population: Inclusion criteria: ED patients prescribed warfarin, rivaroxaban, dabigatran, apixaban, edoxaban or low molecular weight heparin (prevalent users). Exclusion criteria: Patients under 16 years of age. Primary outcome: The incidence of major bleeding (defined by ISTH criteria) within 12 months from the index ED visit. Secondary outcomes: Derivation of an ED prediction score to identify patients at high risk of anticoagulant-associated bleeding within 12 months. Tertiary outcomes: Evaluation of ATRIA, modified HAS-BLED and HEMORR2HAGES scores utility in predicting bleeding within 12 months. Data management: The data will be stored anonymously and securely on RedCAP. A literature search/expert discussion has identified multiple potential risk factors for bleeding. This data is collected at the time of the index ED presentation. A committee of emergency, thrombosis, gastroenterology and cardiology physicians will review each major bleeding case. Analysis: Primary analysis: a multiple logistic regression analysis to identify variables associated with major bleeding diagnosed within 12 months of the index presentation. Using the model β coefficients we will derive a simple clinical decision rule. Secondary analysis: assessing the area under the curve and optimal cut points for pre-existing bleeding prediction scores for predicting major bleeding within 12 months. Sample size calculation: With 3000 patients we expect 2700 to be anticoagulated long term, and at least 135/2700 patients will have a major bleed. This is a sufficient number for multivariate analysis to establish a simple model. We estimate 20,000 anticoagulated ED patient attendances/year. Importance: This is the first study to consider the ED visit an opportunity to prevent bleeding. We will establish a method to identify ED patients at high risk of anticoagulant-associated bleeding.

Audit of strategies to improve sepsis management in emergency departments

Severe sepsis results in ~36,800 UK deaths each year [1]. Prior studies demonstrate the benefit of early recognition and treatment of sepsis in reducing mortality [2]. The Sepsis Six [1] bundle aims to optimise the first hour of sepsis management. We assessed the proportion of emergency department (ED) patients with severe sepsis receiving the Sepsis Six bundle and whether this was improved by a combination of staff education and use of Sepsis Six management stickers in patient notes.

Who Pays? How Reimbursement Impacts the Emergency Department

Background Nationwide from 1996 to 2004, the overall proportion of Emergency Department (ED) reimbursement ratios for outpatient ED visits decreased from 57% to 42%. the continued falling of ED reimbursement ratios, which is the share of ED charges that are ultimately paid, is an indicator of the financial pressures facing the ED. Once the healthcare reforms are put in place what will the impact be on reimbursement rates of overburdened and underfunded emergency departments. Purpose The purpose of this study is to examine if there is a declining disparity in payment rates for ED care based on payment sources in a safety net ED provider. Findings of this study could indicate how the healthcare reforms might impact these types of ED reimbursement ratios in the upcoming years. Methods This was a retrospective study that examined randomly selected charts of all ED visits charts from May 2002 to May 2008 at a level one adult and pediatric emergency trauma center with 45,000 annual visits. This study was IRB approved. Results A regression model was used to predict if there was a relationship between amount received and types of insurance payers within the ED. a significant relationship was found between types of insurance (payers) as the independent variable, and the dependent variables of charges ( p = .00), payments ( p = .00), amount of adjustments (p = .00), and balance remaining after 90 days (p = .00). Conclusions Who pays for the ED services does impact the ED's bottom line. the privately funded patients will provide an ED with a higher reimbursement ratio per year as compared to those patients who are publicly or self pay. This explains why EDs that provide care for 40% or more publicly or self pay patients have seen a decline in reimbursement ratios. Healthcare reform has the potential to change and possibly improve safety net ED rate of reimbursement depending on how private, public and self pay patients pay for ED services.

A Survey of a Small Sample of Emergency Department and Admitted Patients Asking Whether They Expect to Be Tested for HIV Routinely

Many US HIV-positive patients are unaware of their infection. Although there are multiple studies assessing the acceptance of testing, there are none that assess the patient's expectations of routine HIV testing. Through a prospective, cross-sectional, unfunded, convenience sample survey, we assessed the patient's expectation of testing at a regional medical center serving an indigent population. Also, we compared the providers' predictions of the proportion of patients expecting a test. Of the 69 patients, 23% expected a test. The only factor that correlated with this was their desire to be tested (P = .004). Providers' (N = 59) mean prediction was that 21% of the patients expected a test (range: 0%-100%). The proportion of emergency department (ED) patients wanting a test was 52% (of 30) and internal medicine inpatients were 44% (of 39). Nearly a quarter of patients expected routine HIV testing. This finding should encourage a review of policies promoting HIV testing, especially within the ED.