Emergency Department Readmission Rates Research Articles

Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use.

The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients' receipt of recent mental health care. Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined. During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission. Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

Asthma-related emergency admissions and associated healthcare resource use in Alberta, Canada

BackgroundThere is a lack of real-world research assessing asthma management following asthma-related emergency department (ED) discharges. The objective of this study was to characterise follow-up care, healthcare resource use (HCRU)...

Measurement of Procalcitonin as an Indicator of Severity in Patients With Chronic Obstructive Pulmonary Disease Admitted With Respiratory Illness.

IntroductionExacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for hospital admission and a major cause of morbidity and mortality. A useful biomarker or indicator of disease severity at the time of presentation could help guide treatment and identify those with poor prognosis who need early aggressive intervention. We hypothesized that patients who present to the hospital with COPD exacerbations who are found to have elevated procalcitonin (PCT) levels will have worse outcomes such as longer admissions, increased intensive care unit (ICU) utilization, and more frequent readmissions than those with normal levels, regardless of presence or absence of infiltrate on initial chest X-ray (CXR).MethodsWe conducted a retrospective chart review of patients admitted to our facility with a respiratory complaint and a diagnosis of COPD to examine the relation between PCT and disease severity. A total of 156 unique encounters were reviewed, with 87 included in the final data set. Data was collected on baseline medical conditions as well as clinical status at the time of presentation. Primary endpoints included the need for overnight ICU admission, hospital length of stay greater than seven days, and repeat visit within 30 days of discharge. Secondary endpoints included the need for intubation at the time of admission, in-hospital mortality or discharge to hospice, and ICU length of stay.ResultsPatients with elevated PCT levels (>0.25ng/mL) had a significantly increased likelihood of a need for ICU admission (odds ratio 3.18) and hospital length of stay greater than seven days (odds ratio 3.38). There was no statistically significant difference in the Emergency Department readmission rate or any of the secondary outcomes.ConclusionsOur data suggests that PCT may be a useful early biomarker for patients with COPD presenting with an acute respiratory illness.

Effect of age on presentation and outcome in renal colic.

To examine the age-related differences in the presentation, management, and outcomes of patients admitted to the emergency department (ED) with ureteral stones. A retrospective analysis of all patients who visited the ED at a single institution that were found to have a ureteral stone on CT. Clinical, laboratory, and imaging parameters were collected, including outcomes. Patients were subdivided into age groups: 18-30, 31-50, 51-70, and >70 years. Between January 2018 and December 2020, 778 patients were admitted to the ED with a ureteral stone. About 78% (609) were males and 22% (169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Patients in the 36-50 age group, had significantly higher visual analogue scale (VAS) scores (p < 0.0001). Patients older than 70 years old presented with significantly higher serum creatinine levels (p < 0.0001), C-reactive protein (CRP) (p < 0.001) and leukocyte levels (p = 0.002). These patients were also found to have significantly larger stones (mean size of 6.2 mm (SD 4.8) (p < 0.0001)) and underwent percutaneous nephrolithotripsy (PCNL) in significantly higher numbers (56.3% vs 43.8%, (p < 0.0001)). Less than half of the patients older than 50 years were given medical expulsive therapy (MET) with alpha-blockers, compared to more than 50% in the other age groups (p = 0.002). Spontaneous stone expulsion was noted in 70.2% of the 18-35-year group, 62.4% of the 36-50-year-old group, 51.8% of the 51-70-year-old group, and 37% of the >70-year-old group (p < 0.0001). The ED re-admission rates at 7 and 30 days were not significantly different among all age groups. Our data suggests that older patients presented with larger stones, elevated inflammatory markers and creatinine and were more likely to require surgical intervention. The spontaneous stone expulsion rate was inversely associated with age.

133. Creation of an Emergency Department (ED)-Specific Urine Antibiogram and Evaluation of Urinary Tract Infection (UTI) Prescribing Practices at a Tertiary Academic Medical Center

BackgroundInpatient settings have been the focus of most antimicrobial stewardship (AS) practices; however, the Joint Commission has now published requirements for accredited ambulatory healthcare organizations to implement AS. This analysis aimed to create a urine isolate antibiogram and to evaluate microbiological data and prescribing practices for UTI patients in the ED.MethodsThis retrospective cohort study included adults admitted to either of two EDs at University of Minnesota Medical Center and diagnosed with a UTI between 1/1/2018 and 12/31/2018. Patients were excluded if subsequently admitted to an inpatient unit or if they had a repeat culture growing the same organism as the index isolate. Diagnosis of cystitis versus pyelonephritis was based on ICD-10 coding. Data including urinalysis and culture results, susceptibilities, empiric antibiotic selection, and readmissions were collected.ResultsData from 350 isolates were collected for inclusion in the antibiogram. Patient characteristics corresponding to this isolate collection included 78.9% female, median age of 41 years, and 64.6% diagnosed with pyelonephritis. Escherichia coli was the most common organism (70%), followed by Klebsiella pneumoniae (5.4%) and Proteus mirabilis (4%). Combined susceptibilities of E. coli isolates from both EDs were: 49.4% ampicillin, 55.7% ampicillin/sulbactam, 69.8% sulfamethoxazole/trimethoprim, 83.7% ciprofloxacin (CIP), 85.7% cefazolin, 93.9% ceftriaxone, and 94.3% nitrofurantoin (NIT). The most common discharge antibiotics prescribed for cystitis patients were NIT (29.8%) and cephalexin (25%). Pyelonephritis patients were most frequently prescribed CIP (32.3%) and cefdinir (14.2%). Drug-bug mismatches occurred in 19.1% of patients (10.5% cystitis vs. 23.9% pyelonephritis). The rates of ED readmission within 96-hours and inpatient admission within 30 days, for any reason, were 4.3% and 9.1% respectively.ConclusionBased on the ED-specific urine antibiogram generated, NIT (cystitis) and CIP (pyelonephritis) could be considered first-line agents for empiric treatment of UTI at our institution. Drug-bug mismatches were more common in pyelonephritis patients. These data will be used to develop a treatment algorithm aimed at improving treatment of UTI in the ED.Disclosures Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support)Nabriva Therapeutics (Advisor or Review Panel member)

Frequency, profile, and outcomes of patients with acute heart failure transferred directly to home hospitalization from emergency departments

ObjectiveTo describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU). MethodWe included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge. ResultsThe study included 1473 patients (HH/IM/SSU:68/979/384). The HH rate was 4.7% (95% CI 3.8–6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5–12), similar to that of IM (median stay, 8 days; IQR, 5–13; p = .106) and longer than that of SSU (median stay, 4 days; IQR, 3–7; p < .001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI 0.73–1.14) or SSU (HR, 0.77; 95% CI 0.46–1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI 0.25–0.97) and SSU (HR, 0.37; 95% CI 0.19–0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate. ConclusionsDirect transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Acetaminophen, Nonsteroidal Anti-inflammatory Drugs, or Combination of Both Analgesics in Acute Posttrauma Pain: A Randomized Controlled Trial.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (also called paracetamol) are the most frequent analgesics used to relieve posttrauma pain in the emergency department (ED). However, the utility of combining both treatments is still controversial. We sought to explore the benefits of combining an NSAID with acetaminophen compared to acetaminophen alone, or NSAID alone, in the treatment of posttraumatic pain of the extremity after discharge from the ED. This is a prospective, randomized controlled trial, carried out in a single ED from March 2017 to November 2018. The included patients were randomly assigned to receive paracetamol alone, high-dose NSAID (piroxicam) alone, or a combination of paracetamol and high-dose NSAID for 7days after ED discharge. The primary outcome was need for additional oral analgesics. Secondary outcomes included the change of the visual numeric scale (VNS) between ED discharge (VNS D0) and 7days later (VNS D7), ED revisits for residual pain, side effects, and patient satisfaction as assessed by a Likert satisfaction scale. The need for additional oral analgesics was comparable between the paracetamol-NSAID combination group (9.8%) and the paracetamol group (11.4%; p=0.43). ED readmission rate was also comparable between the two groups at 5.6 and 5.8%, respectively (p=0.86). In contrast, need for new analgesics and ED revisit rates were both more frequent in the high-dose NSAID group.Mean VNS decreases on day 7 compared to day 0 were 66, 63, and 67%, respectively, in the paracetamol, NSAID, and paracetamol-NSAID combination groups (p=0.32). Frequency of dissatisfaction was higher in the NSAID group. Side effects were more frequent in the NSAID and paracetamol-NSAID combination groups. This study found that the combination of a high-dose NSAID with paracetamol does not increase the analgesic effect compared to paracetamol alone. We also found that paracetamol alone is superior to high-dose NSAID alone for posttraumatic extremity pain.

Frecuencia, perfil y resultados de los pacientes con insuficiencia cardiaca aguda que ingresan directamente en hospitalización a domicilio desde urgencias

ObjectiveTo describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU). MethodWe included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge. ResultsThe study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p<.001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI, 0.73-1.14) or SSU (HR, 0.77; 95% CI, 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI, 0.25-0.97) and SSU (HR, 0.37; 95% CI, 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate. ConclusionsDirect transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Impact on Length of Stay of a Hospital Medicine Emergency Department Boarder Service.

It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS). To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS. Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder. The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed. The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate. There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates. Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.

Age-related causes of emergency department visits after pediatric adenotonsillectomy at a tertiary pediatric referral center

IntroductionThe complications of tonsillectomy and adenoidectomy (T&A) are well-described and include bleeding, dehydration, nausea, respiratory complications, and pain. After the immediate postoperative phase, the overall 30-day emergency department (ED) return rate is as high as 13.3%. However, few studies have examined the types and rates of late post-operative complications for children undergoing T&A stratified base on patient age. Herein, we aim to better characterize ED return visits for children of all ages, with special attention to those patients under three years of age. MethodsThis is a retrospective case series at a tertiary academic pediatric medical center. All patients 18 years of age or younger who underwent T&A over eighteen months were included. Data including ED return diagnosis, post-operative day of presentation, and need for surgical intervention was recorded for patients who presented to the ED within 30 days of their original surgery. Results5,225 patients were identified, with an overall late complication rate of 12.8%. There was no difference in the 30-day ED readmission rate for children under the age of three, although children under the age of two were more likely to present to the ED. There was a significantly higher risk of dehydration for children under the age of four years, and a significantly higher bleeding risk and need for reoperation for control of post-tonsillectomy hemorrhage (PTH) for children over the age of six. ConclusionsThe overall ED visit rate in this study is 12.8%, with no difference based on age. Patients younger than three years of age are more likely to return to ED for dehydration, while bleeding and need for control of oropharyngeal hemorrhage is more common in older children. Knowledge of the age-related late complications of T&A may direct appropriate anticipatory peri-operative counseling of risks and return precautions.

Emergency Department Readmission Rate within 72 Hours after Discharge; a Letter to Editor.

There are several factors that lead to early return of patients to the medical centers. These could be due to latent illnesses, misdiagnosis or even inadequate medical care due to staff being worn out. Determining the mentioned factors could help decrease the rate of readmission, restore patient's confidence in health centers and decrease the cost of medical care. Chi lung Wu et al. in 2010 sought to find out the major cause of patients’ return within 24 hours after discharge from emergency department (ED) and showed that abdominal pain and fever were the most common causes of patients' return, respectively. They found that, on average, 5.5% of discharged patients returned to the hospital. Tazhibi et al. carried out a research to find out major causes of readmission in Alzahra Hospital, Isfahan, Iran, and concluded that factors related to the patient and hospital could be held responsible for the patients’ readmission to the studied hospital. Verelst S et al., investigating the reasons for patient re-hospitalization within 72 hours after discharge in a teaching hospital in Belgium, found that 1.9% of admissions to the ED were in fact readmissions. 12% of this population were readmitted because of misdiagnosis. Chang SY et al. carried out a research in a teaching hospital in Taiwan to investigate the reasons for non-traumatic patient readmission within 72 hours of their discharge. They reported the rate of 3.5% for their readmissions out of their overall 72000 visits. Misdiagnosis was the most common problem among patients who had been readmitted shortly after discharge. In a retrospective cross-sectional study, we evaluated the medical profiles of all patients who were readmitted within 72 hours of their discharge from the ED of Golestan Hospital, Ahvaz, Iran, during July to December 2013, aiming to find the readmission rate of this ED. 63736 patients were admitted to the ED during the 6-month study period, 635 (0.99 %) cases of which were readmitted within the first 72 hours of discharge (67.1% male). 338 (53.2%) were 16 – 45 years old. Traumatic injuries (37.1%), flank pain (8.3%), acute coronary syndrome (7.2%), Cerebro-vascular accident (5.2%), and abdominal pain (4.8%) were among the most frequent causes of previous ED visit of readmitted patients. Finally, 70.2% of these patients were discharged again, 15.7% were admitted to other hospital wards, and 14.1% were transferred to other hospitals. Comparing the results of the present study with previous ones indicates that readmission rate can vary widely not only among different countries but also among various hospitals of the same country. For instance, in the studied hospital, which is a trauma center in the region, readmission rate of trauma patients is higher. Since readmissions cause unnecessary overcrowding in ED, it would be best if each hospital evaluated their rate of readmission and its causes, and then tried to relieve the problems found. This can be effective in better management of ED, reduction of treatment costs, increasing patient satisfaction, and prevention of ED overcrowding.

Impact of Clinical Pathway and Rapid Direct Influenza Polymerase Chain Reaction Test Introduction on Readmissions Among Non-hospitalized Children with Influenza-Like Illness

BackgroundDiagnosing influenza is challenging in children as influenza-like illness (ILI) symptoms are nonspecific. A clinical pathway was introduced in the emergency department (ED) of a large pediatric hospital to screen and treat patients at high risk of influenza-related complications. A new highly accurate, rapid polymerase chain reaction (PCR) influenza test was introduced the next year to provide more timely results. We aimed to measure the impact of the pathway and new PCR test on rates of all-cause ED readmissions and subsequent hospital admissions in all children with ILI discharged from the ED.MethodsWe conducted a retrospective cohort study of non-hospitalized children≤18 years presenting to the ED with ILI over 3 winter seasons. ILI cases were identified using syndromic surveillance definitions. Outcomes included any return ED encounter or hospital admission within 2 weeks of initial ED visit. We compared difference in outcomes between the years before pathway introduction, after pathway introduction, and after rapid PCR test introduction. Multivariate logistic regression adjusted for pertinent sociodemographic and clinical covariates.ResultsAmong 10799 children with ILI, 6.1% had an ED readmission and 2.5% had a hospital admission within 2 weeks of an initial ED visit. Overall rates of ED readmission or hospitalization did not differ significantly by study year (5.7% vs 6.5% vs 6.1%, P = 0.41, and 2.9% vs 2.4% vs 2.3%, P = 0.36). In multivariate analysis, pathway introduction alone was not associated with likelihood of ED readmission or hospitalizations. However, rapid PCR test introduction with the pathway was associated with lower odds of hospitalization (aOR 0.70, 95% CI 0.51–0.97). High-risk status was associated with higher odds of ED readmission (aOR 1.42, 95% CI 1.21–1.68). High-risk status and severity of illness at the initial ED visit were associated with higher odds of hospitalization (aOR 1.51, 95% CI 1.13–2.03; aOR 10.66, 95% CI 6.05–18.79).ConclusionClinical pathway and rapid PCR test introduction does not decrease all-cause ED readmissions but does decrease all-cause hospital admissions in children with ILI. Clinical factors such as severity of illness and high-risk status play a large role in determining outcomes.Disclosures All authors: No reported disclosures.

Effectiveness of Standardized Combination Therapy for Migraine Treatment in the Pediatric Emergency Department

To compare outcomes of pediatric migraine patients treated in an emergency department (ED) before and after implementation of a standardized combination intravenous therapy regimen aimed toward improving and standardizing abortive migraine therapy. In a pediatric ED, migraines represent 8-18% of all headache visits. Despite this large number, no standard treatment for acute migraine therapy currently exists. The study utilized a retrospective chart review of patients seeking acute migraine treatment at a tertiary care, pediatric ED from August 2006 to March 2010. Inclusion criteria were pediatric migraine patients as defined by International Headache Society guidelines. The comparison population received various migraine therapies based on attending practice preference. After October 2008, patients received standardized intravenous combination therapy involving a normal saline fluid bolus, ketorolac, prochlorperazine, and diphenhydramine. Occasionally, metoclopramide was substituted during prochlorperazine shortages. Reduction in headache pain score was the primary outcome. Secondary outcome measures included length of ED stay, hospital admission rate, and ED readmission rate within 48 hours. The study yielded 87 patients who received standardized combination therapy and 165 comparison patients. No significant difference in patient characteristics existed when evaluating patient demographics, outpatient medication use, and initial headache pain score. When compared with the non-standardized therapy population, the combination therapy patients revealed significant reductions in pain score (decrease of 5.3 vs. 6.9, difference -1.6, 95% confidence interval -2.2 to -0.8, P < .001), length of ED stay (5.3 vs. 4.4 hours, difference 0.9, 95% confidence interval 0.2-1.6, P = .008), and hospital admission rate (32% vs. 3%, P < .001) without changes in ED return rate (7% vs. 2%, P = .148). Standardized combination therapy is effective for acute pediatric migraine therapy in the ED by significantly reducing headache pain scores, length of ED stay, and hospital admission rates.