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Kim G, Han S, Bae SP, Lee J, Heo NH, Lee D, Kim HJ. Lactate Levels as a Predictor of Emergency Department Revisits in Infants With Acute Bronchiolitis. Pediatr Emerg Care 2024; 40:660-664. [PMID: 38713833 DOI: 10.1097/pec.0000000000003220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVE This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB). METHODS A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge. RESULTS Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO 2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15. CONCLUSION Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.
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Affiliation(s)
- Gihyeon Kim
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Seong Phil Bae
- Department of Pediatrics, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Jungwon Lee
- Department of Emergency Medicine, Soonchunhyang University Gumi Hospital, Gumi, Republic of Korea
| | - Nam Hun Heo
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Dongwook Lee
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Hyun Joon Kim
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
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Ho TH, Lin JW, Chi YC, How CK, Chen CT. Neutrophil-to-lymphocyte ratio as a predictor for outcomes in patients with short-term emergency department revisits. J Chin Med Assoc 2024; 87:782-788. [PMID: 38904352 DOI: 10.1097/jcma.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Analysis of short-term emergency department (ED) revisits is a common emergency care quality assurance practice. Previous studies have explored various risk factors of ED revisits; however, laboratory data were usually omitted. This study aimed to evaluate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte (PLR), and systemic immune-inflammation index (SII) in predicting outcomes of patients revisiting the ED. METHODS This retrospective observational cohort study investigated short-term ED revisit patients. The primary outcome measure was high-risk ED revisit, a composite of in-hospital mortality or intensive care unit (ICU) admission after 72-hour ED revisit. The NLR, PLR, and SII were investigated as potential prognostic predictors of ED revisit outcomes. RESULTS A total of 1916 encounters with short-term ED revisit patients were included in the study; among these, 132 (6.9%) encounters, comprising 57 in-hospital mortalities and 95 ICU admissions, were high-risk revisits. High-risk revisit patients had significantly higher NLR, PLR, and SII (11.6 vs 6.6, p < 0.001; 26.2 vs 18.9, p = 0.004; 2209 vs 1486, p = 0.002, respectively). Multiple regression analysis revealed revisit-NLR as an independent factor for predicting poor outcomes post-ED revisits (odds ratio: 1.031, 95% CI: 1.017-1.045, p < 0.001); an optimal cut-off value of 7.9 was proven for predicting high-risk ED revisit. CONCLUSION The intensity of the inflammatory response expressed by NLR was an independent predictor for poor outcomes of ED revisits and should be considered when ED revisits occur. Future prediction models for ED revisit outcomes can include revisit-NLR as a potential predictor to reflect the progressive conditions in ED patients.
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Affiliation(s)
- Tai-Hung Ho
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jin-Wei Lin
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Chi Chi
- Nursing Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chorng-Kuang How
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chung-Ting Chen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan, ROC
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Naeem S, Lozano JM, Ruiz Castaneda AM, Lowe D. Diphenhydramine and Migraine Treatment Failure in Pediatric Patients Receiving Prochlorperazine. Pediatr Emerg Care 2024; 40:e169-e173. [PMID: 38718751 DOI: 10.1097/pec.0000000000003202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
OBJECTIVES The objectives are to determine whether diphenhydramine coadministered with prochlorperazine versus prochlorperazine only is associated with a difference in the risk of migraine treatment failure, as measured by the need for additional therapy, hospitalization rates, and 72-hour return rates, and to compare extrapyramidal adverse effects between groups. METHODS Retrospective cohort of patients aged 7 to 18 years treated in the emergency department for migraines using prochlorperazine with or without diphenhydramine between 2013 and 2019. Patients were included if they had International Classification of Diseases, Ninth or Tenth Revision, codes for migraine or unspecified headache and were treated with prochlorperazine as part of their initial migraine therapy. Data collected included demographics, medications administered, pain scores, neuroimaging, disposition, return visits, and documentation of extrapyramidal adverse effects. Multivariable logistic regression was used to estimate the association between diphenhydramine coadministration and each of the outcomes. RESULTS A total of 1683 patients were included. Overall, 13% required additional therapy with a 16.7% admission rate and a 72-hour return rate of 5.3%. There was no association between initial treatment with diphenhydramine and the odds of additional therapy (adjusted odds ratio [aOR], 0.74 [95% confidence interval {CI}, 0.53-1.03]), admission rates (aOR, 1.22 [95% CI, 0.89-1.67]), or return visit rates (aOR, 0.91 [95% CI, 0.55-1.51]). Extrapyramidal adverse effects occurred in 2.4% of patients in the prochlorperazine group and 0% in the prochlorperazine with diphenhydramine group. CONCLUSIONS There was no association between diphenhydramine coadministration and the need for additional therapy, 72-hour return visit rates or admission rates. Extrapyramidal effects did not occur in patients treated with diphenhydramine.
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Affiliation(s)
- Sobia Naeem
- From the Department of Pediatric Emergency Medicine, Nicklaus Children's Hospital
| | - Juan M Lozano
- Department of Medical and Population Health Science Research, Florida International University Herbert Wertheim College of Medicine
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Garde V, Thornton K, Pardon M, Gangathimmaiah V, Mallett AJ, Greenslade J, Watt K. Functional somatic symptoms in Emergency Department frequent presenters. BMC Emerg Med 2024; 24:122. [PMID: 39020282 PMCID: PMC11256397 DOI: 10.1186/s12873-024-01030-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/21/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Patients with Functional Somatic Symptoms (FSS) are frequently encountered within healthcare settings such as Emergency Departments (ED). There is limited research regarding characterisation and frequency of FSS within frequent presenters to ED and no previous Australian evidence. This study aims to fill this gap. METHODS A retrospective, single-centre study of frequent ED presenters over a 6-month period was undertaken. Patients with > 3 re-presentations/month were reviewed for the presence of FSS using Stephenson and Price's (Stephenson DT, Price JR. Medically unexplained physical symptoms in emergency medicine. Emerg Med J. 2006;23(8):595.) categorisation of FSS. Patients were divided into three groups - FSS, possible FSS (pos-FSS) and non-FSS. The characteristics of these groups were compared using descriptive statistics (chi-square tests, Welch's ANOVA). Person-time at risk during the 6-month study period was estimated for patients in each group and incidence of ED presentation for each group was then calculated. Psychological distress indicators for ED presenters with FSS, as noted by the treating clinician, were also analysed. RESULTS 11% (71/638) of frequent ED presenters were categorised as having FSS and 72% (458/638) as having possible FSS (Pos-FSS). Mean ED presentations in the FSS group during the study period were significantly higher than in the non-FSS and Pos-FSS groups (p < 0.01). Anxiety was found to be the primary psychological distress indicator associated with ED presentations with FSS. CONCLUSION We found that, amongst frequent ED presenters, patients with FSS presented significantly more frequently to ED than those without FSS. We propose revising the model of care for FSS in ED to promote appropriate referral to therapy services as a possible demand reduction strategy to improve patient care and efficiency in ED.
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Affiliation(s)
- Vidula Garde
- Townsville Hospital and Health Service, Townsville, QLD, Australia.
- College of Public Health, Medical and Veterinary Science, James Cook University, Townsville, QLD, Australia.
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia.
| | | | - Madelyn Pardon
- Townsville Hospital and Health Service, Townsville, QLD, Australia
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
| | - Vinay Gangathimmaiah
- Townsville Hospital and Health Service, Townsville, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Andrew J Mallett
- Townsville Hospital and Health Service, Townsville, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kerrianne Watt
- College of Public Health, Medical and Veterinary Science, James Cook University, Townsville, QLD, Australia
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Adania ET, Faria Junior GSDE, Franzoni NR, Pimentel SK. Emergency room readmission, an avoidable problem? Analysis and stratification of readmissions in a trauma reference center. Rev Col Bras Cir 2024; 51:e20243704. [PMID: 38985037 DOI: 10.1590/0100-6991e-20243704-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/31/2024] [Indexed: 07/11/2024] Open
Abstract
INTRODUCTION Hospital readmission is a common way to assess the quality of care provided in an emergency service. In this context, the aim of this study is to quantify and stratify readmissions in a trauma reference emergency service. METHODS A retrospective longitudinal study was conducted with patients readmitted, twice or more, in the emergency service within a maximum period of 30 days from the initial admission - hospitalized or not. Clinical and demographic data were obtained from electronic medical records. RESULTS The readmission rate for the service was 4.11% for all readmissions and 2.23% for avoidable readmissions. Within this group, 61.19% were likely avoidable, 19.47% possibly avoidable, and 19.34% eventually avoidable. Regarding time, 48.16% occurred within one week of the initial readmission. Furthermore, no statistically significant association was found in the analysis of biological sex, occupational accident, and comorbidities. A statistically significant association was found in the analysis of age and ambulance transport (OR 1.37; 95% CI 1.17-1.59). CONCLUSION The study highlighted that there are still readmissions in the emergency department that could be avoided. A significant relationship was observed between readmissions and patient ages, and ambulance transport.
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Chen TY, Huang TY, Chang YC. Using a clinical narrative-aware pre-trained language model for predicting emergency department patient disposition and unscheduled return visits. J Biomed Inform 2024; 155:104657. [PMID: 38772443 DOI: 10.1016/j.jbi.2024.104657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/07/2024] [Accepted: 05/18/2024] [Indexed: 05/23/2024]
Abstract
The increasing prevalence of overcrowding in Emergency Departments (EDs) threatens the effective delivery of urgent healthcare. Mitigation strategies include the deployment of monitoring systems capable of tracking and managing patient disposition to facilitate appropriate and timely care, which subsequently reduces patient revisits, optimizes resource allocation, and enhances patient outcomes. This study used ∼ 250,000 emergency department visit records from Taipei Medical University-Shuang Ho Hospital to develop a natural language processing model using BlueBERT, a biomedical domain-specific pre-trained language model, to predict patient disposition status and unplanned readmissions. Data preprocessing and the integration of both structured and unstructured data were central to our approach. Compared to other models, BlueBERT outperformed due to its pre-training on a diverse range of medical literature, enabling it to better comprehend the specialized terminology, relationships, and context present in ED data. We found that translating Chinese-English clinical narratives into English and textualizing numerical data into categorical representations significantly improved the prediction of patient disposition (AUROC = 0.9014) and 72-hour unscheduled return visits (AUROC = 0.6475). The study concludes that the BlueBERT-based model demonstrated superior prediction capabilities, surpassing the performance of prior patient disposition predictive models, thus offering promising applications in the realm of ED clinical practice.
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Affiliation(s)
- Tzu-Ying Chen
- Graduate Institute of Data Science, Taipei Medical University, Taipei City, Taiwan
| | - Ting-Yun Huang
- Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yung-Chun Chang
- Graduate Institute of Data Science, Taipei Medical University, Taipei City, Taiwan; Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei City, Taiwan.
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Choi Y, Lee DH, Choi YH, Choi JY, Lim JY, Bae SJ. Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location. World J Urol 2024; 42:119. [PMID: 38446234 DOI: 10.1007/s00345-024-04813-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/16/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates. PURPOSE To identify predictors of revisits among patients with ureteral calculi in the ED. DESIGN, SETTING, AND PARTICIPANTS Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit. RESULTS Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021). CONCLUSIONS Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.
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Affiliation(s)
- Yunhyung Choi
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-Ro, Gwangmyeong-Si, 14353, Gyeonggi-do, Republic of Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-Ro, Gwangmyeong-Si, 14353, Gyeonggi-do, Republic of Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, 1071, Anyangcheon-Ro, Yangcheon-Gu, 07985, Seoul, Republic of Korea
| | - Jae Young Choi
- Department of Urology, College of Medicine, Yeungnam University, 170, Hyeonchung-Ro, Nam-Gu, 42415, Daegu, Republic of Korea
| | - Ji Yeon Lim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University, 260, Gonghang-Daero, Gangseo-Gu, 07804, Seoul, Republic of Korea
| | - Sung Jin Bae
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-Ro, Gwangmyeong-Si, 14353, Gyeonggi-do, Republic of Korea.
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Hutchinson CL, Curtis K, McCloughen A. Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry. Australas Emerg Care 2024; 27:71-77. [PMID: 37741746 DOI: 10.1016/j.auec.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 09/25/2023]
Abstract
AIM To identify common characteristics of patients who return to the ED unplanned and factors that may contribute to their decision to return. BACKGROUND Return visits to the Emergency Department (ED) have been associated with adverse events and deficits in initial care provided. There is increasing evidence to suggest that many return visits may be preventable. METHODS The results of primary quantitative measures (QUAN) followed by qualitative measures (qual) were integrated to build on and explain the quantitative data found in the initial phase of the research. RESULTS Integration of results produced three new findings. 1) Most return visits occurred beyond 48 hrs because patients intentionally delayed going back to the ED despite their persisting symptoms; 2) Clinical urgency and deterioration were rarely evident in patients who made return visits in patients and 3) Ineffective communication between the clinician and the patient at discharge may have contributed to patients making the decision to return to the ED. CONCLUSION The decision to return unplanned to the ED is not an immediate response for most patients, and several potentially avoidable factors may influence their decision-making process. Future research should focus on strategies which contribute to the avoidance of unplanned return visits.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, NSW, Australia; Faculty of Health. Southern Cross University, Coffs Harbour Campus, NSW, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia
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Gettel CJ, Galske J, Sather AR, Haidous AK, Hwang U, Brackett AL, Venkatesh AK, Rising KL, Goldberg EM, van Oppen JD, Conroy SP, Carpenter CR. Patient-reported outcome measure use among older adults after emergency department care: A systematic review. Acad Emerg Med 2024; 31:273-287. [PMID: 38366698 DOI: 10.1111/acem.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care. METHODS With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments. RESULTS Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality. CONCLUSIONS PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - James Galske
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Ali K Haidous
- University of Michigan-Dearborn, Dearborn, Michigan, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Alexandria L Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - James D van Oppen
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
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Gettel CJ, Hastings SN, Biese KJ, Goldberg EM. Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population. Clin Geriatr Med 2023; 39:659-672. [PMID: 37798071 PMCID: PMC10716862 DOI: 10.1016/j.cger.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article describes emergency department (ED)-to-community care transitions for older adults and associated challenges, measurement, proven efficacious and effective interventions, and policy considerations. Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care and may benefit from targeted intervention implementation. Future efforts should target optimizing screening techniques to identify those at risk, developing and validating patient-centered outcome measures, and using policy and reimbursement levers to include transitional care management services for older adults within the ED setting.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519, USA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT 06519, USA.
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Box 3003, Durham, NC 27710, USA; Geriatric Research, Education, Clinical Center, Durham VA Health Care System, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin J Biese
- Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB #7594, Chapel Hill, NC 27599, USA; Department of Medicine, Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, 13001 East 17th Place, CB #C290, Aurora, CO 80045, USA
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Tatlıparmak AC, Alpar S, Yilmaz S. Factors influencing recurrent emergency department visits for mild acute respiratory tract infections caused by the influenza virus. PeerJ 2023; 11:e16198. [PMID: 37818329 PMCID: PMC10561640 DOI: 10.7717/peerj.16198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023] Open
Abstract
Background Seasonal viral outbreaks, exemplified by influenza A and B viruses, lead to spikes in emergency department (ED) visits, straining healthcare facilities. Addressing ED overcrowding has become paramount due to its implications for patient care and healthcare operations. Recurrent visits among influenza patients remain an underexplored aspect, necessitating investigation into factors influencing such revisits. Methods Conducted within a tertiary care university hospital, this study adopts an observational retrospective cohort design. The study included adult patients with acute respiratory symptoms diagnosed with influenza using rapid antigen testing. The cohort was divided into single and recurrent ED visitors based on revisits within 10 days of initial discharge. A comparative analysis was performed, evaluating demographics, laboratory parameters, and clinical process data between recurrent visitors and single visitors. Results Among 218 patients, 36.2% (n = 139) experienced recurrent ED visits. Age and gender disparities were not significant. Antibiotics were prescribed for 55.5% (n = 121) and antivirals for 92.7% (n = 202) of patients, with no notable influence on recurrence. Recurrent visitors exhibited lower monocyte counts, hemoglobin levels, higher PDW and P-LCR percentages, and increased anemia prevalence (p = 0.036, p = 0.01, p = 0.004, p = 0.029, p = 0.017, respectively). C-reactive protein (CRP) levels did not significantly affect recurrence. Conclusion This study highlights the pressing concern of recurrent ED visits among mild influenza patients, magnifying the challenges of ED overcrowding. The observed notable prescription rates of antibiotics and antivirals underscore the intricate landscape of influenza management. Diminished monocyte counts, hemoglobin levels, and altered platelet parameters signify potential markers for identifying patients at risk of recurrent visits.
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Affiliation(s)
| | - Suleyman Alpar
- Department of Emergency Medicine, Beykent University, İstanbul, Turkey
| | - Sarper Yilmaz
- Deparment of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, İstanbul, Turkey
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12
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Walsh PS, Brousseau DC, Coleman KD. Return visits after emergency department treatment for sickle cell pain crises. Am J Hematol 2023; 98:E266-E268. [PMID: 37435913 DOI: 10.1002/ajh.27027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/23/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Patrick S Walsh
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David C Brousseau
- Department of Pediatrics, Nemours Children's Health and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware, USA
| | - Keli D Coleman
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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13
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Gale J, Varndell W, James S, Perry L. Unscheduled emergency department presentations with diabetes: Identifying high risk characteristics. Australas Emerg Care 2023; 26:205-210. [PMID: 36528482 DOI: 10.1016/j.auec.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Unscheduled emergency department (ED) presentation by patients with diabetes has seldom been examined. This study aimed to determine the frequency and associated characteristics of presentations in this population. METHODS Using a prospective cross-sectional design, data were collected from patients with diabetes presenting and/or admitted to a tertiary metropolitan hospital in New South Wales, Australia (December 2016-September 2017). A screening interview including brief measures of cognitive and executive function, and clinical details from healthcare records were utilised; details around unscheduled presentations within 90 days were extracted. Independent associations with ED presentation were determined. RESULTS Unscheduled ED presentations were common; 35.4% had at least one within 90 days, and for 20.1% this occurred within 28 days. The screening tool contributed little towards identifying risk of unscheduled presentation. Those attending any community or outpatient follow-up appointment within the first 28 (OR 0.42, 95% CI 0.23-0.76; p = 0.004) or 90 days (OR 0.25; 0.13-0.47; p < 0.001) from the index presentation were less likely to present within that same period. CONCLUSIONS Findings indicated the magnitude of unscheduled ED presentation, care complexity and the value of targeted and timely follow-up. Alternative service support may help maintain and improve diabetes self-management and will require effectiveness and cost-effectiveness evaluation.
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Affiliation(s)
- Julie Gale
- Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Wayne Varndell
- Prince of Wales Hospital, Randwick, New South Wales, Australia; University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Steven James
- University of the Sunshine Coast, Petrie, Queensland, Australia; University of Melbourne, Parkville, Victoria, Australia.
| | - Lin Perry
- Prince of Wales Hospital, Randwick, New South Wales, Australia; University of Technology Sydney, Ultimo, New South Wales, Australia
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14
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Wang LH, Lee HL, Lin CC, Lan CJ, Huang PT, Han CY. Factors Associated with Return Visits by Elders within 72 Hours of Discharge from the Emergency Department. Healthcare (Basel) 2023; 11:1726. [PMID: 37372843 DOI: 10.3390/healthcare11121726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Elders have a higher rate of return visits to the emergency department (ED) than other patients. It is critical to understand the risk factors for return visits to the ED by elders. The aim of this study was to determine the factors associated with return visits to the ED by elders. This study retrospectively reviewed the hospital charts of elders who returned to the ED within 72 h after discharge from ED. The risk factors identified in the Triage Risk Screening Tool were applied in this study. Of the elders discharged from the ED, 8.64% made a return visit to the ED within 72 h. The highest revisit rate occurred within 24 h after discharge. Factors associated with return ED visits within 24 h by elders were difficulty walking and having discharge care needs. The factor associated with ED return visits within 24-48 h was polypharmacy. Difficulty walking, having discharge care needs, and hospitalization within the past 120 days were associated with return visits made within 48-72 h following discharge. Identifying the reasons for return visits to the ED and providing a continuous review of geriatric assessment and discharge planning could reduce unnecessary revisits.
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Affiliation(s)
- Li-Hsiang Wang
- Department of Nursing, China Medical University Hsinchu Hospital, Hsinchu 302, Taiwan
| | - Hui-Ling Lee
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan
| | - Chun-Chih Lin
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan
- Department of Nursing, New Taipei Municipal TuCheng Hospital, Chang Gung Medical Foundation, New Taipei City 236, Taiwan
| | - Chia-Ju Lan
- Department of Nursing, Taichung Armed Forces General Hospital, Taichung 411, Taiwan
| | - Pei-Ting Huang
- Department of Nursing, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu 302, Taiwan
| | - Chin-Yen Han
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan
- Department of Nursing, New Taipei Municipal TuCheng Hospital, Chang Gung Medical Foundation, New Taipei City 236, Taiwan
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15
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Heo S, Jeon K, Park B, Ko RE, Kim T, Hwang SY, Yoon H, Shin TG, Cha WC, Lee SU. Clinical factors predicting return emergency department visits in chemotherapy-induced febrile neutropenia patients. Am J Emerg Med 2023; 67:90-96. [PMID: 36821961 DOI: 10.1016/j.ajem.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Although chemotherapy-induced febrile neutropenia (FN) is the most common and life-threatening oncologic emergency, the characteristics and outcomes associated with return visits to the emergency department (ED) in these patients are uncertain. Hence, we aimed to investigate the predictive factors and clinical outcomes of chemotherapy-induced FN patients returning to the ED. METHOD This single-center, retrospective observational study spanning 14 years included chemotherapy-induced FN patients who visited the ED and were discharged. The primary outcome was a return visit to the ED within five days. We conducted logistic regression analyses to evaluate the factors influencing ED return visit. RESULTS This study included 1318 FN patients, 154 (12.1%) of whom revisited the ED within five days. Patients (53.3%) revisited the ED owing to persistent fever (56.5%), with no intensive care unit admission and only one mortality case who was discharged hopelessly. Multivariable analysis revealed that shock index >0.9 (odds ratio [OR]: 1.45, 95% confidence interval [CI], 1.01-2.10), thrombocytopenia (<100 × 103/uL) (OR: 1.64, 95% CI, 1.11-2.42), and lactic acid level > 2 mmol/L (OR: 1.51, 95% CI, 0.99-2.25) were associated with an increased risk of a return visit to the ED, whereas being transferred into the ED from other hospitals (OR: 0.08; 95% CI, 0.005-0.38) was associated with a decreased risk of a return visit to the ED. CONCLUSION High shock index, lactic acid, thrombocytopenia, and ED arrival type can predict return visits to the ED in chemotherapy-induced FN patients.
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Affiliation(s)
- Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea; Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 06355 Seoul, Republic of Korea
| | - Kyeongman Jeon
- Devision of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea; Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 06355 Seoul, Republic of Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea; Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 06355 Seoul, Republic of Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06355 Seoul, Republic of Korea.
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16
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Balzaretti PL, Reano A, Canonico S, Aurucci ML, Ricotti A, Pili FG, Monacelli F, Vallino D. A geriatric re-evaluation clinic is associated with fewer unplanned returns in the Emergency Department: an observational case-control study. Eur Geriatr Med 2023; 14:123-129. [PMID: 36471122 PMCID: PMC9734542 DOI: 10.1007/s41999-022-00726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The increasing share of older adults is associated with heavier Emergency Health Services utilization. In this context, a significant problem is the rate of unplanned revisits of geriatric patients after discharge from the Emergency Department (ED). We aimed to evaluate whether the referral to a dedicated Geriatric Revaluation Clinic (GRC) after discharge from the ED is associated with fewer early unplanned returns. METHODS We conducted an observational, retrospective, case-control study comparing patients 65 years or older evaluated in a GRC after an ED visit and a control group of same age subjects accessing the ED during the study period and discharged with one of the ICD-9-CM diagnoses used for the cases, for whom defined post-ED assessment was not arranged. The intervention at the GRC consisted of a comprehensive geriatric evaluation. We calculated unadjusted and adjusted OR for unplanned ED revisits within 30 days from ED discharge using two logistic regression models including the variables with statistically significant differences among study groups at univariate analysis. RESULTS During the study period, 121 eligible patients were evaluated at the GRC and were matched to 242 subjects included in the control group. The median age of the study population was 85 years. The adjusted OR for unplanned return after ED discharge and unplanned hospital admission after ED discharge were 0.44 (CI 0.20-0.89) and 0.52 (CI 95% 0.18-1.74), respectively. CONCLUSIONS In a population of older patients discharged from the ED, the referral to a GRC is associated with fewer early unplanned revisits.
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Affiliation(s)
- P L Balzaretti
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy.
| | - A Reano
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - S Canonico
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
| | - M L Aurucci
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - A Ricotti
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - F G Pili
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
| | - F Monacelli
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
| | - D Vallino
- Emergency Department, Azienda Ospedaliera "Ordine Mauriziano", Turin, Italy
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17
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Hall AG, Davlyatov GK, Orewa GN, Mehta TS, Feldman SS. Multiple Electronic Health Record-Based Measures of Social Determinants of Health to Predict Return to the Emergency Department Following Discharge. Popul Health Manag 2022; 25:771-780. [PMID: 36315199 DOI: 10.1089/pop.2022.0088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Health care systems continue to struggle with preventing 30-day readmissions to their institutions. Social determinants of health (SDOH) are important predictors of repeat visits to the hospital. In many health systems, SDOH data are limited to those variables that are most relevant to care delivery or payment (eg, race, gender, insurance status). Despite calls for integrating a more robust set of measures (eg, measures of health behaviors and living conditions) into the electronic health record (EHR), these data often have missing values necessitating the use of imputation to build a comprehensive picture of patients who are likely to return to the health system. Using logistic regression analyses and imputation of missing data from 2017 to 2018, this study uses measures found in the EHR (eg, tobacco use, living situation, problems at home, education) to assess those SDOH that might predict a return to the emergency department within 30 days of discharge from a health system. In both imputed and raw data, the total number of recorded health conditions was the most important predictor and collectively SDOH variables made a relatively small contributions in determining the likelihood of a return to the hospital. Although SDOH variables might be important in the design of programs aimed at preventing readmissions, they may not be useful in readmission predictive models.
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Affiliation(s)
- Allyson G Hall
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ganisher K Davlyatov
- Department of Health Administration and Policy, University of Oklahoma Health Sciences Center, Norman, Oklahoma, USA
| | - Gregory N Orewa
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tapan S Mehta
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
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18
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Gettel CJ, Serina PT, Uzamere I, Hernandez-Bigos K, Venkatesh AK, Rising KL, Goldberg EM, Feder SL, Cohen AB, Hwang U. Emergency department-to-community care transition barriers: A qualitative study of older adults. J Am Geriatr Soc 2022; 70:3152-3162. [PMID: 35779278 PMCID: PMC9669106 DOI: 10.1111/jgs.17950] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2022] [Accepted: 06/15/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Over one-half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post-discharge period. Understanding the experiences of older adults during ED-to-community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED-to-community care transitions. METHODS We conducted a qualitative analysis of community-dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi-structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations. RESULTS Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED-to-community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow-up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance. CONCLUSIONS Older adults identified barriers to successful ED-to-community care transitions that can inform the development of novel and effective interventions.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Peter T. Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ivie Uzamere
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kizzy Hernandez-Bigos
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Kristin L. Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Center for Connected Care, Thomas Jefferson University, Philadelphia, PA, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Shelli L. Feder
- Yale University School of Nursing, Orange, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Andrew B. Cohen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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19
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Casey MF, Richardson LD, Weinstock M, Lin MP. Cost variation and revisit rate for adult patients with asthma presenting to the emergency department. Am J Emerg Med 2022; 61:179-183. [PMID: 36155254 PMCID: PMC9595237 DOI: 10.1016/j.ajem.2022.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care. STUDY OBJECTIVE We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation. METHODS We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering. RESULTS In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00). CONCLUSION Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.
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Affiliation(s)
- Martin F Casey
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America.
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America
| | - Michael Weinstock
- Department of Emergency Medicine, Adena Regional Medical Center, Chillicothe, OH, United States of America; Department of Emergency Medicine, Wexner Medical Center at the Ohio State University, Columbus, OH, United States of America
| | - Michelle P Lin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America
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20
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Overcrowding in Emergency Department: Causes, Consequences, and Solutions—A Narrative Review. Healthcare (Basel) 2022; 10:healthcare10091625. [PMID: 36141237 PMCID: PMC9498666 DOI: 10.3390/healthcare10091625] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Overcrowding in Emergency Departments (EDs) is a phenomenon that is now widespread globally and causes a significant negative impact that goes on to affect the entire hospital. This contributes to a number of consequences that can affect both the number of resources available and the quality of care. Overcrowding is due to a number of factors that in most cases lead to an increase in the number of people within the ED, an increase in mortality and morbidity, and a decrease in the ability to provide critical services in a timely manner to patients suffering from medical emergencies. This phenomenon results in the Emergency Department reaching, and in some cases exceeding, its optimal capacity. In this review, the main causes and consequences involving this phenomenon were collected, including the effect caused by the SARS-CoV-2 virus in recent years. Finally, special attention was paid to the main operational strategies that have been developed over the years, strategies that can be applied both at the ED level (microlevel strategies) and at the hospital level (macrolevel strategies).
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21
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Ramgopal S, Varma S, Victor TW, McCarthy DM, Rising KL. Pediatric Return Visits to the Emergency Department: The Time to Return Curve. Pediatr Emerg Care 2022; 38:e1454-e1461. [PMID: 35727757 DOI: 10.1097/pec.0000000000002790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although 72-hour return visits are a frequently reported metric for pediatric patients discharged from the emergency department (ED), the basis for this metric is not established. Our objective was to statistically derive a cutoff time point for the characterization of pediatric return visits. METHODS We performed a retrospective cohort study using data of patients discharged from any of 44 pediatric EDs. We selected the first encounter per patient from January 1 to December 31, 2019, as the index encounter and included the first return visit within 30 days. We constructed a cumulative hazard curve to characterize the timing of return visits and constructed a multivariable adaptive regression spline model to identify a hinge point in return visit presentations. We identified the association between admission for early return visits and admission for late return visits using generalized linear mixed modeling. RESULTS Of 1,986,778 index ED discharges, 193,605 (9.7%) ED return visits were included. A double-exponential decay model demonstrated superior fit compared with a single exponential model ( P < 0.0001). Multivariable adaptive regression spline modeling identified a hinge at 7 days. When comparing proportions of return visits leading to hospitalization between early (23.8%) and late (15.1%) return visits, early visits (≤7 days) had higher adjusted odds of hospital admission (adjusted odds ratio, 1.73; 95% confidence interval, 1.69-1.77) relative to late return visits (>7 days). Findings were similar in sensitivity analyses within age subgroups, Census region, and in which the diagnosis (using the Diagnosis and Grouping System) was the same between the index and return visit. Among return visits that occurred within 7 days of the index visit, 46.3% had the same diagnosis grouping in both visits. CONCLUSIONS An empirically derived 7-day cutoff may be more appropriate for characterization of pediatric return visits to the ED. Encounters after this period had lower adjusted odds of admission.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Selina Varma
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Timothy W Victor
- Graduate School of Education, University of Pennsylvania, Philadelphia, PA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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22
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Namgung M, Lee DH, Bae SJ, Chung HS, Park JY, Kim K, Lee CA, Kim DH, Kim EC, Lim JY, Han SS, Choi YH. A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods. CHILDREN 2022; 9:children9071003. [PMID: 35883987 PMCID: PMC9322694 DOI: 10.3390/children9071003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022]
Abstract
Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.
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Affiliation(s)
- Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
- Correspondence: ; Tel.: +82-2-2610-6751
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ho Sub Chung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ji Young Park
- Department of Pediatrics, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Keon Kim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Korea;
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, Seoul 01830, Korea;
| | - Eui Chung Kim
- CHA Bundang Medical Center, Department of Emergency Medicine, Seongnam-si 13496, Korea;
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, Seoul 06591, Korea;
| | - Sang Soo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon-si 14584, Korea;
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
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23
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Zhang J, Qian S, Su G, Deng C, Reid D, Curtis K, Sinclair B, Yu P. Emergency department presentations of patients with alcohol use disorders in an Australian regional health district. Subst Abus 2022; 43:1126-1138. [DOI: 10.1080/08897077.2022.2060427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jingxiang Zhang
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
| | - Siyu Qian
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Guoxin Su
- School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
| | - Chao Deng
- School of Medicine and Molecular Horizons, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - David Reid
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Kate Curtis
- Illawarra Health and Medical Research Institute, Wollongong, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Barbara Sinclair
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Ping Yu
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
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Intravenous antibiotics at the index emergency department visit as an independent risk factor for hospital admission at the return visit within 72 hours. PLoS One 2022; 17:e0264946. [PMID: 35303001 PMCID: PMC8932564 DOI: 10.1371/journal.pone.0264946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases. Material and methods This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits. Results Patients receiving intravenous antibiotics at index visits had significantly higher risk—approximately two times—for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34–4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels. Conclusions Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics.
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Brom H, Anusiewicz CV, Udoeyo I, Chittams J, Brooks Carthon JM. Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study. J Clin Nurs 2022; 31:726-732. [PMID: 34240494 PMCID: PMC8741822 DOI: 10.1111/jocn.15932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/25/2021] [Accepted: 06/07/2021] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation. BACKGROUND Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid. DESIGN We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study. METHODS Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit. RESULTS Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01). CONCLUSIONS Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid. RELEVANCE TO CLINICAL PRACTICE Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.
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Affiliation(s)
- Heather Brom
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Colleen V. Anusiewicz
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Danville, PA, USA
| | | | - Jesse Chittams
- BECCA Lab, University of Pennsylvania, Philadelphia, PA, USA
| | - J. Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Danville, PA, USA
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Julie G, James S, Varndell W, Perry L. UNPLANNED REPRESENTATION TO HOSPITAL BY PATIENTS WITH DIABETES: DEVELOPMENT AND PILOT FEASIBILITY TESTING OF A SCREENING TOOL. Contemp Nurse 2022; 57:439-449. [PMID: 35021961 DOI: 10.1080/10376178.2022.2029517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BackgroundUnplanned representation of patients with diabetes recently discharged from emergency department or in-patient hospitals is a common but complex problem worldwide. This study set out to examine the feasibility of a risk screening interview and whether component characteristics may be associated with unplanned representation of patients with diabetes to a tertiary metropolitan hospital.MethodsA screening interview comprised of demographic, social and clinical characteristics was developed and piloted using prospective cross-sectional survey design. A convenience sample of 55 patients was recruited and screened. Outcomes were the occurrence of unplanned representation to hospital within 28 or 90 days of hospital discharge from the index presentation.ResultsThe screening interview was shown to be broadly feasible and acceptable for use by staff and patients, with identified areas for modification. Seventeen participants (30.9%) experienced unplanned representation within 90 days of hospital discharge; for 13 participants (23.6%) this occurred within 28 days. Characteristics linked with unplanned representation to hospital were identified.ConclusionsPreliminary data indicated the feasibility of tool use and informed refinement for future testing of the ability of the screening interview to predict those patients with diabetes at high risk of unplanned representation to hospital to enhance effective care planning.
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Affiliation(s)
- Gale Julie
- South East Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, 4502, Australia
| | - Wayne Varndell
- South East Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Lin Perry
- South East Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia.,Faulty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
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Galarraga JE, DeLia D, Huang J, Woodcock C, Fairbanks RJ, Pines JM. Effects of Maryland's global budget revenue model on emergency department utilization and revisits. Acad Emerg Med 2022; 29:83-94. [PMID: 34288254 DOI: 10.1111/acem.14351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/28/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. METHODS We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. RESULTS ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. CONCLUSIONS GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.
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Affiliation(s)
- Jessica E. Galarraga
- Health Care Delivery Research MedStar Health Research Institute Hyattsville Maryland USA
- Department of Emergency Medicine MedStar Washington Hospital Center Washington DC USA
- Georgetown University School of Medicine Washington DC USA
| | - Derek DeLia
- Health Care Delivery Research MedStar Health Research Institute Hyattsville Maryland USA
- Georgetown University School of Medicine Washington DC USA
| | - Jim Huang
- Health Care Delivery Research MedStar Health Research Institute Hyattsville Maryland USA
| | - Cynthia Woodcock
- The Hilltop Institute University of Maryland Baltimore County Baltimore Maryland USA
| | - Rollin J. Fairbanks
- Department of Emergency Medicine MedStar Washington Hospital Center Washington DC USA
- Georgetown University School of Medicine Washington DC USA
- Quality and Safety MedStar Health Columbia Maryland USA
| | - Jesse M. Pines
- US Acute Care Solutions Canton Ohio USA
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
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Hutchinson CL, Curtis K, McCloughen A, Fethney J, Wiseman G, Hutchinson L. Clinician perspectives on reasons for, implications and management of unplanned patient returns to the Emergency Department: A descriptive study. Int Emerg Nurs 2021; 60:101125. [PMID: 34953437 DOI: 10.1016/j.ienj.2021.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Unplanned return visits to the emergency department (ED) have been associated with adverse outcomes and may reflect the quality of care delivered. Several studies speculate the reasons for return and suggest clinician behaviour as potentially influencing a patient's decision to return to the ED. There is little research about this issue from the clinician's perspective, which is necessary to inform future practice improvement. METHODS A descriptive cross sectional design was employed to ascertain perspectives on identification and management of return visits occurring within 48 hours of discharge. An electronic survey was distributed to all medical, nursing, and clerical staff at one ED. Descriptive statistics were used for quantitative data and content analysis was performed on textual data. Results were categorised as barriers or facilitators, then mapped to the Theoretical Domains Framework. RESULTS A response rate of 59.7% (n=86/144) was achieved. Staff reported increased levels of concern for this patient group but not all staff were aware of the policy for managing return patients (40.7%). Five barriers and three facilitators were identified that mapped to eight influencers of behaviour including knowledge, memory and environmental factors. CONCLUSION Overall, staff were aware of return patients but lacked familiarity with policy and processes to identify and commence relevant protocols. Further review of current practice as well as the patient perspective is required before any intervention to improve practice is developed.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Glen Wiseman
- Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia
| | - Laura Hutchinson
- Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia
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Fruhan S, Bills CB. Odds of return: a prospective study using provider assessment to predict short-term patient return visits to the emergency department. BMJ Open 2021; 11:e053918. [PMID: 34853108 PMCID: PMC8638466 DOI: 10.1136/bmjopen-2021-053918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Previous studies have assessed patient-level characteristics associated with emergency department (ED) return visits, but none have used provider assessment. We prospectively investigate whether clinical providers could accurately predict ED return visits. METHODS Prospective cohort study. SETTING Single academically affiliated urban county hospital. PARTICIPANTS Discharged ED patients over a 14-month period with a provider assessment of the likelihood of patient return within 7 days of ED discharge. MAIN OUTCOME MEASURES The primary outcome of interest was a return visit to the ED within 7 days. Additional outcome measures included a return visit within 72 hours and a return visit resulting in admission. We also measured the accuracy of provider gestalt, and provide measures of sensitivity, specificity, predictive values, and likelihood ratios. RESULTS Of the 11 922 ED discharges included in this study, providers expected 2116 (17.7%) to result in a return visit within 7 days. Providers were much more likely to perceive a return visit if the patient left against medical advice (OR: 5.97, 95% CI: 4.67 to 7.62), or was homeless (OR: 5.69, 95% CI: 5.14 to 6.29). Patients who actually returned were also more likely to be homeless, English speaking and to have left the ED against medical advice on the initial encounter. The strongest predictor of a return visit at both 72 hours and 7 days in multivariable modelling was provider assessment (OR: 3.77, 95% CI: 3.25 to 4.37; OR: 3.72, 95% CI: 3.29 to 4.21, respectively). Overall sensitivity and specificity of provider gestalt as a measure of patient return within 7 days were 47% and 87%, respectively. The positive and negative likelihood ratios were 3.51 and 0.61, respectively. CONCLUSIONS Clinician assessment was the strongest predictor of a return visit in this dataset. Clinician assessment may be used as a way to screen patients during the index visit and enrol them in efforts to decrease return visits.
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Affiliation(s)
- Scott Fruhan
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Litwin SP, Diallo M, Ostrow O. The Parent Perspective on Return Visits to the Pediatric Emergency Department: A Missing Piece of the Puzzle. Pediatr Emerg Care 2021; 37:e1321-e1325. [PMID: 32011554 DOI: 10.1097/pec.0000000000002031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Return visits to the pediatric emergency department (ED) give insight into the unmet needs of patients and families. The aim of this study was to capture the parent perspective on factors contributing to return visits to the pediatric ED. METHODS This is a prospective cohort study consisting of an 11-item survey that was administered to parents of children who had a return visit to the ED less than 72 hours from their initial visit. Surveys were distributed over an 8-month period between November 2015 and June 2016. RESULTS The primary reason parents report for returning to the ED is that their child had ongoing or worsening symptoms (55%). Parents were satisfied with the care they received at the initial ED visit (89% report excellent, very good or good care). For parents who report that the initial visit could have been improved, they report wanting more tests done (54%), a better follow-up plan arranged by the ED (31%), consultation with a specialist (26%), admission to hospital on the initial visit (26%), and better communication and more time spent with the ED physician (21%). The majority (97%) of parents reported that their child has a primary care provider, and 39% of parents brought their child to a health care provider for the same problem in the 7 days before their return visit to the ED. CONCLUSIONS The parent perspective gives important insights into the reasons for return visits to the pediatric ED. Conclusions from this study will help inform future quality improvement initiatives that direct health care resources to provide high value care to patients and families.
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Affiliation(s)
| | - Mamadou Diallo
- From the Division of Emergency Medicine, Department of Pediatrics, Hospital for Sick Children
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Gettel CJ, Voils CI, Bristol AA, Richardson LD, Hogan TM, Brody AA, Gladney MN, Suyama J, Ragsdale LC, Binkley CL, Morano CL, Seidenfeld J, Hammouda N, Ko KJ, Hwang U, Hastings SN. Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; 28:1430-1439. [PMID: 34328674 PMCID: PMC8725618 DOI: 10.1111/acem.14360] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/05/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions. METHODS GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research. RESULTS Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research. CONCLUSIONS ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Department of internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Corrine I. Voils
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lynne D. Richardson
- Department of Emergency Medicine, icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science & Policy, icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Teresita M. Hogan
- Department of Medicine, Section of Emergency Medicine, The University of Chicago School of Medicine, Chicago, Illinois, USA
| | - Abraham A. Brody
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA
| | - Micaela N. Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Joe Suyama
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Luna C. Ragsdale
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA
| | - Christine L. Binkley
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carmen L. Morano
- School of Social Welfare, University at Albany, State University of New York, Albany, New York, USA
| | - Justine Seidenfeld
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nada Hammouda
- Department of Emergency Medicine, icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kelly J. Ko
- West Health Institute, La Jolla, California, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatrics Research, Education, and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Schouten B, Driesen BEJM, Merten H, Burger BHCM, Hartjes MG, Nanayakkara PWB, Wagner C. Experiences and perspectives of older patients with a return visit to the emergency department within 30 days: patient journey mapping. Eur Geriatr Med 2021; 13:339-350. [PMID: 34761369 PMCID: PMC9018642 DOI: 10.1007/s41999-021-00581-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/26/2021] [Indexed: 12/30/2022]
Abstract
Aim To achieve patient-centered care for older patients at the emergency department (ED) it is important to include their perspective and experience, and this can be done through the patient journey method. Findings By mapping the patient journey, we found that waiting times and suboptimal discharge communication are almost always related to a negative experience for older patients. Message The novelty of this study lies within the qualitative patient journey method, which allowed us to include the voice of the patient in issues that have been previously described (i.e. waiting times and discharge communication). We believe this can guide towards patient-centered improvement initiatives that can contribute to a positive ED experience in the future, for example a time-out at the ED and a discharge check list Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00581-6. Purpose Up to 22% of older patients who visit the emergency department (ED) have a return visit within 30 days. To achieve patient-centered care for this group at the ED it is important to involve the patient perspective and strive to provide the best possible experience. The aim of this study was to gain insight into the experiences and perspectives of older patients from initial to return ED visit by mapping their patient journey. Methods We performed a qualitative patient journey study with 13 patients of 70 years and older with a return ED visit within 30 days who presented at the Amsterdam UMC, a Dutch academic hospital. We used semi-structured interviews focusing on the patient experience during their journey and developed a conceptual framework for coding. Results Our sample consisted of 13 older patients with an average age of 80 years, and 62% of them were males. The framework contained a timeline of the patient journey with five chronological main themes, complemented with an ‘experience’ theme, these were divided into 34 subthemes. Health status, social system, contact with the general practitioner, aftercare, discharge and expectations were the five main themes. The experiences regarding these themes differed greatly between patients. The two most prominent subthemes were waiting time and discharge communication, which were mostly related to a negative experience. Conclusions This study provides insight into the experiences and perspectives of older patients from initial to return ED visit. The two major findings were that lack of clarity regarding waiting times and suboptimal discharge communication contributed to negative experiences. Recommendations regarding waiting time (i.e. a two-hour time out at the ED), and discharge communication (i.e. checklist for discharge) could contribute to a positive ED experience and thereby potentially improve patient-centered care. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00581-6.
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Affiliation(s)
- Bo Schouten
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, P/O Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Babiche E J M Driesen
- Department of Emergency Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, P/O Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Brigitte H C M Burger
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Mariëlle G Hartjes
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 1117, P/O Box 7057, 1007 MB, Amsterdam, The Netherlands.,Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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De Jesus O, Rodríguez Beato F, de Jesús Espinosa A. 90-Day Return Visit to the Emergency Department After an Initial Neurosurgical Evaluation. World Neurosurg 2021; 158:e283-e286. [PMID: 34732382 DOI: 10.1016/j.wneu.2021.10.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study evaluated emergency department (ED) neurosurgical reevaluation rates and their causes. Identifying the most significant reasons that make patients return to the ED for a neurosurgical reevaluation can help implement changes to reduce the economic and medical burden of patient turnover. METHODS All patients undergoing neurosurgical reevaluation at our institution's ED after an initial neurosurgical evaluation were enrolled in a prospective 3-month longitudinal registry. Inclusion criteria were all adult patients 21 years of age or older previously evaluated by neurosurgery at our institution's ED who return within 90 days for a neurosurgical reevaluation. RESULTS We found an overall 90-day ED neurosurgical return visit rate of 2.1%. During the study, 34 patients returned to the ED for a neurosurgical reevaluation. Patients returned for a neurosurgical reevaluation at a median of 23.5 days after the initial neurosurgery evaluation. The principal causes for a return visit were altered mental status, headache, and wound infections. Among the returning patients, 59% required hospitalization and 50% required an operation. CONCLUSIONS To our knowledge, this is the first study to prospectively collect data to estimate the 90-day ED return visit rate for a neurosurgical reevaluation following an initial ED neurosurgical evaluation. Some patients still use the ED to get continued care of their condition despite having access to their primary care physician. Better communication, social worker coordination, and prompt follow-up appointments at the neurosurgical outpatient clinic may reduce return visits.
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Affiliation(s)
- Orlando De Jesus
- Section of Neurosurgry, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA.
| | - Freddie Rodríguez Beato
- Section of Neurosurgry, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Aixa de Jesús Espinosa
- Section of Neurosurgry, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA
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Yau FFF, Yang Y, Cheng CY, Li CJ, Wang SH, Chiu IM. Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan. Healthcare (Basel) 2021; 9:healthcare9111470. [PMID: 34828517 PMCID: PMC8620581 DOI: 10.3390/healthcare9111470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
Over a quarter of patients presenting with abdominal pain at emergency departments (EDs) are diagnosed with nonspecific abdominal pain (NSAP) at discharge. This study investigated the risk factors associated with return ED visits in Taiwanese patients with NSAP after discharge. We divided patients into two groups: the study group comprising patients with ED revisits after the index ED visit, and the control group comprising patients without revisits. During the study period, 10,341 patients discharged with the impression of NSAP after ED management. A regression analysis found that older age (OR [95%CI]: 1.007 [1.003–1.011], p = 0.004), male sex (OR [95%CI]: 1.307 [1.036–1.650], p = 0.024), and use of NSAIDs (OR [95%CI]: 1.563 [1.219–2.003], p < 0.001) and opioids (OR [95%CI]: 2.213 [1.643–2.930], p < 0.001) during the index visit were associated with increased return ED visits. Computed tomography (CT) scans (OR [95%CI]: 0.605 [0.390–0.937], p = 0.021) were associated with decreased ED returns, especially for those who were older than 60, who had an underlying disease, or who required pain control during the index ED visit.
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Affiliation(s)
- Fei-Fei Flora Yau
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
| | - Ying Yang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
| | - Chi-Yung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
| | - Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
| | - Su-Hung Wang
- Division of Hepatogastroenterology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan 710, Taiwan;
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
- Correspondence: ; Tel.: +886-978839856
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Trenholm JR, Warner DG, Eagles DD. Occupational Therapy in the Emergency Department: Patient Frailty and Unscheduled Return Visits. The Canadian Journal of Occupational Therapy 2021; 88:395-406. [PMID: 34693736 DOI: 10.1177/00084174211051165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Occupational therapy facilitates care for complex frail emergency department (ED) patients who may have unscheduled return visits (URVs). Purpose. To determine the prevalence of frailty amongst ED patients referred to occupational therapy and if frailty affected the rates and reasons for URVs. Methods. A mixed-methods health records review was conducted of older adults referred to an ED-based occupational therapy program. Findings. Most patients were frail (60.6%). 31.0% of patients discharged home had a URV within 30 days, with no difference in URV rates between frail and non-frail populations. Providing occupational therapy education reduced the frequency of URVs. Frail patients had complex reasons for their URVs, including functional, social/environmental, safety concerns, and/or "failure to thrive". Occupational therapy ED patients were typically vulnerable to moderately frail, dependent in some activities of daily living, and complex. Implications. ED-based occupational therapists must be aware of their patient's frailty and risk of URVs.
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Kim H, Han SJ, Lee JH, Lim J, Moon SD, Moon H, Lee SY, Yoon SW, Jung HW. A Descriptive Study of Emergency Department Visits Within 30 Days of Discharge. Ann Geriatr Med Res 2021; 25:245-251. [PMID: 34689542 PMCID: PMC8749036 DOI: 10.4235/agmr.21.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Unnecessary emergency department (ED) visits are a crucial consideration in discharge planning for acutely admitted patients. This study aimed to identify the reasons for unnecessary visits to the ED within 30 days of discharge from a medical hospitalist unit. METHODS We performed a retrospective review of patients discharged in 2018 from a medical unit of tertiary teaching hospital in Korea. The authors discussed in-depth and determined whether or not an ED visit was unnecessary, and further classified the causes of unnecessary visits into three categories. RESULTS The mean age of the patients was 62.9 years (range, 15-99 years), and among the 1,343 patients discharged from the unit, 720 (53.6%) were men. Overall, 215 patients (16.0%) visited the ED within 30 days after discharge; among them, 16.3% were readmitted. Of the 215 cases of ED visits within 30 days after discharge, 57 (26.5%) were considered unnecessary. Of these, 30 (52.6%) were categorized as having failed care transition, 15 (26.3%) had unestablished care plans for predictable issues, and 12 (21.1%) had insufficient patient education. CONCLUSION A substantial number of short-term ED visits by discharged multimorbid or older medical patients were considered unnecessary. Discharging patients with a thorough discharge plan is essential to avoid unnecessary ED visits.
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Affiliation(s)
- Hyeanji Kim
- Regional Emergency Medical Center, Seoul National University Hospital, Seoul, Korea
| | - Seung Jun Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Jae Hyun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Jin Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Sung do Moon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Hongran Moon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Seo-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Sock-Won Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Hee-Won Jung
- Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sung CW, Lu TC, Fang CC, Lin JY, Yeh HF, Huang CH, Tsai CL. Factors associated with a high-risk return visit to the emergency department: a case-crossover study. Eur J Emerg Med 2021; 28:394-401. [PMID: 34191766 DOI: 10.1097/mej.0000000000000851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND IMPORTANCE Although factors related to a return emergency department (ED) visit have been reported, few studies have examined 'high-risk' return ED visits with serious adverse outcomes. Understanding factors associated with high-risk return ED visits may help with early recognition and prevention of these catastrophic events. OBJECTIVES We aimed to (1) estimate the incidence of high-risk return ED visits, and (2) to investigate time-varying factors associated with these revisits. DESIGN Case-crossover study. SETTINGS AND PARTICIPANTS We used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 651 815 ED visits over a 6-year period. Patient demographics and computerized triage information were extracted. OUTCOME MEASURE AND ANALYSIS A high-risk return ED visit was defined as a revisit within 72 h of the index visit with ICU admission, receiving emergency surgery, or with in-hospital cardiac arrest during the return ED visit. Time-varying factors associated with a return visit were identified. MAIN RESULTS There were 440 281 adult index visits, of which 19 675 (4.5%) return visits occurred within 72 h. Of them, 417 (0.1%) were high-risk revisits. Multivariable analysis showed that time-varying factors associated with an increased risk of high-risk revisits included the following: arrival by ambulance, dyspnea, or chest pain on ED presentation, triage level 1 or 2, acute change in levels of consciousness, tachycardia (>90/min), and high fever (>39°C). CONCLUSIONS We found a relatively small fraction of discharges (0.1%) developed serious adverse events during the return ED visits. We identified symptom-based and vital sign-based warning signs that may be used for patient self-monitoring at home, as well as new-onset signs during the return visit to alert healthcare providers for timely management of these high-risk revisits.
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Affiliation(s)
- Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jia-You Lin
- Department of Emergency Medicine, National Taiwan University Hospital
| | - Huang-Fu Yeh
- Department of Emergency Medicine, National Taiwan University Hospital
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Tsai CL, Ling DA, Lu TC, Lin JCC, Huang CH, Fang CC. Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study. West J Emerg Med 2021; 22:1124-1130. [PMID: 34546889 PMCID: PMC8463058 DOI: 10.5811/westjem.2021.6.52212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database. Methods This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. Results Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172). Conclusion Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.
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Affiliation(s)
- Chu-Lin Tsai
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Dean-An Ling
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Tsung-Chien Lu
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Jasper Chia-Cheng Lin
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Chien-Hua Huang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Cheng-Chung Fang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
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Kim K, Lee CA, Park SH, Kim DH, Kim EC, Lim JY, Han S, Choi YH, Bae SJ, Lee DH. Age-related differences in revisits to the emergency departments of eight Korean university hospitals. Arch Gerontol Geriatr 2021; 97:104489. [PMID: 34332235 DOI: 10.1016/j.archger.2021.104489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/07/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Keon Kim
- Ewha Womans University Seoul Hospital, Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea; Department of Emergency Medicine, College of Medicine, Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450, South Korea
| | - Sang Hyun Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeongdeungpo-gu, Seoul 07345, South Korea
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, 68, Hangeulbiseok-ro, Nowon-gu, Seoul 01830, South Korea
| | - Eui Chung Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam, CHA University, 16, Yatap-ro 65beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13496, South Korea
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-Gu, Seoul 137-701, South Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do 1899-5700, South Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University Medical Center, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul 07985, South Korea
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, 102, Heukseok-ro, Dongjak-gu, Seoul, South Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, South Korea.
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Poh XE, Wu KH, Chen CC, Huang JB, Cheng FJ, Chiu IM. Outcomes for Patients with Urinary Tract Infection After an Initial Intravenous Antibiotics Dose Before Emergency Department Discharge. Infect Dis Ther 2021; 10:1479-1489. [PMID: 34121165 PMCID: PMC8322380 DOI: 10.1007/s40121-021-00469-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/25/2021] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION To investigate the effect of single-dose intravenous antibiotics before emergency department (ED) discharge on the outcomes of patients with urinary tract infections (UTIs). METHODS This is a retrospective study conducted at the EDs of three medical centers. Patients aged over 18 years who presented to the ED with UTI and were discharged without admission between January 1, 2016 and December 31, 2017 were evaluated. The study group received a single dose of effective intravenous antibiotics on the basis of urine culture during the index ED visit following oral antibiotics, while the comparison group received oral antibiotics only. The primary outcomes were ED revisit within 72 h and admission following the return visit. RESULTS A total of 8168 patients were included. Of these, 20.9% received intravenous antibiotics before ED discharge. Patients who received effective intravenous antibiotics before ED discharge were associated with less than 72-h ED revisit (adjusted odds ratio [OR] 0.791, 95% confidence interval [CI] 0.640-0.979]), but not decreased admission following the return visit (adjusted OR 0.921, 95% CI [0.731-1.153]). In subgroup analysis, parenteral antibiotic use during the index ED visit was associated with decreased admission following ED revisit in patients who presented with fever (adjusted OR 0.605; 95% CI 0.443-0.932). CONCLUSION For patients with UTI and clinically well to be discharged from the ED, a single dose of effective intravenous antibiotics before ED discharge was associated with decreased 72-h ED revisit. In patients with febrile UTI, initial intravenous antibiotics were associated with decreased revisit leading to admissions.
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Affiliation(s)
- Xue-Er Poh
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Chien-Chih Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Jyun-Bin Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan.
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Freedman SB, Roskind CG, Schuh S, VanBuren JM, Norris JG, Tarr PI, Hurley K, Levine AC, Rogers A, Bhatt S, Gouin S, Mahajan P, Vance C, Powell EC, Farion KJ, Sapien R, O'Connell K, Poonai N, Schnadower D. Comparing Pediatric Gastroenteritis Emergency Department Care in Canada and the United States. Pediatrics 2021; 147:e2020030890. [PMID: 34016656 PMCID: PMC8785749 DOI: 10.1542/peds.2020-030890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data. METHODS We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit. RESULTS In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8). CONCLUSIONS Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada;
| | - Cindy G Roskind
- Department of Emergency Medicine, Medical Center, Columbia University, New York, New York
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario
| | - John M VanBuren
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jesse G Norris
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Katrina Hurley
- Department of Emergency Medicine, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adam C Levine
- Department of Emergency Medicine, Hasbro Children's Hospital, Rhode Island Hospital and Brown University, Providence, Rhode Island
| | - Alexander Rogers
- Departments of Emergency Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Seema Bhatt
- Division of Emergency Medicine, Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Serge Gouin
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Elizabeth C Powell
- Department of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ken J Farion
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Robert Sapien
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Karen O'Connell
- Departments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University and Children's National Hospital, Washington, DC; and
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
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Hutchinson CL, Curtis K, McCloughen A, Qian S, Yu P, Fethney J. Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study. Australas Emerg Care 2021; 25:88-97. [PMID: 33994336 DOI: 10.1016/j.auec.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission. METHODS A retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care. RESULTS There were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825. CONCLUSION A small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Siyu Qian
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Ping Yu
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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Higher Frequency of Undetected Acute Coronary Syndrome in Elderly Patients with Chest Pain Who Visited the Emergency Department: A Large-Cohort Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6611051. [PMID: 33954184 PMCID: PMC8068555 DOI: 10.1155/2021/6611051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022]
Abstract
Background Acute coronary syndrome (ACS) is a critical disease encountered in the emergency department (ED). Despite the development of diagnostic tools, it may be difficult to diagnose ACS because of atypical symptoms and equivocal test results. We investigated the difference in the rates of revisit and undetected ACS between adult and elderly patients who visited the ED with chest pain. Method Data from 11,323 patients who visited the ED with chest pain at university hospitals in Korea were retrospectively analyzed. The cohort was categorized into two age groups: the adult (30–64 years) and elderly (>65 years). Baseline characteristic data (age, sex, vital signs, triage category, etc.) were obtained. We selected patients who revisited the ED within 30 d and investigated whether ACS was diagnosed. Result The revisit rate was higher in the elderly (12%) than in the adult group (8.3%). The rate of undetected ACS among the revisited patients was 2.91% (18/7,186) in adults and 6.08% (16/1,998) in elderly patients. Conclusion Elderly patients with chest pain had an increased rate of ED revisits and undetected ACS than adult patients. We recommend that old patients should be hospitalized to observe the progression of cardiac complaints or receive short-term follow-up.
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Artenstein AW, Stanaway N, Roy A, Westafer L, Lindenauer PK, Seiler AC, Coelho R, Prather M. An Integrated Mobile Acute Care Service Enhances Value. Popul Health Manag 2021; 24:442-447. [PMID: 33764793 DOI: 10.1089/pop.2020.0289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Reducing the cost of care while enhancing its quality and experience are essential components to success in value-based care. Because emergency department (ED) and hospital settings represent high-cost environments, the authors sought to reduce their unnecessary use by deploying a novel care delivery service that offers mobile, on-demand care for high-acuity conditions in patient homes. This study is a retrospective quality improvement evaluation of the initial year of the mobile acute care model in a health system with a substantial penetration of value-based care. Although all patients were eligible for mobile services as clinically indicated, those in accountable care organizations were prioritized by the care management teams. A variety of operational, clinical, and financial metrics were assessed to determine the program's performance and value. There were 3436 patient encounters during the study period, a utilization rate of 71% that trended upward throughout the year. Of these visits, 44% involved patients in value-based payment models; 80% of these represented patients in Medicare risk agreements. Throughout the year, progressively improving operational and clinical performance were observed, as were consistently high patient satisfaction scores. An estimated 63.8% of total mobile visits resulted in ED avoidance; 21.6% were emergency medical transport avoidant; 14.1% led to avoided hospital observation or inpatient stays. Patients were highly satisfied with the service. In-home mobile care for high-acuity illness can prevent unnecessary ED and hospital use for some patients and is associated with high patient satisfaction. Acute mobile care is a useful component of a value-based care strategy.
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Affiliation(s)
- Andrew W Artenstein
- Department of Medicine, Baystate Health, Springfield, Massachusetts, USA.,The University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Nathan Stanaway
- Department of Emergency Medicine, Baystate Health, Springfield, Massachusetts, USA
| | - Amy Roy
- Baycare Heath Partners, Springfield, Massachusetts, USA
| | - Lauren Westafer
- The University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA.,Department of Emergency Medicine, Baystate Health, Springfield, Massachusetts, USA
| | - Peter K Lindenauer
- Department of Medicine, Baystate Health, Springfield, Massachusetts, USA.,The University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Adrianne C Seiler
- Department of Medicine, Baystate Health, Springfield, Massachusetts, USA.,The University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA.,Baycare Heath Partners, Springfield, Massachusetts, USA
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Rosen T, Bao Y, Zhang Y, Clark S, Wen K, Elman A, Jeng P, Bloemen E, Lindberg D, Krugman R, Campbell J, Bachman R, Fulmer T, Pillemer K, Lachs M. Identifying patterns of health care utilisation among physical elder abuse victims using Medicare data and legally adjudicated cases: protocol for case-control study using data linkage and machine learning. BMJ Open 2021; 11:e044768. [PMID: 33550264 PMCID: PMC7925867 DOI: 10.1136/bmjopen-2020-044768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Physical elder abuse is common and has serious health consequences but is under-recognised and under-reported. As assessment by healthcare providers may represent the only contact outside family for many older adults, clinicians have a unique opportunity to identify suspected abuse and initiate intervention. Preliminary research suggests elder abuse victims may have different patterns of healthcare utilisation than other older adults, with increased rates of emergency department use, hospitalisation and nursing home placement. Little is known, however, about the patterns of this increased utilisation and associated costs. To help fill this gap, we describe here the protocol for a study exploring patterns of healthcare utilisation and associated costs for known physical elder abuse victims compared with non-victims. METHODS AND ANALYSIS We hypothesise that various aspects of healthcare utilisation are differentially affected by physical elder abuse victimisation, increasing ED/hospital utilisation and reducing outpatient/primary care utilisation. We will obtain Medicare claims data for a series of well-characterised, legally adjudicated cases of physical elder abuse to examine victims' healthcare utilisation before and after the date of abuse detection. We will also compare these physical elder abuse victims to a matched comparison group of non-victimised older adults using Medicare claims. We will use machine learning approaches to extend our ability to identify patterns suggestive of potential physical elder abuse exposure. Describing unique patterns and associated costs of healthcare utilisation among elder abuse victims may improve the ability of healthcare providers to identify and, ultimately, intervene and prevent victimisation. ETHICS AND DISSEMINATION This project has been reviewed and approved by the Weill Cornell Medicine Institutional Review Board, protocol #1807019417, with initial approval on 1 August 2018. We aim to disseminate our results in peer-reviewed journals at national and international conferences and among interested patient groups and the public.
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Affiliation(s)
- Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Yuhua Bao
- Department of Health Policy & Research, Weill Cornell Medical College, New York, New York, USA
| | - Yiye Zhang
- Department of Health Policy & Research, Weill Cornell Medical College, New York, New York, USA
| | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Katherine Wen
- Department of Policy Analysis and Management, Cornell University, Ithaca, New York, USA
| | - Alyssa Elman
- Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Philip Jeng
- Department of Health Policy & Research, Weill Cornell Medical College, New York, New York, USA
| | - Elizabeth Bloemen
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel Lindberg
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Richard Krugman
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jacquelyn Campbell
- John Hopkins University School of Nursing, John Hopkins University, Baltimore, Maryland, USA
| | - Ronet Bachman
- Department of Criminology, University of Delaware, Newark, Delaware, USA
| | - Terry Fulmer
- John A Hartford Foundation, New York, New York, USA
| | - Karl Pillemer
- Department of Policy Analysis and Management, Cornell University, Ithaca, New York, USA
| | - Mark Lachs
- Division of Geriatrics and Palliative Care, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
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Gabriel C, Bedi R, Coley KC, Richardson RM, Somma McGivney MA, Baumgartner MA, Vercammen V, Carroll JC. Informing the development of a transitions of care program between an emergency department and regional supermarket chain pharmacies. J Am Pharm Assoc (2003) 2021; 61:S78-S84. [PMID: 33531263 DOI: 10.1016/j.japh.2020.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pharmacist collaboration in transitions of care (TOC) programs is integral to increase patient education and adherence after discharge. This study aimed to conduct a qualitative evaluation of stakeholder perspectives to inform the design and implementation of a TOC program between an emergency department (ED) and regional supermarket chain pharmacies. METHODS Pharmacies from a regional supermarket chain were identified for inclusion on the basis of geographic proximity to a local community hospital ED. Semistructured, one-on-one interviews with the primary investigator were conducted. Interview questions were based on the Consolidation Framework for Implementation Research (CFIR). The following 5 CFIR domains were used: (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) characteristics of individuals, and (5) process. Interviews were audio-recorded and transcribed. Two investigators coded each transcript independently. A thematic analysis was performed. RESULTS A total of 19 interviews were conducted, and the following 7 major themes emerged on analysis: (1) enhance real-time interprofessional communication, (2) establish data sharing between the ED and the community pharmacy, (3) provide timely resolution of prescription insurance issues for new therapies post-ED discharge, (4) use off-site pharmacy resources to support community pharmacy workflow, (5) increase patient education to prevent primary medication nonadherence, (6) reinforce discharge care plans, and (7) focus on community-dwelling older adult patients in an ED care transition program. CONCLUSION Health care providers including pharmacists, physicians, nurses, and care managers, view an ED-to-community pharmacy TOC program as a valuable service to increase patient education on new medications and discharge planning. Establishment of data sharing and reimbursement is integral to the development, implementation, and sustainability of such programs. There is an untapped opportunity for community pharmacists to bridge the gap in care after ED discharge.
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Benjenk I, DuGoff EH, Jacobsohn GC, Cayenne N, Jones CMC, Caprio TV, Cushman JT, Green RK, Kind AJH, Lohmeier M, Mi R, Shah MN. Predictors of Older Adult Adherence With Emergency Department Discharge Instructions. Acad Emerg Med 2021; 28:215-225. [PMID: 32767696 DOI: 10.1111/acem.14105] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/13/2020] [Accepted: 07/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Older adults discharged from the emergency department (ED) are at high risk for adverse outcomes. Adherence to ED discharge instructions is necessary to reduce those risks. The objective of this study is to determine the individual-level factors associated with adherence with ED discharge instructions among older adult ED outpatients. METHODS We performed a secondary analysis of data from the control group of a randomized controlled trial testing a care transitions intervention among older adults (age ≥ 60 years) discharged home from the ED in two states. Taking data from patient surveys and chart reviews, we used multivariable logistic regression to identify patient characteristics associated with adherence to printed discharge instructions. Outcomes were patient-reported medication adherence, provider follow-up visit adherence, and knowledge of "red flags" (signs of worsening health requiring further medical attention). RESULTS A total 824 patients were potentially eligible, and 699 had data in at least one pillar. A total of 35% adhered to medication instructions, 76% adhered to follow-up instructions, and 35% recalled at least one red flag. In the multivariate analysis, no factors were significantly associated with failure to adhere to medications. Participants with poor health status (adjusted odds ratio [AOR] = 0.55, 95% confidence interval [CI] = 0.31 to 0.98) were less likely to adhere to follow-up instructions. Participants who were older (AORs trended downward as age category increased) or depressed (AOR = 0.39, 95% CI = 0.17 to 0.85) or had one or more functional limitations (AOR = 0.62, 95% CI = 0.41 to 0.94) were less likely to recall red flags. CONCLUSION Older adults discharged home from the ED have mixed rates of adherence to discharge instructions. Although it is thought that some subgroups may be higher risk than others, given the opportunity to improve ED-to-home transitions, EDs and health systems should consider providing additional care transition support to all older adults discharged home from the ED.
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Affiliation(s)
- Ivy Benjenk
- From the Department of Health Policy and Management School of Public Health University of Maryland College Park MDUSA
| | - Eva H. DuGoff
- From the Department of Health Policy and Management School of Public Health University of Maryland College Park MDUSA
- the Department of Population Health Sciences School of Medicine and Public HealthUniversity of Wisconsin MadisonWIUSA
- the Berkeley Research Group Washington DCUSA
| | - Gwen C. Jacobsohn
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Nia Cayenne
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Courtney M. C. Jones
- the Department of Emergency MedicineUniversity of Rochester Medical Center RochesterNYUSA
| | - Thomas V. Caprio
- the Department of Public Health SciencesUniversity of Rochester Medical Center RochesterNYUSA
- the Department of Medicine Division of Geriatrics University of Rochester Medical Center Rochester NYUSA
| | - Jeremy T. Cushman
- the Department of Emergency MedicineUniversity of Rochester Medical Center RochesterNYUSA
- the Department of Public Health SciencesUniversity of Rochester Medical Center RochesterNYUSA
| | - Rebecca K. Green
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Amy J. H. Kind
- the Division of Geriatrics and Gerontology Department of Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
- and the William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center Madison WIUSA
| | - Michael Lohmeier
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Ranran Mi
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Manish N. Shah
- the Department of Population Health Sciences School of Medicine and Public HealthUniversity of Wisconsin MadisonWIUSA
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
- the Division of Geriatrics and Gerontology Department of Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
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Chen EM, Ahluwalia A, Parikh R, Nwanyanwu K. Ophthalmic Emergency Department Visits: Factors Associated With Loss to Follow-up. Am J Ophthalmol 2021; 222:126-136. [PMID: 32882220 PMCID: PMC8328190 DOI: 10.1016/j.ajo.2020.08.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe follow-up rates for patients referred for outpatient ophthalmic care after emergency department (ED) discharge and identify patient and visit characteristics associated with loss to follow-up (LTFU). DESIGN Single-institution retrospective cohort study. METHODS We analyzed the medical records of 2,206 patients seen in the ED for an eye-related issue who were subsequently scheduled for ophthalmology follow-up between 2013 and 2019 at a single tertiary health system. The main outcome measures were the frequency of and risk factors for LTFU and ED revisits. RESULTS In total, 1,649 (74.8%) patients completed follow-up within 2 months of an index ED visit. In multivariable analysis, younger age (P < .001), a nonurgent ophthalmic condition or nonophthalmic primary diagnosis (P < .001), scheduled follow-up >5 days after the ED visit (P < .001), additional follow-up appointments (<.001), no prior history of ophthalmology appointments (P = .045), a visual acuity of 20/40 or better (P = .027), and having Medicaid or being uninsured (P < .001) were significantly associated with LTFU. The presence of an interpreter significantly increased the likelihood of follow-up among non-English speaking patients (P < .001). LTFU was significantly associated with an ED revisit within 4 months of an index visit, and the ED revisit rate was significantly higher for patients LTFU vs those who completed follow-up (5.7% vs 1.1%; P < .001). CONCLUSIONS A quarter of patients referred for ophthalmic care after an ED presentation were LTFU. We identified numerous factors associated with LTFU that could be used to develop interventions to enhance follow-up. In addition, patients who were LTFU were more likely to revisit the ED for the same ophthalmic condition.
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Affiliation(s)
- Evan M Chen
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aneesha Ahluwalia
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ravi Parikh
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA; Manhattan Retina and Eye Consultants, New York, New York, USA
| | - Kristen Nwanyanwu
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA.
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Luciani-McGillivray I, Cushing J, Klug R, Lee H, Cahill JE. Nurse-Led Call Back Program to Improve Patient Follow-Up With Providers After Discharge From the Emergency Department. J Patient Exp 2021; 7:1349-1356. [PMID: 33457586 PMCID: PMC7786663 DOI: 10.1177/2374373520947925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Phone calls to patients after discharge from the emergency department (ED) serve as reminders to schedule medical follow-up, support adherence to discharge instructions, and reduce revisits to already-crowded EDs. An existing, nurse-administered, call-back program contacted randomly selected ED patients 24 to 48 hours following discharge. This program did not improve patient follow-up (48.68%) nor reduce the ED revisit rate (6.7% baseline vs 6.0% postimplementation). Plan-Do-Study-Act methodology tested a modification to the existing program consisting of a second, scripted phone call from a trained volunteer at 72 to 96 hours postdischarge. Volunteers utilized a patient list and script, and nurses provided expertise to eliminate identified barriers to follow-up. Follow-up rate and ED revisit were monitored through the electronic medical record. A total of 894 patients participated between October 2017 and June 2018. Follow-up increased from 48.68% to 65.5% (P < .0001) and ED revisit decreased significantly (4.5% vs 8.6%, P < .001). This innovative nurse-led, systematic postdischarge call-back program utilizing hospital volunteers increased patient compliance with post-ED medical follow-up while significantly reducing the rate of patient revisit to the ED within 7 days of discharge.
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Affiliation(s)
- Ines Luciani-McGillivray
- Department of Nursing, Massachusetts General Hospital Department of Emergency Medicine, Boston, MA, USA
| | - Julie Cushing
- Department of Nursing, Massachusetts General Hospital Department of Emergency Medicine, Boston, MA, USA
| | - Rebecca Klug
- Department of Nursing, Massachusetts General Hospital Department of Emergency Medicine, Boston, MA, USA
| | - Hang Lee
- Biostatistics Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer E Cahill
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
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Optimizing emergency department care transitions to outpatient settings: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:2667-2680. [DOI: 10.1016/j.ajem.2020.07.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/18/2022] Open
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