Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

Using demand analysis and system status management for predicting ED attendances and rostering

INTRODUCTION

It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically.

OBJECTIVES

To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand.

METHODS

Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients.

RESULTS

The yearly ED attendances increased from 113387 (2004) to 120764 (2005) and to 125773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays.

CONCLUSION

We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.

Primary care quality and subsequent emergency department utilization for children in Wisconsin Medicaid

OBJECTIVE

Children enrolled in Medicaid have disproportionately high emergency department (ED) visit rates. Despite the growing importance of patient reported quality-of-care assessments, little is known about the association between parent-reported quality of primary care and ED utilization for these high-risk children. Our goal was to determine the association between parent-reported primary care quality and subsequent ED utilization for children in Medicaid.

METHODS

We studied a retrospective cohort of children enrolled in Wisconsin Medicaid. Parents of children sampled during fall 2002 and fall 2004 completed Consumer Assessment of Healthcare Providers and Systems surveys assessing their child's primary care quality in 3 domains: family centeredness, timeliness, and realized access. Primary outcomes were the rates of subsequent nonurgent and urgent ED visits, extracted from claims data for the year after survey completion. Negative binomial regression was used to determine the association between the domains of care and ED utilization.

RESULTS

A total of 5468 children were included. High-quality family centeredness was associated with a 27% (95% confidence interval [95% CI] 11%-40%) lower nonurgent ED visit rate, but no lowering of the urgent visit rate. High-quality timeliness was associated with 18% (95% CI, 3%-31%) lower nonurgent and 18% (95% CI, 1%-33%) lower urgent visit rates. High-quality realized access was associated with a 27% (95% CI, 8%-43%) lower nonurgent visit rate and a 33% (95% CI, 14%-48%) lower urgent visit rate.

CONCLUSIONS

Parent-reported high-quality timeliness, family centeredness, and realized access for a publicly insured child are associated with lower nonurgent ED, with high-quality timeliness and realized access associated with lower urgent ED utilization.

Alignment of emergency medicine research efforts with Clinical and Translational Science Awards

The Clinical and Translational Science Awards (CTSA) represent a major new funding pathway for health science investigators seeking National Institutes of Health (NIH) funds. This new pathway provides institutional-level support for clinical and translational research and is not tied to one organ system or disease process, fitting well with emergency medicine (EM) research needs. These awards open unique opportunities for advancing EM research. The CTSA mechanism provides institutional support from the NIH to promote both clinical and translational science. Of the 60 expected awards, 38 sites are currently funded. EM investigators can benefit the institutions applying for these awards and simultaneously gain from involvement. Some opportunities for participation provided by the CTSA include research training programs, joining multidisciplinary research teams, seed grant funding, and use of the CTSA-developed research infrastructure. Involvement of EM can benefit institutions by enhancing acute care research collaboration both within and among institutions. Emergency medicine researchers at institutions either planning to submit a CTSA application or with funded CTSA grants are encouraged to become actively involved in CTSA-related research programs.

Can the emergency department algorithm detect changes in access to care?

OBJECTIVES

The "emergency department algorithm" (EDA) uses emergency department (ED) diagnoses to assign probabilities that a visit falls into each of four categories: nonemergency, primary care-treatable emergency, preventable emergency needing ED care, and nonpreventable emergency. The EDA's developers report that it can evaluate the medical safety net because patients with worse access to care will use EDs for less urgent conditions. After the Oregon Health Plan (OHP, Oregon's expanded Medicaid program) underwent cutbacks affecting access to care in 2003, the authors tested the ability of the EDA to detect changes in ED use.

METHODS

All visits to 22 Oregon EDs during 2002 were compared with visits during 2004. For each payer category, mean probabilities that ED visits fell into each of the four categories were compared before versus after the OHP cutbacks.

RESULTS

The largest change in mean probabilities after the cutbacks was 2%. Attempts to enhance the sensitivity of the EDA through other analytic strategies were unsuccessful. By contrast, ED visits by the uninsured increased from 6,682/month in 2002 to 9,058/month in 2004, and the proportion of uninsured visits leading to hospital admission increased by 51%.

CONCLUSIONS

The EDA was less useful in demonstrating changes in access to care than were other, simpler measures. Methodologic concerns with the EDA that may account for this limitation are discussed. Given the widespread adoption of the EDA among health policy researchers, the authors conclude that further refinement of the methodology is needed.

Impact of health care system interventions on emergency department utilization and overcrowding in Singapore

Background

Public emergency departments (EDs) in Singapore were facing increasing attendances (visits) with frequent overcrowding in the 10 years from 1975 to 1985. Over the next 12 years a series of social interventions were carried out to minimize “unnecessary” attendances at these EDs.

Aims

This paper reviews the various interventions carried out on ED utilization to determine their impact and usefulness.

Methods

Emergency and non-emergency attendances at the six main public EDs were analysed over the 32 years of the review and especially just before and soon after the application of four major interventions relating to use of EDs, including: (1) public education campaigns, (2) financial disincentives, (3) redirection to primary health care centres and (4) use of alternative clinics.

Results

The 12-year period of social interventions resulted in a fall in the proportion of non-emergency patients using the EDs from 57% to 18%. Public education campaigns each resulted in a fall in inappropriate attendances of 27% to 67%. Financial disincentives were able to demonstrate an impact if they were significant and resulted in a heavier fiscal cost to the patient than if available primary health clinics were used. Redirection of non-emergencies away from EDs resulted in significant public relations issues with only mild decreases in non-emergency attendances. Alternative clinics may provide some respite if actively promoted by ED staff, but are able to generate their own separate patient clientele.

Conclusions

Public education and financial measures that seek to change the pattern of ED utilization in a community must go hand in hand with an easily accessible primary health care system for best effect. Co-ordination of such efforts requires active support from all levels of the health service and political leadership. An active feedback loop is needed for better outcomes management.

A novel emergency department based prevention intervention program for people living with HIV: evaluation of early experiences

BACKGROUND

HIV prevention is increasingly focused on people living with HIV (PLWH) and the role of healthcare settings in prevention. Emergency Departments (EDs) frequently care for PLWH, but do not typically endorse a prevention mission. We conducted a pilot exploratory evaluation of the first reported ED program to address the prevention needs of PLWH.

METHODS

This retrospective observational cohort evaluation reviewed program records to describe the first six months of participants and programmatic operation. Trained counselors provided a risk assessment and counseling intervention combined with three linkage interventions: i) linkage to health care, ii) linkage to case management, and iii) linkage to partner counseling and referral.

RESULTS

Of 81 self-identified PLWH who were approached, 55 initially agreed to participate. Of those completing risk assessment, 17/53 (32%, 95 CI 20% to 46%) reported unprotected anal/vaginal intercourse or needle sharing in the past six months with a partner presumed to be HIV negative. Counseling was provided to 52/53 (98%). For those requesting services, 11/15 (73%) were linked to healthcare, 4/23 (17%) were coordinated with case management, and 1/4 (25%) completed partner counseling and referral.

CONCLUSION

Given base resources of trained counselors, it was feasible to implement a program to address the prevention needs for persons living with HIV in an urban ED. ED patients with HIV often have unmet needs which might be addressed by improved linkage with existing community resources. Healthcare and prevention barriers for PLWH may be attenuated if EDs were to incorporate CDC recommended prevention measures for healthcare providers.

National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia

OBJECTIVES

To measure the quality of emergency department (ED) care for patients with acute myocardial infarction (AMI) and pneumonia (PNA) and to estimate the number of preventable deaths in these patients.

METHODS

The authors performed a cross sectional study of ED visits with the diagnosis of AMI or PNA from 1998 to 2004. Data from the National Hospital Ambulatory Medical Care Survey were used. The study involved 544 EDs across the United States. The authors measured the proportion of patients receiving recommended therapies for AMI (aspirin and beta-blockers [BBs]) and PNA (appropriate antibiotics and pulse oximetry). The excess deaths associated with current care were estimated.

RESULTS

Aspirin was administered to 40% and BBs to 17% of patients with AMI. Recommended antibiotics were administered to 69% and pulse oximetry was measured in 46% of patients with PNA. During the study period, the percentage receiving BBs and recommended antibiotics increased. There were more than 2.7 million opportunities to improve care and 22,000 excess deaths per year associated with current treatment of AMI and PNA.

CONCLUSIONS

Quality of care in the ED management of AMI and PNA is below national goals. This deficiency accounts for significant preventable deaths.

Impact of nurse staffing level on emergency department market share

BACKGROUND

Emergency departments (EDs) function at the interface of complex systems of the hospital and play a critical role in safety net systems. Adequate level of nurse staffing is crucial in meeting patients' needs and assuring their safety in EDs.

PURPOSES

This study examined the impact of nurse staffing on ED market shares.

METHODOLOGY/APPROACH

Data were collected from 122 hospitals operating nationally designated emergency medical centers. Multiple regression analyses were conducted to explain ED market share with the nurse staffing level.

FINDINGS

After controlling for hospital and regional characteristics, nurse staffing level significantly influenced market shares. Specifically, increasing one level from the baseline nurse staffing resulted in 29% higher ED market share.

PRACTICE IMPLICATIONS

Higher nurse staffing level is sensitively linked to the higher market share in emergency care services. These findings provide an initiative for hospital managers and nurse administrators to recruit and retain more nurses for pursuing higher nurse staffing. Furthermore, continuous effort should be made to develop a high standard of establishing and maintaining an adequate level of nurse staffing.

Beyond pulmonary edema: diagnostic, risk stratification, and treatment challenges of acute heart failure management in the emergency department

The majority of heart failure hospitalizations in the United States originate in the emergency department (ED). Current strategies for acute heart failure syndromes have largely been tailored after chronic heart failure guidelines and care. Prospective ED-based acute heart failure syndrome trials are lacking, and current guidelines for disposition are based on either little or no evidence. As a result, the majority of ED acute heart failure syndrome patients are admitted to the hospital. Recent registry data suggest there is a significant amount of heterogeneity in acute heart failure syndrome ED presentations, and diagnostics and therapeutics may need to be individualized to the urgency of the presentation, underlying pathophysiology, and acute hemodynamic characteristics. A paradigm shift is necessary in acute heart failure syndrome guidelines and research: prospective trials need to focus on diagnostic, therapeutic, and risk-stratification algorithms that rely on readily available ED data, focusing on outcomes more proximate to the ED visit (5 days). Intermediate outcomes (30 days) are more dependent on inpatient and outpatient care and patient behavior than ED management decisions. Without these changes, the burden of acute heart failure syndrome care is unlikely to change. This article proposes such a paradigm shift in acute heart failure syndrome care and discusses areas of further research that are necessary to promote this change in approach.

Emergency department overcrowding and children

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

Quality of primary care and subsequent pediatric emergency department utilization

OBJECTIVE

Our objective was to determine whether parent-reported, high-quality primary care was associated with decreased nonurgent pediatric emergency department utilization.

METHODS

A retrospective analysis of prospectively collected data for a cohort of children from the 2000-2001 and 2001-2002 Medical Expenditure Panel Survey panels was performed. Baseline parent-reported quality of primary care with respect to family-centeredness, timeliness, and realized access (a measure of the child's ability to receive necessary care and referrals) was assessed by using composite scores from the Consumer Assessment of Healthcare Providers and Systems survey. The primary outcomes were the numbers of subsequent nonurgent and urgent emergency department visits per child.

RESULTS

Of 8823 children included, 70.0% rated family-centeredness, 88.2% rated realized access, and 55.6% rated timeliness as high quality. After adjustment for demographic factors and health status, high-quality family-centeredness was associated with a 42% reduction in nonurgent emergency department visits for publicly insured children and a 49% reduction for children < or = 2 years of age. Greater realized access was associated with a 44% reduction in nonurgent emergency department visits for children 3 to 11 years of age and a 56% reduction for children > or = 12 years of age. Greater realized access was also associated with decreased nonurgent emergency department visits for publicly and privately insured children (37% and 35%, respectively). There was no significant association between timeliness and nonurgent emergency department utilization, nor was any quality-of-care domain associated with urgent emergency department utilization.

CONCLUSIONS

Parent-reported, high-quality family-centeredness and a high level of realized access to primary care were associated with decreased subsequent nonurgent emergency department visits for children. Parent reports of health care quality in these domains provide important complementary information on health care quality.

The future of emergency medicine public health research

This chapter addresses past successes and challenges and then elaborates on the potential for further advances in three areas that bridge emergency medicine and the broader public health and health services research agenda: (1) monitoring health care access; (2) surveillance of diseases, injuries, and health risks; and (3) delivering clinical preventive services. This article also suggests ways to advance policy-relevant research on systems of health and social welfare that impact the health of the public.

The relationship between hospital capacity characteristics and emergency department volumes in Korea

OBJECTIVE

To describe the level of emergency department (ED) volumes according to the hospital characteristics and to identify the relationship between hospital capacity characteristics and ED volumes in Korea.

METHOD

A survey was conducted to acquire information on the ED, its' hospital (facility, personnel, equipment), and the number of ED patients, as part of the National Emergency Medical Centers Assessment Program. Data from 106 nation-wide LEMCs were used. Multiple regression analysis was performed to determine the hospital capacity characteristics related with ED volumes.

RESULTS

The number of ED patients differed according to bed size, nurse staffing, residency training program, and the availability of emergency care-related equipment of the hospital. In the multiple regression analysis, the significant factors which explained the ED volumes were nurse staffing, inpatients per bed, and the population in the area where hospitals are located. The hospitals that were nurse staffing level 2, with more inpatients per bed and larger population of the service area, had more ED patients.

CONCLUSIONS

With the service area population, the ED volumes significantly related with nurse staffing and inpatients per bed. These could be used as one of criteria to designate a LEMC.

Uncompensated Care Provided by Emergency Physicians in Florida Emergency Departments

Uncompensated emergency department (ED) visits can negatively affect patients, clinicians, and hospitals, particularly as overcrowding occurs. Florida provides a unique market to analyze uncompensated ED care due to the high percent of for-profit hospitals, which typically provide significantly less uncompensated care, coupled with the older population that is more likely to be insured through Medicare. A survey of 188 Florida hospital emergency physician groups was conducted to estimate the level of uncompensated care provided by each ED physician group in 1998. The response rate was 44 percent (eighty-three ED physician groups). All ED physician groups provided substantial uncompensated care regardless of hospital ownership type. Uncompensated care averaged 46.8 percent and ranged from 25.8 to 79.4 percent. A model was developed to predict the amount of uncompensated care using ED volume and payer mix. A rise in the percent of self-pay patients causes a disproportionate increase in uncompensated care, such that EDs with high levels of self-pay visits have markedly higher uncompensated care rates. The results suggest the need for a uniform reporting method of ED physician uncompensated care cost.

Health department collaboration with emergency departments as a model for public health programs among at-risk populations

OBJECTIVES

Accessing at-risk and underserved populations for intervention remains a major obstacle for public health programs. Emergency departments (EDs) care for patients not otherwise interacting with the health care system, and represent a venue for such programs. A variety of perceived and actual barriers inhibit widespread implementation of ED-based public health programs. Collaboration between local health departments and EDs may overcome such barriers. The goal of this study was to assess the effectiveness of a health department-funded, ED-based public health program in comparison with other similar community-based programs through analysis of data reported by health department-funded HIV counseling and testing centers in one Ohio county.

METHOD

Data for HIV counseling and testing at publicly funded sites in southwestern Ohio from January 1999 through December 2002 were obtained from the Ohio Department of Health. Demographic and risk-factor profiles were compared between the counseling and testing program located in the ED of a large, urban teaching hospital and the other publicly funded centers in the same county.

RESULTS

A total of 26,382 patients were counseled and tested; 5,232 were ED patients, and 21,150 were from community sites. HIV positivity was 0.86% (95% confidence interval [CI] 0.64%, 1.15%) in the ED and 0.65% (95% CI 0.55%, 0.77%) elsewhere. The ED program accounted for 19.8% of all tests and 24.7% of all positive results. The ED notified 77.3% of individuals testing positive and 84.4% of individuals testing negative. At community program centers, 88.3% of patients testing positive and 63.8% of patients testing negative were notified of results. All ED patients notified of positive status were successfully referred to infectious disease specialists.

CONCLUSIONS

Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.

Clinical review: Emergency department overcrowding and the potential impact on the critically ill

Critical care constitutes a significant and growing proportion of the practice of emergency medicine. Emergency department (ED) overcrowding in the USA represents an emerging threat to patient safety and could have a significant impact on the critically ill. This review describes the causes and effects of ED overcrowding; explores the potential impact that ED overcrowding has on care of the critically ill ED patient; and identifies possible solutions, focusing on ED based critical care.

Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Emergency department overcrowding in the United States: an emerging threat to patient safety and public health

Numerous reports have questioned the ability of United States emergency departments to handle the increasing demand for emergency services. Emergency department (ED) overcrowding is widespread in US cities and has reportedly reached crisis proportions. The purpose of this review is to describe how ED overcrowding threatens patient safety and public health, and to explore the complex causes and potential solutions for the overcrowding crisis. A review of the literature from 1990 to 2002 identified by a search of the Medline database was performed. Additional sources were selected from the references of the articles identified. There were four key findings. (1) The ED is a vital component of America's health care "safety net". (2) Overcrowding in ED treatment areas threatens public health by compromising patient safety and jeopardising the reliability of the entire US emergency care system. (3) Although the causes of ED overcrowding are complex, the main cause is inadequate inpatient capacity for a patient population with an increasing severity of illness. (4) Potential solutions for ED overcrowding will require multidisciplinary system-wide support.