Association between ambulance diversion and survival among patients with acute myocardial infarction

Elimination of Emergency Department Ambulance Divert during the COVID-19 Pandemic Was Not Associated with an Increase in the Average Number of Ambulance Arrivals per Day

INTRODUCTION

During the COVID-19 pandemic, ambulance divert in our EMS system reached critical levels. We hypothesized that eliminating ambulance divert would not be associated with an increase in the average number of daily ambulance arrivals. Our study objective was to quantify the EMS and emergency department (ED) effects of eliminating ambulance divert during the COVID-19 pandemic.

METHODS

Regional hospital divert data were obtained for the 10-county Twin Cities metro from MNTrac, a state-supported online system designed to allow hospitals to indicate their divert status to EMS. ED metrics are reported for a single Level I trauma center and were obtained by a deidentified data pull from our electronic medical record covering the 12 months prior to the elimination of divert (2021) and the 12 months after divert elimination (2022). The decision to eliminate divert occurred in November 2021, based on data available through October, with an implementation date of January 2022. The primary study outcome was to quantify the effect of the elimination of divert on the number of ambulances arriving per day at the study hospital.

RESULTS

Regional utilization of ambulance divert increased steadily by 859% from January to October 2021 when 355 individual divert events occurred, totaling 809 h (34 days). There was no significant difference in the number of ambulances that arrived to the study hospital in 2021 (30,774) vs 2022 (30,421) p = 0.15. As compared to 2021, in 2022 there was no significant increase in mean ambulance arrivals per day (84/day vs 83/day, p = 0.08), time to room Emergency Severity Index level 2 (ESI) patients (28 min vs 28 min, p = 0.90), or time to obtain emergent head CT in acute "code stroke" patients (12 min vs 12 min, p = 0.15). Ambulance turnaround interval in the ED did not appreciably increase (16 min vs 17 min, p = 0.15).

CONCLUSION

Elimination of ambulance divert was not associated with increases in the number of mean daily ambulance arrivals or EMS turnaround intervals, delays in ESI 2 patients being placed in beds, or prolonged time to head CT in stroke code patients.

Impact of increased reimbursement for ambulance transportation on hospital acceptance in Japan: a difference-in-difference study

OBJECTIVE

Emergency medical services (EMS) often face difficulties in finding accepting hospitals in Japan. The universal medical insurance system in Japan increased the reimbursement for ambulance transportation acceptance at night, and on Sundays and holidays from 1 April 2016. This study investigated the effect of the reimbursement increase on the number of EMS calls, and transportation time from arrival at the scene to arrival at the hospital.

DESIGN

A difference-in-difference study. The treatment group consisted of people who called an ambulance at night while the control group consisted of people who called an ambulance during the daytime.

SETTING

The national ambulance records of the Fire and Disaster Management Agency in Japan from 1 April 2015 to 31 December 2016.

PARTICIPANTS

7 625 463 ambulance dispatches were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOME MEASURES

The changes in EMS calls, transportation time and the number of ambulance transports per 1000 population in one month in a comparison of daytime and night-time transport.

RESULTS

The treatment effect (night-time vs daytime) on the number of EMS calls was -0.013 (95% CI, -0.023 to -0.004), which was significant. The transportation time decreased slightly by 0.080 min (95% CI, -0.157 to -0.004). No impact was observed on the number of ambulance transports per 1000 population per month (0.00; 95% CI, -0.008 to 0.002).

CONCLUSION

An increase in reimbursement for ambulance transportation acceptance was associated with a decrease in the number of EMS calls. Further strategies for decreasing the number of EMS calls are needed to avoid delays in the treatment of emergency patients with critical illness.

COVID-19 Policies, Pandemic Disruptions, and Changes in Child Mental Health and Sleep in the United States

IMPORTANCE

The adverse effects of COVID-19 containment policies disrupting child mental health and sleep have been debated. However, few current estimates correct biases of these potential effects.

OBJECTIVES

To determine whether financial and school disruptions related to COVID-19 containment policies and unemployment rates were separately associated with perceived stress, sadness, positive affect, COVID-19-related worry, and sleep.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was based on the Adolescent Brain Cognitive Development Study COVID-19 Rapid Response Release and used data collected 5 times between May and December 2020. Indexes of state-level COVID-19 policies (restrictive, supportive) and county-level unemployment rates were used to plausibly address confounding biases through 2-stage limited information maximum likelihood instrumental variables analyses. Data from 6030 US children aged 10 to 13 years were included. Data analysis was conducted from May 2021 to January 2023.

EXPOSURES

Policy-induced financial disruptions (lost wages or work due to COVID-19 economic impact); policy-induced school disruptions (switches to online or partial in-person schooling).

MAIN OUTCOMES AND MEASURES

Perceived stress scale, National Institutes of Health (NIH)-Toolbox sadness, NIH-Toolbox positive affect, COVID-19-related worry, and sleep (latency, inertia, duration).

RESULTS

In this study, 6030 children were included in the mental health sample (weighted median [IQR] age, 13 [12-13] years; 2947 [48.9%] females, 273 [4.5%] Asian children, 461 [7.6%] Black children, 1167 [19.4%] Hispanic children, 3783 [62.7%] White children, 347 [5.7%] children of other or multiracial ethnicity). After imputing missing data, experiencing financial disruption was associated with a 205.2% [95% CI, 52.9%-509.0%] increase in stress, a 112.1% [95% CI, 22.2%-268.1%] increase in sadness, 32.9% [95% CI, 3.5%-53.4%] decrease in positive affect, and a 73.9 [95% CI, 13.2-134.7] percentage-point increase in moderate-to-extreme COVID-19-related worry. There was no association between school disruption and mental health. Neither school disruption nor financial disruption were associated with sleep.

CONCLUSIONS AND RELEVANCE

To our knowledge, this study presents the first bias-corrected estimates linking COVID-19 policy-related financial disruptions with child mental health outcomes. School disruptions did not affect indices of children's mental health. These findings suggest public policy should consider the economic impact on families due to pandemic containment measures, in part to protect child mental health until vaccines and antiviral drugs become available.

Are hospitals with both medical/surgical and psychiatric services associated with decreased difficulty in ambulance transfer for patients with self-harm behaviour? A nationwide retrospective observational study using ambulance transfer data in Japan

OBJECTIVES

Ambulance diversion and prolonged prehospital transfer time have a significant impact on patient care outcomes. Self-harm behaviour in particular is associated with difficulty in hospital acceptance and longer prehospital transfer time. This study aimed to determine if hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres are associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer time for patients seeking medical care after self-harm behaviour.

DESIGN AND SETTING

A retrospective observational study using the database of Japanese ambulance dispatch data in 2015.

PARTICIPANTS

Patients who were transferred by ambulances after self-harm behaviour.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Multivariable logistic regression analysis and multivariable linear regression analysis were performed to assess whether the presence of hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres in the city were associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer time.

RESULTS

The number of transfers due to self-harm behaviour in 2015 was 32 849. There was an association between decreased difficulty in hospital acceptance and the presence of high-level emergency care centres (OR 0.63, 95% CI 0.55 to 0.71, p<0.01) and hospitals with both medical/surgical and psychiatric inpatient beds (OR 0.50, 95% CI 0.38 to 0.66, p<0.01). There was a significant reduction in prehospital transfer time in the city with high-level emergency care centres (4.21 min, 95% CI 3.53 to 4.89, p<0.01) and hospitals with medical/surgical and psychiatric inpatient beds (3.46 min, 95% CI 2.15 to 4.77, p<0.01).

CONCLUSION

Hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres were associated with significant decrease in difficulty in hospital acceptance and shorter prehospital transfer time.

Association of emergency department crowding with inpatient outcomes

OBJECTIVE

To examine the association of higher emergency department (ED) census with inpatient outcomes on the day of discharge (inpatient length of stay, in-hospital mortality, ED revisits, and readmissions).

DATA SOURCES AND STUDY SETTING

All-payer ED and inpatient discharge data and hospital characteristics data from all non-federal, general, and acute care hospitals in the state of California from October 1, 2015 to December 31, 2017.

STUDY DESIGN

In retrospective data analysis, we examined whether ED census was associated with inpatient outcomes for all inpatients, including those not admitted through the ED. The main predictor variable was ED census on day of discharge, categorized based on hospital year and day of week. Separate linear regression models with robust SEs and hospital fixed effects examined the association of ED census on inpatient outcomes (length of stay, 3-day ED revisit, 30-day all-cause readmission, in-hospital mortality), controlling for patient and visit-level factors. We stratified analyses by whether admission was elective or unscheduled.

EXTRACTION METHODS

Inpatient discharges in non-federal, general medical hospitals with EDs.

PRINCIPAL FINDINGS

We examined 5,784,253 discharges. The adjusted model showed that, compared to when the ED was below the median, higher ED census on the day of discharge was associated with longer inpatient length of stay, lower readmissions, and higher in-hospital mortality (90th percentile for length of stay: +0.8% [95% confidence interval, CI: +0.6% to +1.1%]; readmissions: -0.59 percentage points [or -5.6%] [95% CI: -0.0071 to -0.0048]; mortality: +0.14 percentage points [or +5.4%] [95% CI: +0.0009 to +0.0018]). [Correction added on 18 November 2022, after first online publication: '[odds rato, OR -5.6%]' and '[OR +5.4%]' of the preceding sentence have been corrected to '[or -5.6%]' and '[or +5.4%]', respectively, in this version.] Results for length of stay were primarily driven by patients with elective admissions, while results for readmissions and in-hospital mortality were primarily driven by patients with unscheduled admissions.

CONCLUSIONS

This study suggests that ED crowding may affect inpatients throughout the hospital, even patients who are already admitted to the hospital.

The influence of ambulance offload time on 30-day risks of death and re-presentation for patients with chest pain

OBJECTIVE

To assess whether ambulance offload time influences the risks of death or ambulance re-attendance within 30 days of initial emergency department (ED) presentations by adults with non-traumatic chest pain.

DESIGN, SETTING

Population-based observational cohort study of consecutive presentations by adults with non-traumatic chest pain transported by ambulance to Victorian EDs, 1 January 2015 - 30 June 2019.

PARTICIPANTS

Adults (18 years or older) with non-traumatic chest pain, excluding patients with ST elevation myocardial infarction (pre-hospital electrocardiography) and those who were transferred between hospitals or not transported to hospital (eg, cardiac arrest or death prior to transport).

MAIN OUTCOME MEASURES

Primary outcome: 30-day all-cause mortality (Victorian Death Index data).

SECONDARY OUTCOME

Transport by ambulance with chest pain to ED within 30 days of initial ED presentation.

RESULTS

We included 213 544 people with chest pain transported by ambulance to EDs (mean age, 62 [SD, 18] years; 109 027 women [51%]). The median offload time increased from 21 (IQR, 15-30) minutes in 2015 to 24 (IQR, 17-37) minutes during the first half of 2019. Three offload time tertiles were defined to include approximately equal patient numbers: tertile 1 (0-17 minutes), tertile 2 (18-28 minutes), and tertile 3 (more than 28 minutes). In multivariable models, 30-day risk of death was greater for patients in tertile 3 than those in tertile 1 (adjusted rates, 1.57% v 1.29%; adjusted risk difference, 0.28 [95% CI, 0.16-0.42] percentage points), as was that of a second ambulance attendance with chest pain (adjusted rates, 9.03% v 8.15%; adjusted risk difference, 0.87 [95% CI, 0.57-1.18] percentage points).

CONCLUSIONS

Longer ambulance offload times are associated with greater 30-day risks of death and ambulance re-attendance for people presenting to EDs with chest pain. Improving the speed of ambulance-to-ED transfers is urgently required.

Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban

Background

The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED).

Methods

We obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states.

Results

Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2).

Conclusion

Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08358-8.

The Impact of Delayed Symptomatic Treatment Implementation in the Intensive Care Unit

We estimated the harm related to medication delivery delays across 12,474 medication administration instances in an intensive care unit using retrospective data in a large urban academic medical center between 2012 and 2015. We leveraged an instrumental variables (IV) approach that addresses unobserved confounds in this setting. We focused on nurse shift changes as disruptors of timely medication (vasodilators, antipyretics, and bronchodilators) delivery to estimate the impact of delay. The average delay around a nurse shift change was 60.8 min (p < 0.001) for antipyretics, 39.5 min (p < 0.001) for bronchodilators, and 57.1 min (p < 0.001) for vasodilators. This delay can increase the odds of developing a fever by 32.94%, tachypnea by 79.5%, and hypertension by 134%, respectively. Compared to estimates generated by a naïve regression approach, our IV estimates tend to be higher, suggesting the existence of a bias from providers prioritizing more critical patients.

Potential bypassing of nearest emergency department by EMS transports

OBJECTIVE

Guidelines recommend emergency medical services (EMS) patients to be transported to the nearest appropriate emergency department (ED). Our objective was to estimate the prevalence of EMS transport to an ED other than the nearest ED ("potential bypassing").

DATA SOURCES

Illinois Prehospital Patient Care Report Data of EMS transports (July 2019 to December 2019).

DATA COLLECTION/EXTRACTION METHODS

We identified all EMS ground transports with an advanced life-support (ALS) paramedic to an ED for patients aged 21 years and older. Using street address of incident location, we performed geocoding and driving route analyses and obtained estimated driving distance and time to the destination ED and alternative EDs.

MAIN OUTCOME AND MEASURES

Our main outcomes were dichotomous indicators of potential bypassing of the nearest ED based on distance and time. As secondary outcomes we examined potential bypassing indicators based on excess driving distance and time.

STUDY DESIGN

We used Poisson regression models to obtain adjusted relative rates of potential bypassing indicators by acuity level, primary impression, patient demographics and geographic characteristics.

PRINCIPAL FINDINGS

Our study cohort of 361,051 EMS transports consisted of 5.8% critical, 37.2% emergent and 57.0% low acuity cases transported to 222 EDs. The observed rate of potential bypassing was approximately 34% of cases for each acuity level. Treating the cardiovascular primary impression code group as the reference case, we found small to no differences in potential bypassing rates across other primary impression code groups of all acuity levels, with the exception of critical acuity trauma cases for which potential bypassing rate was 64% higher (incidence rate ratio = 1.64, 95% confidence interval, 1.54-1.74). Compared to zip codes with one ED within a 5-mile vicinity, potential bypassing was higher in areas with no ED or multiple EDs within a 5-mile vicinity.

CONCLUSION

Approximately one-third of EMS transports potentially bypassed the nearest ED. EMS transport destination may be motivated by factors other than proximity.

Use of a Novel Patient-Flow Model to Optimize Hospital Bed Capacity for Medical Patients

BACKGROUND

There is no known method for determining the minimum number of beds in hospital inpatient units (IPs) to achieve patient waiting-time targets. This study aims to determine the relationship between patient waiting time-related performance measures and bed utilization, so as to optimize IP capacity decisions.

METHODS

The researchers simulated a novel queueing model specifically developed for the IPs. The model takes into account salient features of patient-flow dynamics and was validated against hospital census data. The team used the model to evaluate inpatient capacity decisions against multiple waiting time outcomes: (1) daily average, peak-hour average, and daily maximum waiting times; and (2) proportion of patients waiting strictly more than 0, 1, and 2 hours. The results were published in a simple Microsoft Excel toolbox to allow administrators to conduct sensitivity analysis.

RESULTS

To achieve the hospital's goal of rooming patients within 30 to 60 minutes of IP bed requests, the model predicted that the optimal daily average occupancy levels should be 89%-92% (182-188 beds) in the Medicine cohort, 74%-79% (41-43 beds) in the Cardiology cohort, and 72%-78% (23-25 beds) in the Observation cohort. Larger IP cohorts can achieve the same queueing-related performance measure as smaller ones, while tolerating a higher occupancy level. Moreover, patient waiting time increases rapidly as the occupancy level approaches 100%.

CONCLUSION

No universal optimal IP occupancy level exists. Capacity decisions should therefore be made on a cohort-by-cohort basis, incorporating the comprehensive patient-flow characteristics of each cohort. To this end, patient-flow queueing models tailored to the IPs are needed.

Association of Cardiac Care Regionalization With Access, Treatment, and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND

Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes.

METHODS

Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state.

RESULTS

For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality.

CONCLUSIONS

Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.

The association of Medicaid expansion and racial/ethnic inequities in access, treatment, and outcomes for patients with acute myocardial infarction

Introduction

After having an acute myocardial infarction (AMI), racial and ethnic minorities have less access to care, decreased rates of invasive treatments such as percutaneous coronary intervention (PCI), and worse outcomes compared with white patients. The objective of this study was to determine whether the Affordable Care Act’s expansion of Medicaid eligibility was associated with changes in racial disparities in access, treatments, and outcomes after AMI.

Methods

Quasi-experimental, difference-in-differences-in-differences analysis of non-Hispanic white and minority patients with acute myocardial infarction in California and Florida from 2010–2015, using linear regression models to estimate the difference-in-differences. This population-based sample included all Medicaid and uninsured patients ages 18–64 hospitalized with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act beginning as early as July 2011 in certain counties, and Florida, which did not expand Medicaid. The main outcomes included rates of admission to hospitals capable of performing PCI, rates of transfer for patients who first presented to hospitals that did not perform PCI, rates of PCI during hospitalization and rates of early (within 48 hours of admission) PCI, rates of readmission to the hospital within 30 days, and rates of in-hospital mortality.

Results

A total of 55,991 hospital admissions met inclusion criteria, 32,540 of which were in California and 23,451 were in Florida. Among patients with AMI who initially presented to a non-PCI hospital, the likelihood of being transferred increased by 12 percentage points (95% CI 2 to 21) for minority patients relative to white patients after the Medicaid expansion. The likelihood of undergoing PCI increased by 3 percentage points (95% CI 0 to 5) for minority patients relative to white patients after the Medicaid expansion. We did not find an association between the Medicaid expansion and racial disparities in overall likelihood of admission to a PCI hospital, hospital readmissions, or in-hospital mortality.

Conclusions

The Medicaid expansion was associated with a decrease in racial disparities in transfers and rates of PCI after AMI. We did not find an association between the Medicaid expansion and admission to a PCI hospital, readmissions, and in-hospital mortality. Additional factors outside of insurance coverage likely continue to contribute to disparities in outcomes after AMI. These findings are crucial for policy makers seeking to reduce racial disparities in access, treatment and outcomes in AMI.

Association Between State Medicaid Expansion and Emergency Access to Acute Care Hospitals in the United States

IMPORTANCE

State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals.

OBJECTIVE

To determine the relationship between state Medicaid expansion and emergency access to acute care hospitals in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study linked hospital-level data from the Centers for Medicare & Medicaid Services from 2007 to 2017 to US Census data for all 50 US states and the District of Columbia. Geospatial analyses and difference-in-differences regression models were used to compare temporal changes in the size of the population without 30-minute access to acute care hospitals between 32 states that expanded Medicaid with the population without access in 19 that did not, before and after expansion. Analyses focused on the total population and those with low incomes; secondary analyses examined emergency access to safety-net hospitals.

EXPOSURES

State-level Medicaid expansion.

MAIN OUTCOMES AND MEASURES

Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital.

RESULTS

States that did not expand Medicaid experienced an increase in the population without access to hospitals overall (without expansion: 6.76% to 6.79% [0.03%]; vs with expansion: 5.65% to 5.35% [-0.30%]; difference-in-differences, 0.33%; 95% CI, 0.33%-0.34%; P < .001) and for low-income persons (without expansion: 7.43% to 7.39% [-0.04%]; vs with expansion: 6.25% to 6.15% [-0.10%]; difference-in-differences, 0.06%; 95% CI, 0.05%-0.07%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 421 000 more persons overall and 48 000 more low-income persons would have retained access. States that did not expand Medicaid experienced an increase in the population without access to safety-net hospitals overall (46.91% to 47.70% [0.79%] vs 33.94% to 33.07% [-0.87%]; difference-in-differences, 1.66%; 95% CI, 1.64%-1.66%; P < .001) and for low-income persons (45.28% to 46.14% [0.86%] vs 33.00% to 32.23% [-0.77%]; difference-in-differences, 1.63%; 95% CI, 1.63%-1.67%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 2 242 000 more persons overall and 364 000 more low-income persons would have retained access.

CONCLUSIONS AND RELEVANCE

States that did not expand Medicaid under the Patient Protection and Affordable Care Act were associated with worse emergency access to acute care hospitals compared with states that expanded Medicaid.

Emergency Department Closures And Openings: Spillover Effects On Patient Outcomes In Bystander Hospitals

High-occupancy hospitals may be sensitive to neighboring emergency department (ED) closures and openings, as they already operate at or near capacity. We conducted a retrospective analysis using data for the period 2001-13 to examine outcomes of and treatment received by patients with acute myocardial infarction at so-called bystander EDs that had been exposed to nearby ED closures or openings. We used changes in driving time between an ED and the next-closest one as a proxy for a closure or opening: If driving time increased, for instance, it meant that a nearby ED had closed. When a high-occupancy ED was exposed to a closure that resulted in increased driving time of thirty minutes or more to the next-closest ED, one-year mortality and thirty-day readmission rates increased by 2.39 and 2.00 percentage points, respectively, while the likelihood of receiving percutaneous coronary intervention (PCI) declined by 2.06 percentage points. Exposure to ED openings that resulted in decreased driving times of thirty minutes or more was associated with reductions in thirty-day mortality at bystander hospitals and an increased likelihood of receiving PCI. Our findings suggest that limited resources at high-occupancy bystander hospitals make them sensitive to changes in the availability of emergency care in neighboring communities.

Effects of Medicaid expansion on access, treatment and outcomes for patients with acute myocardial infarction

INTRODUCTION

Uninsured patients have decreased access to care, lower rates of percutaneous coronary intervention (PCI), and worse outcomes after acute myocardial infarction (AMI). The aim of this study was to determine whether expanding insurance coverage through the Affordable Care Act's expansion of Medicaid eligibility affected access to PCI hospitals, rates of PCI, 30-day readmissions, and in-hospital mortality after AMI.

METHODS

Quasi-experimental, difference-in-differences analysis of Medicaid and uninsured patients with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act, and Florida, which did not, from 2010-2015. This study accounts for the early expansion of Medicaid in certain California counties that began as early as July 2011. Main outcomes included rates of admission to PCI hospitals, rates of transfer for patients who initially presented to non-PCI hospitals, rates of PCI, rates of early PCI defined as within 48 hours of hospital admission, in-hospital mortality, and 30-day readmission.

RESULTS

55,991 hospital admissions between 2010-2015 met inclusion criteria. Of these, 32,540 were in California, which expanded Medicaid, and 23,451 were in Florida, which did not. 30-day readmission rates after AMI decreased by an absolute difference of 1.22 percentage points after the Medicaid expansion (95% CI -2.14 to -0.30, P < 0.01). This represented a relative decrease in readmission rates of 9.5% after AMI. No relationship between the Medicaid expansion and admission to PCI hospitals, transfer to PCI hospitals, rates of PCI, rates of early PCI, or in-hospital mortality were observed.

CONCLUSIONS

Hospital readmissions decreased by 9.5% after the Affordable Care Act expanded Medicaid eligibility, although there was no association found between Medicaid expansion and access to PCI hospitals or treatment with PCI. Better understanding the ways that Medicaid expansion might affect care for vulnerable populations with AMI is important for policymakers considering whether to expand Medicaid eligibility in their state.

Association between long boarding time in the emergency department and hospital mortality: a single-center propensity score-based analysis

Once diagnostic work-up and first therapy are completed in patients visiting the emergency department (ED), boarding them within the ED until an in-hospital bed became available is a common practice in busy hospitals. Whether this practice may harm the patients remains a debate. We sought to determine whether an ED boarding time longer than 4 h places the patients at increased risk of in-hospital death. This retrospective, propensity score-matched analysis and propensity score-based inverse probability weighting analysis was conducted in an adult ED in a single, academic, 1136-bed hospital in France. All patients hospitalized via the adult ED from January 1, 2013 to March 31, 2018 were included. Hospital mortality (primary outcome) and hospital length of stay (LOS) were assessed in (1) a matched cohort (1:1 matching of ED visits with or without ED boarding time longer than 4 h but similar propensity score to experience an ED boarding time longer than 4 h); and (2) the whole study cohort. Sensitivity analysis to unmeasured confounding and analyses in pre-specified cohorts of patients were conducted. Among 68,632 included ED visits, 17,271 (25.2%) had an ED boarding time longer than 4 h. Conditional logistic regression performed on a 10,581 pair-matched cohort, and generalized estimating equations with adjustment on confounders and stabilized propensity score-based inverse probability weighting applied on the whole cohort showed a significantly increased risk of hospital death in patients experiencing an ED boarding time longer than 4 h: odds ratio (OR) of 1.13 (95% confidence interval [95% CI] 1.05-1.22), P = 0.001; and OR of 1.12 (95% CI 1.03-1.22), P = 0.007, respectively. Sensitivity analyses showed that these findings might be robust to unmeasured confounding. Hospital LOS was significantly longer in patients exposed to ED boarding time longer than 4 h: median difference 2 days (95% CI 1-2) (P < 0.001) in matched analysis and mean difference 1.15 days (95% CI 1.02-1.28) (P < 0.001) in multivariable unmatched analysis. In this single-center propensity score-based cohort analysis, patients experiencing an ED boarding time longer than 4 h before being transferred to an in-patient bed were at increased risk of hospital death.

Emergency healthcare delivery for young adults during a planned mass gathering: A retrospective observational study

OBJECTIVE

To describe patient presentation characteristics and outcomes for people aged 16-18 years pre, during and post a planned youth mass gathering event (MGE): 'Schoolies week' on the Gold Coast, Queensland, Australia.

METHODS

This was a retrospective observational study, including patient presentations by all young adults requiring care in the ED or in-event health services (EHS) over a 21-day period in 2014. Data analysis included descriptive and inferential statistics.

RESULTS

A total of 1029 patient presentations were made by people aged 16-18 years to the ED and EHS over the 21-day study period (139 pre, 695 during [275 in ED, 420 in EHS], 195 post Schoolies week). Some ED patient characteristics and outcomes varied between the pre, during and post Schoolies periods, such as patients age (P < 0.001), usual place of residence (P < 0.001) and not waiting for treatment (P = 0.015). Of the 24 375 registered MGE attendees, 420 (1.72% [95% confidence interval 1.57-1.89], 17.2/1000) presented for in-event care. Most patients were allocated an Australasian Triage Scale category of 4 (n = 162, 65.6%), with toxicology related presentations (n = 169, 44.9%). Transportation to hospital was undertaken for seven MGE attendees (0.03% [95% confidence interval 0.01-0.06], 0.3/1000).

CONCLUSIONS

Establishment of an in-event model of care for 1 week during Schoolies served as an effective hospital avoidance strategy for a planned youth MGE. Such in-event models of care may be considered for other similar future MGE.

Ambulance diversions following public hospital emergency department closures

OBJECTIVE

To examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs private.

DATA SOURCES/STUDY SETTING

Ambulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California's Office of Statewide Health Planning and Development and the American Hospital Association (2007).

STUDY DESIGN

We match public and private (nonprofit or for-profit) hospitals by distance and size. We use random-effects models examining diversion probability and timing of private hospitals following diversions by neighboring public vs matched private hospitals.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Hospitals are 3.6 percent more likely to declare diversions if neighboring diverting hospitals are public vs private (P < 0.001). Hospitals declaring diversions have lower ED occupancy (P < 0.001) after neighboring public (vs private) hospitals divert. Hospitals have 4.2 percent shorter diversions if neighboring diverting hospitals are public vs private (P < 0.001). When the neighboring hospital ends its diversion first, hospitals terminate diversions 4.2 percent sooner if the neighboring hospital is public vs private (P = 0.022).

CONCLUSIONS

Sample hospitals respond differently to diversions by neighboring public (vs private) hospitals, suggesting that these hospitals might be strategically declaring ambulance diversions to avoid treating low-paying patients served by public hospitals.

The Impact of Cardiac-induced Post-traumatic Stress Disorder Symptoms on Cardiovascular Outcomes: Design and Rationale of the Prospective Observational Reactions to Acute Care and Hospitalizations (ReACH) Study

Aims:

As many as 1 in 8 acute coronary syndrome (ACS) patients develop posttraumatic stress disorder (PTSD) due to the ACS, and ACS-induced PTSD may increase secondary cardiovascular disease (CVD) risk. However, prior studies have been small and underpowered to test plausible behavioral or biological mechanisms of the hypothesized PTSD-secondary CVD risk association. In this paper, we describe the design and methods of a large prospective observational cohort study to estimate the prognostic significance of ACS-induced PTSD, mechanisms for its association with CVD risk, and emergency department (ED) factors that may increase PTSD risk, in a cohort of patients evaluated for acute coronary syndrome (ACS) in the ED of a large, urban academic medical center.

Methods:

The Reactions to Acute Care and Hospitalization (ReACH) study follows 1,741 racially, ethnically, and socioeconomically diverse patients initially presenting to the ED with ACS symptoms. Psychosocial factors are assessed at baseline. Medication adherence is monitored by electronic pill bottle (eCAP). Participants are contacted by phone at 1-, 6-, and 12-months post-hospitalization to assess PTSD symptoms, hospital readmission, and recurrent CVD events/mortality (proactively searched and confirmed by medical records).

Conclusion:

This study will provide the most accurate estimates to date of PTSD’s association with recurrent CVD events and mortality and will test whether medication adherence mediates that association. Further, it will provide estimates of the contribution of ED and hospital factors to PTSD risk in ACS patients. If our hypotheses are supported, we will have identified PTSD as a novel target for secondary risk reduction.

Should I be more concerned about patient care or the four-hour target?

UK emergency departments (EDs) are high-pressure environments focused on delivering care in the most efficient way to patients with a range of health problems. For many people EDs are the front door of the NHS and are a focus of significant media and political interest. People who attend EDs are often anxious and a main element of their concern is waiting time for treatment. In UK EDs the four-hour target is a main NHS target and a cornerstone of evaluating ED performance. There is ongoing debate about whether spending additional time in EDs affects patient care and outcomes, with some research showing increased mortality associated with longer stays and some showing no effect on mortality. Evidence suggests that patients are spending longer in UK EDs and it is possible that those who remain longer than four hours could have worse outcomes. This article identifies the effects of prolonged ED length of stay through a systematic literature review of data published since implementation of the four-hour target to measure the relationship between breaching the target and morbidity and mortality.

Statewide Method of Measuring Ambulance Patient Offload Times

OBJECTIVE

Ambulance patient offload time (APOT) also known colloquially as "Wall time" has been described in various jurisdictions but seems to be highly variable. Any attempt to improve APOT requires the use of common definitions and standard methodology to measure the extent of the problem.

METHODS

An Ambulance Offload Delay Task Force in California developed a set of standard definitions and methodology to measure APOT for transported 9-1-1 patients. It is defined as the time "interval between the arrival of an ambulance at an emergency department and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient." Local EMS agencies voluntarily reported data according to the standard methodology to the California EMS Authority (State agency).

RESULTS

Data were reported for 9-1-1 transports during 2017 from 9 of 33 local EMS Agencies in California that comprise 37 percent of the state population. These represent 830,637 ambulance transports to 126 hospitals. APOT shows significant variation by EMS agency with half of the agencies demonstrating significant delays. Offload times vary markedly by hospital as well as by region. Three-fourths of hospitals detained EMS crews more than one hour, 40% more than two hours, and one-third delayed EMS return to service by more than three hours.

CONCLUSION

This first step to address offload delays in California consists of standardized definitions for data collection to address the significant variability inherent in obtaining data from 33 local agencies, hundreds of EMS provider agencies, and 320 acute care hospital Emergency Departments that receive 9-1-1 ambulance transports. The first year of standardized data collection of ambulance patient offload times revealed significant ambulance patient offload time delays that are not distributed uniformly, resulting in a substantial financial burden for some EMS providers in California.

Closure simulation for reduction of emergency patient diversion: a discrete agent-based simulation approach to minimizing ambulance diversion

Background

The city of Munich uses web-based information system IVENA to promote exchange of information regarding hospital offerings and closures between the integrated dispatch center and hospitals to support coordination of the emergency medical services. Hospital crowding resulting in closures and thus prolonged transportation time poses a major problem. An innovative discrete agent model simulates the effects of novel policies to reduce closure times and avoid crowding.

Methods

For this analysis, between 2013 and 2017, IVENA data consisting of injury/disease, condition, age, estimated arrival time and assigned hospital or hospital-closure statistics as well as underlying reasons were examined. Two simulation experiments with three policy variations are performed to gain insights on the influence of diversion policies onto the outcome variables.

Results

A total of 530,000+ patients were assigned via the IVENA system and 200,000+ closures were requested during this time period. Some hospital units request a closure on more than 50% of days. The majority of hospital closures are not triggered by the absolute number of patient arrivals, but by a sudden increase within a short time period. Four of the simulations yielded a specific potential for shortening of overall closure time in comparison to the current status quo.

Conclusion

Effective solutions against crowding require common policies to limit closure status periods based on quantitative thresholds. A new policy in combination with a quantitative arrival sensor system may reduce closing hours and optimize patient flow.

Impact Of Ambulance Diversion: Black Patients With Acute Myocardial Infarction Had Higher Mortality Than Whites

This study investigated whether emergency department crowding affects blacks more than their white counterparts and the mechanisms behind which this might occur. Using a nonpublic database of patients in California with acute myocardial infarction between 2001 and 2011 and hospital-level data on ambulance diversion, we found that hospitals treating a high share of black patients with acute myocardial infarction were more likely to experience diversion and that black patients fared worse compared to white patients experiencing the same level of emergency department crowding as measured by ambulance diversion. The ninety-day and one-year mortality rates among blacks exposed to high diversion levels were 2.88 and 3.09 percentage points higher, respectively, relative to whites, representing a relative increase of 19 percent and 14 percent for ninety-day and one-year death, respectively. Interventions that decrease the need for diversion in hospitals serving a high volume of blacks could reduce these disparities.

Deconstructing the 4-h rule for access to emergency care and putting patients first

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED-in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED-in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care.

Factors associated with the difficulty in hospital acceptance among elderly emergency patients: A population-based study in Osaka City, Japan

AIM

We aimed to investigate prehospital factors associated with difficulty in hospital acceptance among elderly emergency patients.

METHODS

We reviewed ambulance records in Osaka City from January 2013 through December 2014, and enrolled all elderly emergency patients aged ≥65 years who were transported by on-scene emergency medical service personnel to a hospital that the personnel had selected. The definition of difficulty in hospital acceptance was to the requirement for ≥4 phone calls to hospitals by emergency medical service personnel before receiving a decision from the destination hospitals. Prehospital factors associated with difficulty in hospital acceptance were examined through logistic regression analysis.

RESULTS

During the study period, 72 105 elderly patients were included, and 13 332 patients (18.5%) experienced difficulty in hospital acceptance. In the simple linear regression model, hospital selection time increased significantly with an increasing number of phone calls (R²  = 0.774). In the multivariable analysis, older age (P for trend <0.001), calls from a healthcare facility (adjusted odds ratio [AOR] 1.23, 95% confidence interval [CI] 1.15-1.32), night-time (AOR 2.17, 95% CI 2.08-2.26) and weekend/holidays (AOR 1.43, 95% CI 1.38-1.49) were significantly associated with difficulty in hospital acceptance. A positive association was observed between gastrointestinal emergency-related symptoms and difficulty in hospital acceptance among elderly patients with symptoms of internal disease (AOR 1.71, 95% CI 1.53-1.91).

CONCLUSIONS

In Japan, which has a rapidly aging population, a comprehensive strategy for elderly emergency patients, especially for advanced age groups or nursing home residents, is required. Geriatr Gerontol Int 2017; 17: 2441-2448.

Trends in the supply of California's emergency departments and inpatient services, 2005-2014: a retrospective analysis

OBJECTIVES

Given increasing demand for emergency care, there is growing concern over the availability of emergency department (ED) and inpatient resources. Existing studies of ED bed supply are dated and often overlook hospital capacity beyond ED settings. We described recent statewide trends in the capacity of ED and inpatient hospital services from 2005 to 2014.

DESIGN

Retrospective analysis.

SETTING

Using California hospital data, we examined the absolute and per admission changes in ED beds and inpatient beds in all hospitals from 2005 to 2014.

PARTICIPANTS

Our sample consisted of all patients inpatient and outpatient) from 501 hospital facilities over 10-year period.

OUTCOME MEASURES

We analysed linear trends in the total annual ED visits, ED beds, licensed and staffed inpatient hospital beds and bed types, ED beds per ED visit, and inpatient beds per admission (ED and non-ED).

RESULTS

Between 2005 and 2014, ED visits increased from 9.8 million to 13.2 million (an increase of 35.0%, p<0.001). ED beds also increased (by 29.8%, p<0.001), with an average annual increase of 195.4 beds. Despite this growth, ED beds per visit decreased by 3.9%, from 6.0 ED beds per 10 000 ED visits in 2005 to 5.8 beds in 2014 (p=0.01). While overall admission numbers declined by 4.9% (p=0.06), inpatient medical/surgical beds per visit grew by 11.3%, from 11.6 medical/surgical beds per 1000 admissions in 2005 to 12.9 beds in 2014 (p<0.001). However, there were reductions in psychiatric and chemical dependency beds per admission, by -15.3% (p<0.001) and -22.4% (p=0.05), respectively.

CONCLUSIONS

These trends suggest that, in its current state, inadequate supply of ED and specific inpatient beds cannot keep pace with growing patient demand for acute care. Analysis of ED and inpatient supply should capture dynamic variations in patient demand. Our novel 'beds pervisit' metric offers improvements over traditional supply measures.

The impact of ED crowding on early interventions and mortality in patients with severe sepsis

OBJECTIVE

Critically ill patients require significant time and care coordination in the emergency department (ED). We hypothesized that ED crowding would delay time to intravenous fluids and antibiotics, decrease utilization of protocolized care, and increase mortality for patients with severe sepsis or septic shock.

METHODS

This was a retrospective cohort study of severe sepsis patients admitted to the hospital from the ED between January 2005 and February 2010. Associations between four validated measures of ED crowding (occupancy, waiting patients, admitted patients, and patient-hours) assigned at triage, and time of day, time to antibiotics and fluids, and mortality were tested by analyzing trends across crowding quartiles.

RESULTS

During the study period, 2913 severe sepsis patients were admitted to the hospital and 1127 (38.7%) qualified for protocolized care. In-hospital mortality was 14.3% overall and 26% for patients qualifying for protocolized care. Time to IV fluids was delayed as ED occupancy rate increased and as patient hours increased. Time to antibiotics increased as occupancy rates, patient hours, and the number of boarding inpatients increased. Implementation rates of protocolized care decreased from 71.3% to 50.5% (p<0.0001, OR 0.39) as the number of ED inpatient boarders increased; initiation of protocolized care was significantly higher as occupancy increased (OR 1.52). Mortality was unaffected by crowding parameters in all analyses.

CONCLUSIONS

With increased ED crowding, time to critical severe sepsis therapies significantly increased and protocolized care initiation decreased. As crowding increases, EDs must implement systems that optimize delivery of time-sensitive therapies to critically ill patients.

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries

OBJECTIVE

Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.

DATA SOURCES AND STUDY SETTING

Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.

STUDY DESIGN

We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).

DATA EXTRACTION METHODS

We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.

PRINCIPAL FINDINGS

Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.

CONCLUSIONS

There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity.

Comparative analysis of three prehospital emergency medical services organizations in India and Pakistan

OBJECTIVES

Strengthened emergency medical services (EMS) are urgently required in South Asia to reduce needless death and disability. Several EMS models have been introduced in India and Pakistan, and research on these models can facilitate improvements to EMS in the region. Our objective was to conduct a cross-case comparative analysis of three EMS organizations in India and Pakistan - GVK EMRI, Aman Foundation and Rescue 1122 - in order to draw out similarities and differences in their models.

STUDY DESIGN

Case study methodology was used to systematically explore the organizational models of GVK EMRI (Karnataka, India), Aman Foundation (Karachi, Pakistan), and Rescue 1122 (Punjab, Pakistan).

METHODS

Qualitative methods - interviews, document review and non-participant observation - were utilized, and using a process of constant comparison, data were analysed across cases according to the WHO health system 'building blocks'.

RESULTS

Emergent themes under each health system 'building block' of service delivery, health workforce, medical products and technology, health information systems, leadership and governance, and financing were described. Cross-cutting issues not applicable to any single building block were further identified.

CONCLUSIONS

This cross-case comparison, the first of its kind in low- and middle-income countries, highlights key innovations and lessons, and areas of further research across EMS organizations in India, Pakistan and other resource-poor settings.

California emergency department closures are associated with increased inpatient mortality at nearby hospitals

Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51 percent while the number of EDs nationwide decreased by 6 percent, which placed unprecedented strain on the nation's EDs. To investigate the effects of an ED's closing on surrounding communities, we identified all ED closures in California during the period 1999-2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that one-quarter of hospital admissions in this period occurred near an ED closure and that these admissions had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policy makers decide how to regulate ED closures.

Risk-Adjusted Variation of Publicly Reported Emergency Department Timeliness Measures

STUDY OBJECTIVE

The Centers for Medicare & Medicaid Services (CMS) recently published emergency department (ED) timeliness measures. These data show substantial variation in hospital performance and suggest the need for process improvement initiatives. However, the CMS measures are not risk adjusted and may provide misleading information about hospital performance and variation. We hypothesize that substantial hospital-level variation will persist after risk adjustment.

METHODS

This cross-sectional study included hospitals that participated in the Emergency Department Benchmarking Alliance and CMS ED measure reporting in 2012. Outcomes included the CMS measures corresponding to median annual boarding time, length of stay of admitted patients, length of stay of discharged patients, and waiting time of discharged patients. Covariates included hospital structural characteristics and case-mix information from the American Hospital Association Survey, CMS cost reports, and the Emergency Department Benchmarking Alliance. We used a γ regression with a log link to model the skewed outcomes. We used indirect standardization to create risk-adjusted measures. We defined "substantial" variation as coefficient of variation greater than 0.15.

RESULTS

The study cohort included 723 hospitals. Risk-adjusted performance on the CMS measures varied substantially across hospitals, with coefficient of variation greater than 0.15 for all measures. Ratios between the 10th and 90th percentiles of performance ranged from 1.5-fold for length of stay of discharged patients to 3-fold for waiting time of discharged patients.

CONCLUSION

Policy-relevant variations in publicly reported CMS ED timeliness measures persist after risk adjustment for nonmodifiable hospital and case-mix characteristics. Future "positive deviance" studies should identify modifiable process measures associated with high performance.

Do patients hospitalised in high-minority hospitals experience more diversion and poorer outcomes? A retrospective multivariate analysis of Medicare patients in California

OBJECTIVE

We investigated the association between crowding as measured by ambulance diversion and differences in access, treatment and outcomes between black and white patients.

DESIGN

Retrospective analysis.

SETTING

We linked daily ambulance diversion logs from 26 California counties between 2001 and 2011 to Medicare patient records with acute myocardial infarction and categorised patients according to hours in diversion status for their nearest emergency departments on their day of admission: 0, <6, 6 to <12 and ≥ 12 h. We compared the amount of diversion time between hospitals serving high volume of black patients and other hospitals. We then use multivariate models to analyse changes in outcomes when patients faced different levels of diversion, and compared that change between black and white patients.

PARTICIPANTS

29,939 Medicare patients from 26 California counties between 2001 and 2011.

MAIN OUTCOME MEASURES

(1) Access to hospitals with cardiac technology; (2) treatment received; and (3) health outcomes (30-day, 90-day, and 1-year death and 30-day readmission).

RESULTS

Hospitals serving high volume of black patients spent more hours in diversion status compared with other hospitals. Patients faced with the highest level of diversion had the lowest probability of being admitted to hospitals with cardiac technology compared with those facing no diversion, by 4.4% for cardiac care intensive unit, and 3.4% for catheterisation laboratory and coronary artery bypass graft facilities. Patients experiencing increased diversion also had a 4.3% decreased likelihood of receiving catheterisation and 9.6% higher 1-year mortality.

CONCLUSIONS

Hospitals serving high volume of black patients are more likely to be on diversion, and diversion is associated with poorer access to cardiac technology, lower probability of receiving revascularisation and worse long-term mortality outcomes.

National Differences in Regional Emergency Department Boarding Times: Are US Emergency Departments Prepared for a Public Health Emergency?

OBJECTIVES

Boarding admitted patients decreases emergency department (ED) capacity to accommodate daily patient surge. Boarding in regional hospitals may decrease the ability to meet community needs during a public health emergency. This study examined differences in regional patient boarding times across the United States and in regions at risk for public health emergencies.

METHODS

A retrospective cross-sectional analysis was performed by using 2012 ED visit data from the American Hospital Association (AHA) database and 2012 hospital ED boarding data from the Centers for Medicare and Medicaid Services Hospital Compare database. Hospitals were grouped into hospital referral regions (HRRs). The primary outcome was mean ED boarding time per HRR. Spatial hot spot analysis examined boarding time spatial clustering.

RESULTS

A total of 3317 of 4671 (71%) hospitals were included in the study cohort. A total of 45 high-boarding-time HRRs clustered along the East/West coasts and 67 low-boarding-time HRRs clustered in the Midwest/Northern Plains regions. A total of 86% of HRRs at risk for a terrorist event had high boarding times and 36% of HRRs with frequent natural disasters had high boarding times.

CONCLUSIONS

Urban, coastal areas have the longest boarding times and are clustered with other high-boarding-time HRRs. Longer boarding times suggest a heightened level of vulnerability and a need to enhance surge capacity because these regions have difficulty meeting daily emergency care demands and are at increased risk for disasters. (Disaster Med Public Health Preparedness. 2016;10:576-582).

The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke

BACKGROUND

Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission.

OBJECTIVES

The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA.

METHODS

This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables.

RESULTS

The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size.

CONCLUSIONS

These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.

Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality

Ambulance diversion, which occurs when a hospital emergency department (ED) is temporarily closed to incoming ambulance traffic, is an important system-level interruption that causes delays in treatment and potentially lower quality of care. There is little empirical evidence investigating the mechanisms through which ambulance diversion might affect patient outcomes. We investigated whether ambulance diversion affects access to technology, likelihood of treatment, and ultimately health outcomes for Medicare patients with acute myocardial infarction in twenty-six California counties. We found that patients whose nearest hospital ED had significant ambulance diversions experienced reduced access to hospitals with cardiac technology. This led to a 4.6 percent decreased likelihood of revascularization and a 9.8 percent increase in one-year mortality compared to patients who did not experience diversion. Policy makers may wish to consider creating a policy to specifically manage certain time-sensitive conditions that require technological intervention during periods of ambulance diversion.

Surgical risks associated with winter sport tourism

Background

Mass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context.

Methods

We selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics.

Results

A total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists’ influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716).

Conclusion

Surgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies.

Emergency department crowding predicts admission length-of-stay but not mortality in a large health system

BACKGROUND

Emergency department (ED) crowding has been identified as a major threat to public health.

OBJECTIVES

We assessed patient transit times and ED system crowding measures based on their associations with outcomes.

RESEARCH DESIGN

Retrospective cohort study.

SUBJECTS

We accessed electronic health record data on 136,740 adults with a visit to any of 13 health system EDs from January 2008 to December 2010.

MEASURES

Patient transit times (waiting, evaluation and treatment, boarding) and ED system crowding [nonindex patient length-of-stay (LOS) and boarding, bed occupancy] were determined. Outcomes included individual inpatient mortality and admission LOS. Covariates included demographic characteristics, past comorbidities, severity of illness, arrival time, and admission diagnoses.

RESULTS

No patient transit time or ED system crowding measure predicted increased mortality after control for patient characteristics. Index patient boarding time and lower bed occupancy were associated with admission LOS (based on nonoverlapping 95% CI vs. the median value). As boarding time increased from none to 14 hours, admission LOS increased an additional 6 hours. As mean occupancy decreased below the median (80% occupancy), admission LOS decreased as much as 9 hours.

CONCLUSIONS

Measures indicating crowded ED conditions were not predictive of mortality after case-mix adjustment. The first half-day of boarding added to admission LOS rather than substituted for it. Our findings support the use of boarding time as a measure of ED crowding based on robust prediction of admission LOS. Interpretation of measures based on other patient ED transit times may be limited to the timeliness of care.

Reducing ambulance diversion at hospital and regional levels: systemic review of insights from simulation models

Introduction:

Optimal solutions for reducing diversion without worsening emergency department (ED) crowding are unclear. We performed a systematic review of published simulation studies to identify: 1) the tradeoff between ambulance diversion and ED wait times; 2) the predicted impact of patient flow interventions on reducing diversion; and 3) the optimal regional strategy for reducing diversion.

Methods:

Data Sources: Systematic review of articles using MEDLINE, Inspec, Scopus. Additional studies identified through bibliography review, Google Scholar, and scientific conference proceedings. Study Selection: Only simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems were included. Data extraction: Independent extraction by two authors using predefined data fields.

Results:

We identified 5,116 potentially relevant records; 10 studies met inclusion criteria. In models that quantified the relationship between ED throughput times and diversion, diversion was found to only minimally improve ED waiting room times. Adding holding units for inpatient boarders and ED-based fast tracks, improving lab turnaround times, and smoothing elective surgery caseloads were found to reduce diversion considerably. While two models found a cooperative agreement between hospitals is necessary to prevent defensive diversion behavior by a hospital when a nearby hospital goes on diversion, one model found there may be more optimal solutions for reducing region wide wait times than a regional ban on diversion.

Conclusion:

Smoothing elective surgery caseloads, adding ED fast tracks as well as holding units for inpatient boarders, improving ED lab turnaround times, and implementing regional cooperative agreements among hospitals are promising avenues for reducing diversion.

Measuring the relationship between costs and outcomes: the example of acute myocardial infarction in German hospitals

In this paper, we propose a methodological approach to measure the relationship between hospital costs and health outcomes. We propose to investigate the relationship for each condition or disease area by using patient-level data. We examine health outcomes as a function of costs and other patient-level variables by using the following: (1) two-stage residual inclusion with Murphy-Topel adjustment to address costs being endogenous to health outcomes, (2) random-effects models in both stages to correct for correlation between observation, and (3) Cox proportional hazard models in the second stage to ensure that the available information is exploited. To demonstrate its application, data on mortality following hospital treatment for acute myocardial infarction (AMI) from a large German sickness fund were used. Provider reimbursement was used as a proxy for treatment costs. We relied on the Ontario Acute Myocardial Infarction Mortality Prediction Rules as a disease-specific risk-adjustment instrument. A total of 12,284 patients with treatment for AMI in 2004-2006 were included. The results showed a reduction in hospital costs by €100 to increase the hazard of dying, that is, mortality, by 0.43%. The negative association between costs and mortality confirms that decreased resource input leads to worse outcomes for treatment after AMI.

Site of hospital readmission and mortality: a population-based retrospective cohort study

BACKGROUND

Unplanned hospital readmission is a complex process, particularly if the patient is readmitted to an acute care institution other than the original hospital. This study tested the hypothesis that readmission to an alternative hospital is associated with increased mortality compared with readmission to the original hospital.

METHODS

We performed a population-based retrospective cohort analysis set between 1995 and 2010 for all 21 acute care adult general hospitals in the Greater Toronto and Hamilton Area. Participants were consecutive adults (age ≥ 18 yr) readmitted through the emergency department within 30 days after hospital discharge. The primary outcome measure was all-cause mortality within 30 days after readmission.

RESULTS

Of the 198 149 patients included in the study, 38 134 (19.2%) died within 30 days after readmission. Patients readmitted to an alternative hospital were more likely than those readmitted to the original hospital to be older, reside in a chronic-care facility and arrive by ambulance. Alternative-hospital readmission was associated with a higher risk of death within 30 days (22.3% v. 18.6%, p < 0.001; odds ratio [OR] 1.26, 95% confidence interval [CI] 1.23-1.30). The increased risk was substantially less after adjustment for patient- and hospital-level covariables (adjusted OR 1.06, 95% CI 1.02-1.10). Unadjusted Kaplan-Meier survival curves separated early and the absolute difference in mortality continued throughout the entire 1-year follow-up period, but no difference between groups was observed based on adjusted survival analyses.

INTERPRETATION

Among patients readmitted within 30 days after discharge, readmission to an alternative hospital was associated with a higher risk of death than readmission to the original hospital. Whether this adverse prognosis reflects a true causal relation or residual confounding is unknown.

Is emergency department crowding associated with increased "bounceback" admissions?

OBJECTIVE

Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions.

METHODS

We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission.

RESULTS

We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00).

CONCLUSIONS

Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.