Most Transfers from Urgent Care Centers to Emergency Departments Are Discharged and Many Are Unnecessary

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population

BACKGROUND

Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes.

METHODS

This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA.

RESULTS

A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001).

CONCLUSION

This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Strength in the gap: A rapid review of principles and practices for urgent care centres

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Evaluating urgent care center referrals to the emergency department

Background and objectives

Urgent care centers (UCCs) are increasingly popular with an estimated number of 9600 stand-alone centers in the United States compared to emergency departments (EDs). These facilities offer a potentially more convenient and affordable option for patients seeking care for a variety of low-acuity conditions. Because of the limitations of UCCs, patients occasionally are referred to EDs for further care. Prior studies have attempted to evaluate the appropriateness of these UCC referrals. Our study is the first to consider if these referrals require ED-specific care and the diagnostic concordance of these referrals.

Methods

We performed a retrospective chart review to identify patients who were referred from UCCs to our ED between October 2020 and June 2021. We used a Boolean search strategy to screen charts for the terms urgent care, emergency department, referral, or transfer. Cases were manually screened until 300 met the inclusion criteria. Cases had to feature the patient being seen by a UCC provider and directly referred to the ED on the same day. Patients who presented to the ED of their own volition were excluded. Three independent abstractors reviewed the charts. All abstractors and a senior investigator piloted the use of a data collection sheet and discussed the management of any ambiguous data. A senior physician reviewed all discrepancies among abstractors. Data collected included ED final diagnosis and whether the final diagnosis was similar to the UCC diagnosis. A referral was deemed to require ED-specific care and resources if (1) the patient was admitted, (2) imaging (other than an x-ray) was performed, (3) specialist consultation was required, or (4) care was provided in the ED that is not conventionally available at UCCs.

Results

From the 300 patient charts, 55% of patients referred from UCCs to the ED did not require ED-specific care or resources and 64% had discordant diagnoses between UCC diagnosis and ED diagnosis. A total of 41% of patients underwent advanced imaging studies, 26% received specialty consultations, and 15% were admitted. Subgroup analysis for lacerations, extremity/fracture care, and abnormal electrocardiograms (ECGs) showed disproportionally high levels of discordant diagnoses and referrals that did not require ED-specific care or resources.

Conclusion

Our data found that 55% of patients referred to EDs from UCCs did not require ED-specific care or resources and 64% carried a discordant diagnosis between UC and ED diagnosis. We suggest quality remedies, such as educational sessions and engagement with telemedicine sub-specialists as well as a coordinated formalized system for UCC to ED referrals.

Virtual First Uses Virtual Emergency Medicine Clinicians as a Health System Entry Point: A Cross-Sectional Survey Study (Preprint)

BACKGROUND

The COVID-19 pandemic accelerated the use and acceptance of telemedicine. Simultaneously, emergency departments (EDs) have experienced increased ED boarding. With this acceptance of telemedicine and the weighty increase in patient boarding, we proposed the innovative Virtual First (VF) program to leverage emergency medicine clinicians' (EMCs) ability to triage patients. VF seeks to reduce unnecessary ED visits by connecting patients with EMCs prior to seeking in-person care rather than using traditional ED referral systems.

OBJECTIVE

The goal of this study is to investigate how patients' access to EMCs from home via the establishment of VF changed how patients sought care for acute care needs.

METHODS

VF is a synchronous virtual video visit at a tertiary care academic hospital. VF was staffed by EMCs and enabled full management of patient complaints or, if necessary, referral to the appropriate level of care. Patients self-selected this service as an alternative to seeking in-person care at a primary care provider, urgent care center, or ED. A postvisit convenience sample survey was collected through a phone SMS text message or email to VF users. This is a cross-sectional survey study. The primary outcome measure is based on responses to the question "How would you have sought care if a VF visit was not available to you?" Secondary outcome measures describe valued aspects and criticisms. Results were analyzed using descriptive statistics.

RESULTS

There were 3097 patients seen via VF from July 2021 through May 2022. A total of 176 (5.7%) patients completed the survey. Of these, 87 (49.4%) would have sought care at urgent care centers if VF had not been available. There were 28 (15.9%) patients, 26 (14.8%) patients, and 1 (0.6%) patient that would have sought care at primary care providers, EDs, or other locations, respectively. Interestingly, 34 (19.3%) patients would not have sought care. The most valued aspect of VF was receiving care in the comfort of the home (n=137, 77.8%). For suggested improvements, 58 (33%) patients most commonly included "Nothing" as free text.

CONCLUSIONS

VF has the potential to restructure how patients seek medical care by connecting EMCs with patients prior to ED arrival. Without the option of VF, 64.2% (113/177) of patients would have sought care at an acute care facility. VF's innovative employment of EMCs allows for acute care needs to be treated virtually if feasible. If not, EMCs understand the local resources to better direct patients to the appropriate site. This has the potential to substantially decrease patient costs because patients are given the appropriate destination for in-person care, reducing the likelihood of the need for transfer and multiple ED visits.

Pediatric Urgent Care Center Management of Traumatic Injuries in Infants and Children: Adherence to Evidence-Based Practice Guidelines

OBJECTIVES

To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage.

METHODS

A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed to members of the Society for Pediatric Urgent Care. Clinician management decisions were evaluated against evidence-based practice guidelines.

RESULTS

Eighty-three completed questionnaires were returned (25% response rate). Fifty-three physician and 25 advanced practice provider (APP) questionnaires were analyzed. Most respondents were adherent to evidence-based practice guidelines in the following scenarios: cervical spine injury; head injury without neurologic symptoms; blunt abdominal injury; laceration without bleeding, foreign body, or signs of infection; first-degree burn; second-degree burn with less than 10% total body surface area; animal bite with and without probable tenosynovitis; and orthopedic fractures. Fever respondents were adherent in the following scenarios: head injury with altered mental status (adherence: physicians, 64%; APPs, 44%) and laceration with foreign body and persistent hemorrhage (adherence: physicians, 52%; APPs, 41%). Most respondents (56%) were unaware of Stop the Bleed and only 48% reported having a bleeding control kit/tourniquet at their urgent care.

CONCLUSIONS

Providers in our sample demonstrated adherence with pediatric trauma evidence-based practice guidelines. Increased PUC provider trauma care certification, PUC incorporation of Stop the Bleed education, and PUC presence of equipment and medications would further improve emergency preparedness.

Patient Insurance Status Is Associated With Care Received After Transfer Among Pediatric Patients in the Emergency Department

OBJECTIVE

To determine whether frequency of interfacility transfer varied by insurance status among pediatric emergency department (ED) patients. Secondarily, we tested for an association between insurance status and odds of transfer with discharge from the second ED without observation or admission.

METHODS

We used the 2016 New York State ED and Inpatient Databases to identify all patients <18 years. ED and hospital characteristics were from American Hospital Association and National ED Inventory-USA. Among all ED patients, we calculated the proportion transferred stratified by insurance status (private, public, none). Among ED-to-ED transfers, we identified transfers without subsequent observation or admission, and used hierarchical logistic regression modeling (adjusting for patient and transferring ED/hospital characteristics) to determine whether insurance status was associated with odds of discharge from the second ED without observation or admission.

RESULTS

Of 1,303,575 pediatric ED visits, 6086 (0.5%) were transferred. Transfers were less frequent among patients with public or no insurance. Of 3801 ED-to-ED transfers, 1451 (38%) were without subsequent observation or admission. In bivariate and multivariable analysis, transferred patients with public and with no insurance were less likely to be discharged without observation or admission relative to privately insured patients.

CONCLUSION

Among ED-to-ED transfers, pediatric patients with public or without insurance were more often kept for observation or admission at the second hospital after transfer. Differences in disease acuity or in providers' perception of follow-up availability may play a role in explaining these patterns. This disparity merits further investigation.

Resource utilization of adult patients referred to the emergency department from an urgent care center

BACKGROUND

The rise of urgent care centers (UCC) continues to serve as an alternative to emergency departments (ED) for patients with a perceived lower acuity complaint. Patients that are deemed to be higher acuity are often evaluated at an UCC and then redirected to EDs. However, limited data exist on resource utilization by patients who are transferred from UCCs to EDs. The objective of this study was to compare resource utilization in the ED between patients who were transferred from UCCs and those who were initially evaluated in the ED.

METHODS

This was a retrospective study of adult patients transferred from UCCs in Staten Island, NY to Staten Island University Hospital, between 1 March 2018 and 31 December 2018.  The first group (UCC Group) included those initially evaluated at an UCC and then referred to the ED. The second group (ED Group) included those who had their initial evaluation in the ED.

RESULTS

572 subjects were enrolled in the UCC Group, and 84,481 in the ED Group. The UCC Group was more likely to undergo laboratory tests, plain radiographs and computed tomography, electrocardiograms, intravenous fluids, and parenteral medications. Patients in the UCC group were also more likely to be admitted to an inpatient bed or placed into ED observation (p < 0.0001). Overall, ED length of stay was longer in the UCC Group (p < 0.001).

CONCLUSIONS

Patients referred from an UCC required more ED resources and were more likely to be admitted to a hospital bed compared to those who initially self-referred to the ED.

Lessons learned from an evaluation of referrals to the emergency department

BACKGROUND

Emergency department (ED) crowding is an international phenomenon dependent on input, throughput, and output factors. This study aims to determine whether patterns of potentially unnecessary referrals from either primary care physicians (PCPs) or urgent care centers (UCCs) can be identified, thereby to reduce ED visits by patients who could be treated elsewhere. Literature from the United States reports up to 35% unnecessary referrals from UCCs.

METHODS

A retrospective cohort study was conducted of patients referred to an ED in Jerusalem by either their PCP or a group of UCCs with a full range of laboratory tests and basic imaging capabilities between January 2017 and December 2017. The data were analyzed to identify referrals involving diagnoses, specialist consultations, and examinations unavailable in the PCP's office or UCC (e.g., ultrasound, CT, echocardiogram, or stress test); these referrals were considered necessary for completion of the patient work-up. If patients were evaluated by an ED physician and sent home after an examination or laboratory test available at least in the UCC, the referrals were considered potentially unnecessary.

RESULTS

Significantly more referrals were made by PCPs than UCCs (1712 vs. 280, p < 0.001). Significant differences were observed for orthopedics, general surgery, and obstetrics/gynecology referrals (p = 0.039, p < 0.001, p = 0.003). A higher percentage of patients referred by PCPs had potentially unnecessary visits compared to patients referred by UCCs (13.9% vs. 7.9%, p = 0.005).

CONCLUSION

A robust UCC system may help further reduce potentially unnecessary visits (including complex patients) to the ED.

2019 Update on Medical Overuse: A Review

IMPORTANCE

Medical overuse is an important cause of patient harm and medical waste.

OBSERVATION

This structured literature review of English-language articles supplemented by examination of tables of contents of high-impact journals published in 2018 identified articles related to medical overuse. Articles were appraised for their methodologic quality, clinical relevance, and influence on patients. Of 1499 candidate articles, 839 addressed medical overuse. Of these, 117 were deemed to be most significant, with the 10 highest-ranking articles selected by author consensus. The most important articles on medical overuse identified issues with testing, including that procalcitonin does not affect antibiotic duration in patients with lower respiratory tract infection (4.2 vs 4.3 days); incidentalomas are present in 22% to 38% of common magnetic resonance imaging or computed tomography studies; 9% of women dying of stage IV cancer are still screened with mammography; and computed tomography lung cancer screening offers stable benefit and higher rates of harm for patients at lower risk. Articles related to overtreatment reported that urgent care clinics commonly overprescribe antibiotics (in 39% of all visits, patients received antibiotics) and that treatment of subclinical hypothyroidism had no effect on clinical outcomes. Three studies highlighted services that should be questioned, including using opioids for chronic noncancer pain (meta-analysis found no clinically significant benefit), stress ulcer prophylaxis for intensive care unit patients (mortality, 31.1% with pantoprazole vs 30.4% with placebo), and supplemental oxygen for patients with normal oxygen levels (mortality relative risk, 1.21; 95% CI, 1.03-1.43). A policy article found that state medical liability reform was associated with reduced invasive testing for coronary artery disease, including 24% fewer angiograms.

CONCLUSIONS AND RELEVANCE

The findings suggest that many tests are overused, overtreatment is common, and unnecessary care can lead to patient harm. This review of these 2018 findings aims to inform practitioners who wish to reduce overuse and improve patient care.

Adult emergency department referrals from urgent care centers

BACKGROUND

Although urgent care centers (UCCs) can often evaluate and treat minor injuries/illnesses, patients may present with life threatening conditions that require immediate recognition, stabilization, and transfer to a higher level of care, beyond the capabilities of most UCCs.

OBJECTIVE

To describe adult ED referrals from UCCs and to determine the percentage of referrals considered critical, complex, and simple.

METHODS

A prospective study was conducted between 8/2016-8/2017 on patients >18 years referred directly to our ED from surrounding UCCs. Referrals were categorized based on investigations/procedures performed or medications/consultations received in the ED.

RESULTS

We analyzed 317 patient encounters; 23 (7.3%) considered critical, 254 (80.1%) complex, and 40 (12.6%) simple. The most common chief complaints for all ED referrals were abdominal pain (62 encounters), chest pain (28), shortness of breath (16), eye pain/injury (16), and leg pain/swelling (15). 68% of patients received laboratory diagnostic investigations and 69% received radiologic investigations. 37% of patients required consultation from a subspecialist. 78% of patients were discharged home. The most common primary diagnoses for all ED referrals were nonspecific abdominal pain (27 encounters), laceration (22), fracture (20), nonspecific chest pain (12), cellulitis (12), and pneumonia (12). The most common primary diagnoses for critical referrals were appendicitis (7) and fracture (3).

CONCLUSION

Many adult ED referrals in our sample were considered complex and few were considered critical. Individual UCCs should evaluate their current states of ED referrals, and develop educational and preparedness strategies based on the epidemiology of adult emergencies that may occur.