Refusing care to emergency department of patients: evaluation of published triage guidelines

Factors reducing inappropriate attendances to emergency departments before and during the COVID-19 pandemic: A multicentre study

INTRODUCTION

Inappropriate attendances (IAs) to emergency departments (ED) create an unnecessary strain on healthcare systems. With decreased ED attendance during the COVID-19 pandemic, this study postulates that there are less IAs compared to before the pandemic and identifies factors associated with IAs.

METHODS

We performed a retrospective review of 29,267 patient presentations to a healthcare cluster in Singapore from 7 April 2020 to 1 June 2020, and 36,370 patients within a corresponding period in 2019. This time frame coincided with local COVID-19 lockdown measures. IAs were defined as patient presentations with no investigations required, with patients eventually discharged from the ED. IAs in the 2020 period during the pandemic were compared with 2019. Multivariable logistic regression was performed to identify factors associated with IAs.

RESULTS

There was a decrease in daily IAs in 2020 compared to 2019 (9.91±3.06 versus 24.96±5.92, P<0.001). IAs were more likely with self-referrals (adjusted odds ratio [aOR] 1.58, 95% confidence interval [CI] 1.50-1.66) and walk-ins (aOR 4.96, 95% CI 4.59-5.36), and those diagnosed with non-specific headache (aOR 2.08, 95% CI 1.85-2.34), or non-specific low back pain (aOR 1.28, 95% CI 1.15-1.42). IAs were less likely in 2020 compared to 2019 (aOR 0.67, 95% CI 0.65-0.71) and older patients (aOR 0.79 each 10 years, 95% CI 0.78-0.80).

CONCLUSION

ED IAs decreased during COVID-19. The pandemic has provided a unique opportunity to examine factors associated with IAs.

Delayed emergencies: The composition and magnitude of non-respiratory emergency department visits during the COVID-19 pandemic

IMPORTANCE

COVID-19 has been associated with excess mortality among patients not diagnosed with COVID-19, suggesting disruption of acute health care provision may play a role.

OBJECTIVE

To determine the degree of declines in emergency department (ED) visits attributable to COVID-19 and determine whether these declines were concentrated among patients with fewer comorbidities and lower severity visits.

DESIGN

We conducted a differences-in-differences analysis of all commercial health insurance claims for ED visits in the first 20 weeks of 2018, 2019, and 2020. The intervention period began March 9 (week 11) of 2020, following state stay-at-home orders.

SETTING

We analyzed claims from Blue Cross Blue Shield of Louisiana (BCBSLA), located in a state with an early US COVID-19 outbreak. Visit and patient risk was assessed through comorbidities previously described as increasing the risk of COVID-19 decompensation, the hospital location's COVID-19 outbreak status, and the Ambulatory Care Sensitive Condition algorithm.

PARTICIPANTS

The study population comprised all ED visits from all BCBSLA members, whether admitted or discharged. There were 332,917 ED visits over the study period. The study population spanned member demographics including sex, age, and geography. Uninsured adults were not included due to data limitations.

EXPOSURES

The COVID-19 outbreak beginning March 9, 2020 in Louisiana.

MAIN OUTCOMES AND MEASURES

The main outcome of interest for this analysis is the difference (percent change) in all ED visits, categorized as either respiratory or non-respiratory, from week 1-20 in 2019 and week 1-10 in 2020, compared to week 11-20 in 2020.

RESULTS

In this differences-in-differences study using data from a commercial health insurer, we found that non-respiratory ED visits declined by 39%, whereas respiratory visits did not experience a significant decline. Visits that were potentially deferrable or from lower risk patient populations showed greater declines, but even high-risk patients and non-avoidable visits experienced large declines in non-respiratory ED visits. Non-respiratory ED visits declined by only 18% in areas experiencing COVID outbreak.

CONCLUSIONS AND RELEVANCE

COVID-19 has resulted in significant avoidance of ED care, comprising a mix of deferrable and high severity care. Hospital and public health pronouncements should emphasize appropriate care seeking.

Liu S, A. Camargo C, Aburawi E, Moeckel M, Slagman A, Christ M, Singer A, Tazarourte K, Rathlev NK, A. Grossman S, Bellou A. Association between boarding in the emergency department and in-hospital mortality: A systematic review

IMPORTANCE

Boarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events.

STUDY OBJECTIVE

The objective of our systematic review was to determine whether ED boarding (EDB) time is associated with in-hospital mortality (IHM).

METHODS

A systematic search was conducted in academic databases to identify relevant studies. Medline, PubMed, Scopus, Embase, Cochrane, Web of Science, Cochrane, CINAHL and PsychInfo were searched. We included all peer-reviewed published studies from all previous years until November 2018. Studies performed in the ED and focused on the association between EDB and IHM as the primary objective were included. Extracted data included study characteristics, prognostic factors, outcomes, and IHM. A search update in PubMed was performed in May 2019 to ensure the inclusion of recent studies before publishing.

RESULTS

From the initial 4,321 references found through the systematic search, the manual screening of reference lists and the updated search in PubMed, a total of 12 studies were identified as eligible for a descriptive analysis. Overall, six studies found an association between EDB and IHM, while five studies showed no association. The last remaining study included both ICU and non-ICU subgroups and showed conflicting results, with a positive association for non-ICU patients but no association for ICU patients. Overall, a tendency toward an association between EDB and IHM using the pool random effect was observed.

CONCLUSION

Our systematic review did not find a strong evidence for the association between ED boarding and IHM but there is a tendency toward this association. Further well-controlled, international multicenter studies are needed to demonstrate whether this association exists and whether there is a specific EDB time cut-off that results in increased IHM.

The impact of general practitioners working in or alongside emergency departments: a rapid realist review

OBJECTIVES

Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak.

DESIGN

Rapid realist literature review.

SETTING

Emergency departments.

INCLUSION CRITERIA

Articles describing general practitioners working in or alongside emergency departments.

AIM

To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system.

RESULTS

Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes.

CONCLUSIONS

Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research.

PROSPERO REGISTRATION NUMBER

CRD42017069741.

Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses

IMPORTANCE

Insurers have increasingly adopted policies to reduce emergency department (ED) visits that they consider unnecessary. One common approach is to retrospectively deny coverage if the ED discharge diagnosis is determined by the insurer to be nonemergent.

OBJECTIVE

To characterize ED visits that may be denied coverage if the ED coverage denial policy of a large national insurer, Anthem, Inc, is widely adopted.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of probability-sampled ED visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample occurring from January 1, 2011, to December 31, 2015, was conducted. Visits by commercially insured patients aged 15 to 64 years were examined. Those with ED discharge diagnoses defined by Anthem's policy as nonemergent and therefore subject to possible denial of coverage were classified as denial diagnosis visits. The primary presenting symptoms among denial diagnosis visits were identified, and all visits by commercially insured adults presenting with these primary symptoms were classified as denial symptom visits.

MAIN OUTCOMES AND MEASURES

Each visit cohort as a weighted proportion of commercially insured adult ED visits. The proportion of each visit cohort that received ED-level care, defined as visits where patients were triaged as urgent or emergent, received 2 or more diagnostic tests, or were admitted or transferred, was also examined.

RESULTS

From 2011 to 2015, 15.7% (95% CI, 15.0%-16.4%) of commercially insured adult ED visits (4440 of 28 304) were denial diagnosis visits (mean [SD] patient age, 36.6 [14.0] years; 2592 [58.7%] female and 2962 [63.5%] white). Among these visits, 39.7% (95% CI, 37.1%-42.3%) received ED-level care: 24.5% (95% CI, 21.7%-27.4%) were initially triaged as urgent or emergent and 26.0% (95% CI, 23.8%-28.3%) received 2 or more diagnostic tests. These denial diagnosis visits shared the same presenting symptoms as 87.9% (95% CI, 87.3%-88.4%) of commercially insured adult ED visits (24 882 of 28 304) (mean [SD] patient age, 38.5 [14.1] years; 14 362 [57.9%] female and 17 483 [68.7%] white). Among these denial symptom visits, 65.1% (95% CI, 63.4%-66.9%) received ED-level care: 43.2% (95% CI, 40.2%-46.4%) were triaged as urgent or emergent, 51.9% (95% CI, 50.0%-53.9%) received 2 or more diagnostic tests, and 9.7% (95% CI, 8.8%-10.6%) were admitted or transferred.

CONCLUSIONS AND RELEVANCE

Anthem's nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient's perspective. This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial.

Psychiatric presentations to an A&E department

A survey is described of people presenting with psychiatric problems to a north London accident and emergency (A&E) department over three months. Forty per cent presented with deliberate self-harm and 25% of these left before being assessed. Twenty per cent of those with problems compatible with a diagnosis of severe mental illness also left before being seen by a doctor. Differences between presentations ‘out-of-hours' and ‘in-hours' are described. Factors predicting admission were: previous psychiatric admission, symptoms of a psychotic or affective disorder and non-permanent accommodation. The survey has implications for the process of triage in A&E departments and the organisation of mental health liaison services.

Primary care services co-located with Emergency Departments across a UK region: early views on their development

BACKGROUND

Co-location of primary care services with Emergency Departments (ED) is one initiative aiming to reduce the burden on EDs of patients attending with non-urgent problems. However, the extent to which these services are operating within or alongside EDs is not currently known.This study aimed to create a typology of co-located primary care services in operation across Yorkshire and Humber (Y&H) as well as identify early barriers and facilitators to their implementation and sustainability.

METHODS

A self-report survey was sent to the lead consultant or other key contact at 17 EDs in the Y&H region to establish the extent and configuration of co-located primary care services. Semi-structured interviews were then conducted with urgent and unscheduled care stakeholders across five hospital sites to explore the barriers and facilitators to the formation and sustainability of these services.

RESULTS

Thirteen EDs completed the survey and interviews were carried out with four ED consultants, one ED nurse and three general practitioners (GPs). Three distinct models were identified: 'Primary Care Services Embedded within the ED' (seven sites), 'Co-located Urgent Care Centre' (two sites) and 'GP out-of-hours' (nine sites). Qualitative data were analysed using framework analysis. Four interview themes emerged (justification for the service, level of integration, referral processes and sustainability) highlighting some of the challenges in implementing these co-located primary care services.

CONCLUSION

Creating a service within or alongside the ED in which GPs can use their distinct skills and therefore add value to the existing skill mix of ED staff is an important consideration when setting up these systems. Effective triage arrangements should also be established to ensure appropriate patients are referred to GPs. Further research is required to identify the full range of models nationally and to carry out a rigorous assessment of their impact.

Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department

BACKGROUND

Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED).

METHODS

The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians.

RESULTS

An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487-6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2-6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians.

CONCLUSION

Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation.

Designing for Risk Assessment Systems for Patient Triage in Primary Health Care: A Literature Review

Background

This literature review covers original journal papers published between 2011 and 2015. These papers review the current status of research on the application of human factors and ergonomics in risk assessment systems’ design to cope with the complexity, singularity, and danger in patient triage in primary health care.

Objective

This paper presents a systematic literature review that aims to identify, analyze, and interpret the application of available evidence from human factors and ergonomics to the design of tools, devices, and work processes to support risk assessment in the context of health care.

Methods

Electronic search was performed on 7 bibliographic databases of health sciences, engineering, and computer sciences disciplines. The quality and suitability of primary studies were evaluated, and selected papers were classified according to 4 classes of outcomes.

Results

A total of 1845 papers were retrieved by the initial search, culminating in 16 selected for data extraction after the application of inclusion and exclusion criteria and quality and suitability evaluation.

Conclusions

Results point out that the study of the implications of the lack of understanding about real work performance in designing for risk assessment in health care is very specific, little explored, and mostly focused on the development of tools.

Predictive factors for hospitalization of nonurgent patients in the emergency department

Nonurgent emergency department (ED) patients are a controversial issue in the era of ED overcrowding. However, a substantial number of post-ED hospitalizations were found, which prompted for investigation and strategy management. The objective of this study is to identify risk factors for predicting the subsequent hospitalization of nonurgent emergency patients. This was a retrospective study of a database of adult nontrauma ED visits in a medical center for a period of 12 months from January 2013 to December 2013. Patient triages as either Taiwan Triage and Acuity Scale (TTAS) level 4 or 5 were considered "nonurgent." Basic demographic data, primary and secondary diagnoses, clinical parameters including blood pressure, heart rate, body temperature, and chief complaint category in TTAS were analyzed to determine if correlation exists between potential predictors and hospitalization in nonurgent patients.A total of 16,499 nonurgent patients were included for study. The overall hospitalization rate was 12.47 % (2058/16,499). In the multiple logistic regression model, patients with characteristics of males (odds ratio, OR = 1.37), age more than 65 years old (OR = 1.56), arrival by ambulance (OR = 2.40), heart rate more than 100/min (OR = 1.47), fever (OR = 2.73), and presented with skin swelling/redness (OR = 4.64) were predictors for hospitalization. The area under receiver-operator calibration curve (AUROC) for the prediction model was 0.70. Nonurgent patients might still be admitted for further care especially in male, the elderly, with more secondary diagnoses, abnormal vital signs, and presented with dermatologic complaints. Using the TTAS acuity level to identify patients for diversion away from the ED is unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.

Are patients who call a primary care office referred to the emergency department by non-healthcare personnel without the input of a physician?

Objective. We hypothesized that a significant percentage of patients who are referred to the Emergency Department (ED) after calling their primary care physician's (PCP) office receive such instructions without the input of a physician. Methods. We enrolled a convenience sample of stable adults at an inner-city ED. Patients provided written answers to structured questions regarding PCP contact prior to the ED visit. Continuous data are presented as means ± standard deviation; categorical data as frequency of occurrence. 95% confidence intervals were calculated. Results. The study group of 660 patients had a mean age of 41.7 ± 14.7 years and 72.6% had income below $20,000/year. 472 patients (71.51%; 67.9%-74.8%) indicated that they had a PCP. A total of 155 patients (23.0%; 19.9%-26.4%) called to contact their PCP prior to ED visit. For patients who called their PCP office and were directed by phone to the ED, the referral pattern was observed as follows: 31/98 (31.63%; 23.2%-41.4%) by a non-health care provider without physician input, 11/98 (11.2%; 6.2%-19.1%) by a non-healthcare provider after consultation with a physician, 12/98 (12.3%; 7.7%-20.3%) by a nurse without physician input, and 14/98 (14.3%; 8.6%-22.7%) by a nurse after consultation with physician. An additional 11/98, 11.2%; 6.2-19.1%) only listened to a recorded message and felt the message was directing them to the ED. Conclusion. A relatively small percentage of patients were referred to the ED without the consultation of a physician in our overall population. However, over half of those that contacted their PCP's office felt directed to the ED by non-health care staff.

Classificação de risco em pediatria: construção e validação de um guia para enfermeiros

RESUMOObjetivo:construir e validar um guia abreviado do protocolo de Acolhimento com Classificação de Risco em pediatria.Método:estudo metodológico, desenvolvido em duas etapas: elaboração do guia e validação aparente e de conteúdo. A elaboração baseou-se na estratificação do conteúdo do protocolo em cinco indicadores de risco, conforme a complexidade, sendo submetido à validação por nove juízes divididos em dois grupos: docentes-pesquisadores e enfermeiros.Resultados:na validação aparente, os juízes consideraram os 25 itens do guia claros e compreensíveis com concordância acima de 70%. Na validação de conteúdo, 17 (68%) itens foram considerados relevantes por 88,9% dos juízes. Os oito itens considerados irrelevantes foram alterados conforme sugestões dos juízes, alcançando-se o Índice de Validade de Conteúdo global de 0,98.Conclusão:o estudo resultou num guia de classificação de risco pediátrico válido para avaliar a criança nos serviços de emergência.

Reduced Hospital Duration of Stay Associated with Revised Emergency Department-Intensive Care Unit Admission Policy: A before and after Study

BACKGROUND

Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients.

OBJECTIVE

To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level.

METHODS

We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex.

RESULTS

We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged.

CONCLUSIONS

A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.

Association of Medicare and Medicaid insurance with increasing primary care-treatable emergency department visits in the United States

OBJECTIVES

Policymakers have increasingly focused on emergency department (ED) utilization for primary care-treatable conditions as a potentially avoidable source of rising health care costs. The objective was to determine the association of health insurance type and arrival time, as indicators of limited availability of primary care, with primary care-treatable classification of ED visits.

METHODS

This was a retrospective analysis of a nationally representative sample of 241,167 ED visits from the 1997 to 2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS). Probabilities of ED visits being primary care-treatable were categorized based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The association of health insurance type and arrival time was determined with the average probability of the primary diagnosis being primary care-treatable using multivariable linear regression.

RESULTS

Compared to privately insured visits, Medicaid visits had a 1.7% (95% confidence interval [CI] = 1.2% to 2.2%) and uninsured visits a 2.4% (95% CI = 1.9% to 3.0%) higher probability of primary care-treatable classification, while Medicare visits had a 1.4% (95% CI = 0.7% to 2.0%) lower probability during the overall study period. Compared to business hours, weekend visits had a 1.5% (95% CI = 1.0% to 2.0%) higher probability of being primary care-treatable during the overall study period. From 1997 to 2009, the overall adjusted probability of ED visits being primary care-treatable increased by 0.19% (95% CI = 0.10 to 0.28) per year. This probability increased at a rate of 0.52% per year for Medicare visits (95% CI = 0.38% to 0.65%), more than double that of Medicaid visits (0.25% per year, 95% CI = 0.13% to 0.37%). By contrast, there was no significant change from 1997 to 2009 in the average probability of ED visits being primary care-treatable by privately insured (0.05% per year, 95% CI = -0.07 to 0.16) or uninsured (0.00% per year, 95% CI = -0.12 to 0.13) individuals.

CONCLUSIONS

These findings add to prior work that implicates insurance type and arrival time in the variation of primary care-treatable ED visits. Although primary care-treatable classification of ED visits was most associated with uninsured or Medicaid visits, this classification increased most rapidly among Medicare visits during the study period.

Reconnecting patients with their primary care provider: an intervention for reducing nonurgent pediatric emergency department visits

OBJECTIVE

Intervention to reduce nonurgent pediatric emergency department (PED) visits over a 12-month follow-up.

METHODS

Prospective, randomized, controlled trial enrolled children seen in the PED for nonurgent concerns. Intervention subjects received a structured session/handout specific to their primary care provider (PCP), which outlined ways to obtain medical advice. Visitation to the PED and PCP were followed over 12 months.

RESULTS

A total of 164 patients were assigned to the intervention and 168 patients to the control. At 12-month follow-up, the intervention group had a lower rate of nonurgent PED utilization compared with the control group (70 [43%] patients in the intervention compared with 91 [54%] in the control; P = .047). At 12 months, there was an increase in the rate of sick visits to PCP in the intervention group when compared with the control (P = .036).

CONCLUSIONS

Intervention designed in cooperation with pediatricians was able to decrease nonurgent PED utilization and redirect patients to their PCP for future sick visits over a 12-month period.

Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits

IMPORTANCE

Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care.

OBJECTIVE

To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use.

DESIGN, SETTING, AND PARTICIPANTS

The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses.

MAIN OUTCOMES AND MEASURES

Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits.

RESULTS

Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room.

CONCLUSIONS AND RELEVANCE

Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.

A novel approach to identifying targets for cost reduction in the emergency department

This article introduces a novel framework that classifies emergency department (ED) visits according to broad categories of severity, identifying those categories of visits that present the most potential for reducing costs associated with the ED. Although cost savings directly attributable to the ED are apt to be an important emphasis of organizations operating under reformed payment systems, our framework suggests that a focus on diverting low-acuity visits away from the ED would result in far less savings compared with strategies aimed at reducing admissions and to a lesser extent improving the efficiency of ED care for intermediate or complex conditions. We conclude that targeting these categories, rather than minor injuries/illnesses, should be the primary focus of cost-reduction strategies from the ED. Given this understanding, we then discuss the implications of these findings on the financing of an emergency care system that needs to account for the required fixed costs of "stand-by capacity" of the ED and explore ways in which the ED can be better integrated into a patient-centered health care system.

Triage Ability of Emergency Medical Services Providers and Patient Disposition: A Prospective Study

Study objective:

To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.

Methods:

A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.

Results:

A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).

Conclusion:

Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

The ethics of health care reform: impact on emergency medicine

The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reform's likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.

Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France

BACKGROUND

For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.

METHODS

We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.

RESULTS

Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).

CONCLUSIONS

The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns

Background

It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.

Methods

Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.

Results

We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).

Conclusions

We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

Emergency department triage: an ethical analysis

Background

Emergency departments across the globe follow a triage system in order to cope with overcrowding. The intention behind triage is to improve the emergency care and to prioritize cases in terms of clinical urgency.

Discussion

In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.

Summary

We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach.

A systematic review of triage-related interventions to improve patient flow in emergency departments

BACKGROUND

Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments.

METHODS

A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group.

RESULTS

The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient.

CONCLUSIONS

Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Impact of policy changes on emergency department use by Medicaid enrollees in Oregon

OBJECTIVE

In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use.

METHODS

This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus).

RESULTS

Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue.

CONCLUSION

The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

Validation of an algorithm for categorizing the severity of hospital emergency department visits

BACKGROUND

Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated.

OBJECTIVE

To assess the validity of the NYU algorithm.

RESEARCH DESIGN

A longitudinal study in a single integrated delivery system from January 1999 to December 2001.

SUBJECTS

A total of 2,257,445 commercial and 261,091 Medicare members of an integrated delivery system.

MEASURES

ED visits were classified as emergent, nonemergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation approach.

RESULTS

Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within 1-day (odds ratio = 3.37, 95% CI: 3.31-3.44) or death within 30-days (odds ratio = 2.81, 95% CI: 2.62-3.00) than visits categorized as nonemergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for nonemergent conditions was not related to socio-economic status or insurance type.

CONCLUSIONS

The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for nonemergencies.

The appropriateness of referrals to a pediatric emergency department via a telephone health line

OBJECTIVE

We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral.

METHODS

A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED.

RESULTS

Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, and 347 were physician-referred. Groups were similar at baseline for sex, but health line-referred patients were significantly younger. Using explicitly set criteria, there was no significant difference in visit appropriateness among the health line-referrals (66%), the self- or parent-referrals (77%) and the physician-referrals (73%) (p = 0.11). However, when the examining physician determined visit appropriateness, physician-referred patients (80%) were deemed appropriate significantly more often than those referred by the health line (56%, p < 0.001) or by self- or parent-referral (63%, p = 0.002). There was no significant difference between these latter 2 referral routes (p = 0.50). In keeping with their greater acuity, physician-referred patients were significantly more likely to have investigations, receive some treatment, be admitted to hospital and have longer lengths of stay. Patients who were self- or parent-referred, and those who were health line-referred were similar to each other in these outcomes.

CONCLUSION

There was no significant difference in visit appropriateness based on the route of referral when we used set criteria; however, there was when we used treating physician opinion, triage category and resource use.

Low-severity musculoskeletal complaints evaluated in the emergency department

Patients with musculoskeletal disorders represent a considerable percentage of emergency department volume. Although patients with acute or high-severity conditions are encouraged to seek care in the emergency department, patients with nonacute, low-severity conditions may be better served elsewhere. This study prospectively assessed patients presenting to the emergency department with nonacute, low-severity musculoskeletal conditions to test the hypothesis that these patients have access to care outside the emergency department. One thousand ten adult patients with a musculoskeletal complaint were identified, and a detailed questionnaire was completed by 862 (85.3%) during their emergency department stay. Three hundred fifty (40.6%) patients presented with nonacute, low-severity conditions. Patients with nonacute, low-severity problems were less likely to have a primary care physician (62.5% versus 72.3%) or to have medical insurance (82.5% versus 87.7%), but a majority had both (59.3%). Only 14.3% had neither. Forty-four percent of all patients with primary care physicians believed their primary care physician was incapable of managing musculoskeletal problems. Appropriate use of the emergency department by patients with musculoskeletal disorders may require not only increased access to insurance and primary care, but also improved public understanding of the scope of care offered by primary care physicians and the conflicting demands placed on emergency department providers.

LEVEL OF EVIDENCE

Level I, prognostic study.

Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999-2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to "stabilize" a patient suffering from an "emergency medical condition" before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users' characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.

Accuracy of triage nurses in predicting patient disposition

OBJECTIVE

Increasing demand to reduce patient waiting times and improve patient flow has led to the introduction of a number of strategies such as fast track and patient streaming. The triage nurse is primarily responsible for identifying suitable patients, based on prediction of likely admission or discharge. The aim of the present study was to explore the accuracy with which triage nurses predict patient disposition.

METHODS

Over two separate 1-week periods, triage nurses at two urban tertiary hospitals electronically recorded in real time whether they thought each patient would be admitted or discharged. The patient's ultimate disposition (admission or discharge), age, sex, diagnostic group, triage category and time of arrival were also recorded.

RESULTS

In total, 1342 patients were included in the study, of which 36.0% were subsequently admitted. Overall, the triage nurse correctly predicted the disposition in 75.7% of patients (95% CI: 73.2-78.0). Nurses were more accurate at predicting discharge than admission (83.3% vs 65.1%, P = 0.04). Triage nurses were most accurate at predicting admission in patients with higher triage categories and most accurate at predicting discharge in patients with injuries and febrile illnesses (89.6%, 95% CI: 85.6-92.6). Predicted discharge was least accurate for patients with cardiovascular disease, with 41.1% (95% CI: 26.4-57.8) of predicted discharges in this category subsequently requiring admission.

CONCLUSION

Triage nurses can accurately predict likely discharge in specific subgroups of ED patients. This supports the role of triage nurses in appropriately identifying patients suitable for 'fast track' or streaming.

Perceptions of service quality and sacrifice in patients with minor medical conditions using emergency care

This study investigated the role of perceptions of service quality and sacrifice in patients attending the accident and emergency (A&E) departments with minor medical conditions that can be treated by their general practitioner (GP). Perceptions of service quality were measured using modified service quality performance indicators. Perceptions of monetary and non-monetary sacrifice were also captured. Questionnaire-based data were gathered prospectively through a random sample of adult patients who exhibited minor medical conditions at a UK teaching hospital A&E department. Service quality perceptions played a major part in the decision to attend A&E, whereas sacrifice perceptions did not. Perceptions of competence and credibility were the most important quality determinants and were rated higher for A&E than GP. Given that there were some misconceptions about the quality and nature of services each setting provides, recent reforms bringing about an ever-expanding range of healthcare service options may cause further confusion in patient decision-making.

The Effect of Low-Complexity Patients on Emergency Department Waiting Times

STUDY OBJECTIVE

The extent to which patients presenting to emergency departments (EDs) with minor conditions contribute to delays and crowding is controversial. To test this question, we study the effect of low-complexity ED patients on the waiting times of other patients.

METHODS

We obtained administrative records on all ED visits to Ontario hospitals from April 2002 to March 2003. For each ED, we determined the association between the number of new low-complexity patients (defined as ambulatory arrival, low-acuity triage level, and discharged) presenting in each 8-hour interval and the mean ED length of stay and time to first physician contact for medium- and high-complexity patients. Covariates were the number of new high- and medium-complexity patients, mean patient age, sex distribution, hospital teaching status, work shift, weekday/weekend, and total patient-hours. Autoregression modeling was used given correlation in the data.

RESULTS

One thousand ninety-five consecutive 8-hour intervals at 110 EDs were analyzed; 4.1 million patient visits occurred, 50.8% of patients were women, and mean age was 38.4 years. Low-, medium-, and high-complexity patients represented 50.9%, 37.1%, and 12% of all patients, respectively. Mean (median) ED length of stay was 6.3 (4.7), 3.9 (2.8), and 2.2 (1.6) hours for high-, medium-, and low-complexity patients, respectively, and mean (median) time to first physician contact was 1.1 (0.7), 1.3 (0.9), and 1.1 (0.8) hours. In adjusted analyses, every 10 low-complexity patients arriving per 8 hours was associated with a 5.4-minute (95% confidence interval [CI] 4.2 to 6.0 minutes) increase in mean length of stay and a 2.1-minute (95% CI 1.8 to 2.4 minutes) increase in mean time to first physician contact for medium- and high-complexity patients. Results were similar regardless of ED volume and teaching status.

CONCLUSION

Low-complexity ED patients are associated with a negligible increase in ED length of stay and time to first physician contact for other ED patients. Reducing the number of low-complexity ED patients is unlikely to reduce waiting times for other patients or lessen crowding.

Emergency outpatient services in the city of Berlin: factors for appropriate use and predictors for hospital admission

OBJECTIVES

To determine the proportion of patients making inappropriate use of medical care at hospital emergency rooms. To identify the factors that influence appropriateness of use and the probability of subsequent hospital admission.

METHODS

Data were collected from 815 patients at three gynaecological/internal medicine emergency clinics in Berlin, Germany using multiple data sources: (i) standardized interviews covered service use history, psychosocial variables, migration history and sociodemographics; (ii) medical data were retrieved from patients' medical records, including case histories, diagnoses and therapies; (iii) emergency room physicians were asked to evaluate patients' language comprehension, physician-patient relationship and treatment urgency. Statistical analyses included chi tests, correlational and logistic regression analyses.

RESULTS

According to a self-constructed index measuring appropriateness of emergency service use, about half of the patients' visits would have to be classified as inappropriate. Age, chronic illness and the time of day of the emergency service attendance were significantly associated with appropriateness of use. The probability of a hospital admission following the emergency treatment increased with patients' age and the physician's evaluation of treatment urgency. Remarkably, and contrary to the results of international studies, the patient's ethnicity played no significant role with respect to the appropriateness of use of emergency outpatient services or the likelihood of subsequent hospital admission.

Evaluation of a Fast Track Unit

BACKGROUND

Emergency departments (EDs) are struggling with overcrowding. The Institute for Healthcare Improvement recently concluded that reducing delays is critical to improving all aspects of emergency care. To reduce cycle times and improve patient flow, we developed a separate stream of care focused on low-acuity patients in our academic ED.

METHODS

Strict triage criteria were developed, and patients were seen by a physician's assistant in a dedicated section of the ED. Two anonymous surveys (patient and staff) and a time cycle analysis were performed before and after the intervention.

RESULTS

Eighty-seven preintervention patient surveys (response rate = 60%) and 91 postintervention surveys (response rate = 79%) were collected. Demographic data were comparable. All domains of patient satisfaction were significantly improved in the postintervention group and were correlated with the length of stay that decreased from 127 to 53 minutes (P < .001).

CONCLUSIONS

This study supports an emphasis on improving turnaround time as a primary driver of satisfaction, and demonstrates that a simple intervention characterized by focusing existing resources on the needs of a specific population can significantly improve health care delivery. Thoughtful alignment of resources with the needs of specific patient populations should similarly streamline care in other clinical settings.

Emergency department overcrowding: the Emergency Department Cardiac Analogy Model (EDCAM)

Increasing patient numbers, changing demographics and altered patient expectations have all contributed to the current problem with 'overcrowding' in emergency departments (EDs). The problem has reached crisis level in a number of countries, with significant implications for patient safety, quality of care, staff 'burnout' and patient and staff satisfaction. There is no single, clear definition of the cause of overcrowding, nor a simple means of addressing the problem. For some hospitals, the option of ambulance diversion has become a necessity, as overcrowded waiting rooms and 'bed-block' force emergency staff to turn patients away. But what are the options when ambulance diversion is not possible? Christchurch Hospital, New Zealand is a tertiary level facility with an emergency department that sees on average 65,000 patients per year. There are no other EDs to whom patients can be diverted, and so despite admission rates from the ED of up to 48%, other options need to be examined. In order to develop a series of unified responses, which acknowledge the multifactorial nature of the problem, the Emergency Department Cardiac Analogy model of ED flow, was developed. This model highlights the need to intervene at each of three key points, in order to address the issue of overcrowding and its associated problems.

Propuesta y validación del Protocolo de Adecuación de Urgencias Hospitalarias modificado

BACKGROUND AND OBJECTIVE

Hospital Emergency inappropriate attendances need to be evaluated, including emergencies that can be solved in primary care. The study aim was to validate a Hospital Emergency Appropriateness Evaluation Protocol (HEAEP) having into account patient health care setting.

MATERIAL AND METHOD

An HEAEP with explicit criteria was developed. We randomly chose 100 emergency medical records among all patients attended at the Granada Hospital Ruiz de Alda in the first quarter of 2000. Records were evaluated by six emergency specialists to compare results provided by the HEAEP.

RESULTS

The HEAEP identified as appropriate all attendances so classified by experts. As inappropriate, HEAEP only pointed out 69% of the emergency visits considered as inappropriate by experts.

CONCLUSIONS

The modified HEAEP shown a good internal validity and high reproducibility. The main advantage is to point out as inappropriate emergency attendances that can be solved in primary care.

Inappropriate Emergency Department Visits and Use of the Health Care for the Homeless Program Services by Homeless Adults in the Northeastern United States

This study tested whether the use of the Health Care for the Homeless Program (HCHP) by homeless adults was associated with reduced risk of inappropriate emergency department (ED) use. Researchers interviewed 941 homeless adults at 52 soup kitchens. Of those interviewed, 508 reported having at least 1 ED visit during the last 6 months. Then, 243 subjects' 688 ED records were retrieved. Inappropriateness of each ED use was evaluated based on clinical criteria. Logistic regressions were applied. Having two or more HCHP visits [odds ratio (OR) = 0.43, 95% confidence interval (CI) 0.19, 0.90] by homeless adults was associated with decreased odds of having inappropriate ED visits.

How to minimize inappropriate utilization of Accident and Emergency Departments: improve the validity of classifying the general practice cases amongst the A&E attendees

Studies have found that one-third to two-thirds of all patients attending Accident and Emergency (A and E) Departments could be managed appropriately by general practitioners (GPs). There is also evidence that referral to GPs can be acceptable to patients. The question of primary concern is screening non-urgent cases with high degrees of sensitivity (S), specificity (SP), and positive predictive value (PPV). This paper reports the findings of the validity (S, SP and PPV) of nurses and patients in triaging A and E visitors. A cross sectional study was conducted over a 1 year period and subjects were randomly selected from four A and E Departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. S, SP and PPVs were computed for both non-weighted and weighted conditions. The gold standard for defining the true urgency status of each selected patient was based on a review of the patient's record 3-21 days (or longer if necessary) following the A and E visit. The record review in each A and E was blinded and done independently by a panel of two (and if disagreement existed, three) senior emergency physicians who did not practice in the same hospital. The greatest weights would be for incorrect decisions with greatest impact on patients' well being. The most accurate unweighted nurses' triage classification had an average sensitivity of 87.8%, specificity of 83.9%, and a PPV of 70.1%. When weighted, the average sensitivity reduced to 75%, specificity to 65.7%, and PPV to 54%. The most accurate unweighted patients' self-triage classification yielded a sensitivity of 62.5%, specificity of 69.2%, and a PPV of 58.1%, and correspondingly reduced to 43.3, 49.2 and 38.6% if weights were applied. Validity of the derived patients' self-classifications was too inaccurate for practical use. Hong Kong's current use of a five-point urgency scale by nurses would be further refined for identifying non-urgent visitors. If a mechanism was put in place for additional screening on visitors with a borderline semi-urgent or non-urgent status, the nurses could safely reassign non-urgent patients to GP care. If implemented, a significant impact on hospital costs could be realized.

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

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

Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations

OBJECTIVES

To explore whether differences in disease prevalence, disease severity, or emergency department (ED) admission thresholds explain why black persons, Medicaid, and uninsured patients have higher hospitalization rates for ambulatory care sensitive (ACS) conditions.

MATERIALS AND METHODS

The National Hospital Ambulatory Care Survey was used to analyze the ED utilization, disease severity (assessed by triage category), hospitalization rates, and follow-up plans for adults with five chronic ACS conditions (asthma, chronic obstructive lung disease, congestive heart failure, diabetes mellitus, and hypertension). The National Health Interview Survey was used to estimate the prevalence of these conditions in similarly aged US adults.

RESULTS

Black persons, Medicaid, and uninsured patients make up a disproportionate share of ED visits for these chronic ACS conditions. Cumulative prevalence of these conditions was higher in black persons (33%) compared with white persons (27%) and Hispanic persons (22%), but did not differ among the payment groups. All race or payment groups were assigned to similar triage categories and similar percentages of their ED visits resulted in hospitalization. Black persons and Hispanic persons (odds ratios for both = 0.7), were less likely than white persons, whereas Medicaid and uninsured patients (odds ratios for both = 0.8), were less likely than private patients to have follow-up with the physician who referred them to the ED.

CONCLUSIONS

The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity. Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups.

[Emergency department utilization by children aged less than two years old]

BACKGROUND

Emergency department visits are rising although birth rate is decreasing.

OBJECTIVE

To compare emergency department.(ED) utilization in the cohorts of children born in 1991 and 1996 in a health district.

METHOD

We performed a two-year retrospective cohort study in the health district of Mieres (Spain). All children born in the health district in 1991 (n 600) and 1996 (n 423) were included. The number of visits to the ED was obtained and the frequency and mean number of visits in the first 2 years of life were calculated according to age, sex, and area of residence.

RESULTS

The gross number of visits did not vary (1991: 852; 1996: 853), despite a decrease in birth rate. The number of children who attended the ED at least once increased by 34.8 % (1991, 60.6 %; 1996, 82 %) and the frequency of visits increased by 41.7 % (1991, 142.2 %; 1996, 201.4 %). More than 60 % of visits were made by 20 % (1991) of the children and by 29 % (1996). The percentage of children who attended the ED, the frequency rate and the mean number of visits were significantly higher in the municipality nearest the hospital than in the remaining municipalities in the health district.

CONCLUSIONS

Although the gross number of visits to the ED remained unchanged, ED utilization increased substantially in only 5 years.

Five-level triage system more effective than three-level in tertiary emergency department

INTRODUCTION

The study objectives were to compare reliability and validity of a 3-level (3L) triage system with a new 5-level (5L) triage system and determine the effect of nursing experience on triage reliability.

METHODS

The study was conducted in a southeastern tertiary emergency department. With a stratified random sample, reliability of 3L triage ratings was measured with weighted kappa (time 1). The 5L system was then implemented, and weighted kappa was remeasured (time 2). Validity was assessed by comparing case mix, sensitivity, and specificity at times 1 and 2, and comparing 5L ratings with physician billing (Evaluation and Management) codes and nursing resource intensity at time 2.

RESULTS

Time 1 case mix (15,324 patients) was: level 1, 6%; level 2, 36%; level 3, 59%, and time 2 (16,024 patients) was: level 1, 1%; level 2, 8%; level 3, 38%; level 4, 41%; level 5, 13%. Three hundred-five triage ratings were evaluated from time 1, and 303 were evaluated from time 2. Weighted kappa was 0.53 for time 1 and 0.68 for time 2. Spearman correlations were: 5L and nursing resource intensity, 0.55 (P <.0001); and 5L and Em, 0.57 (P <.0001). Sensitivity was 58% for the 3L and 68% for the 5L. Specificity was 83% for the 3L and 91% for the 5L. Under-triage rates were 28% for the 3L and 12% for the 5L, and less-experienced nurses were more likely to under-triage using the 3L system.

DISCUSSION

The 5L triage system is safer and provides greater discrimination, better reliability, and improved sensitivity and specificity than the 3L triage system.

Access to care: a review of the emergency medicine literature

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.

Feasibility of paramedic treatment and referral of minor illnesses and injuries

BACKGROUND

Approximately 40% of Hennepin County Medical Center's (HCMC's) ambulance runs are for minor medical conditions as defined by billing criteria ["ALS minor," i.e., no advanced life support (ALS) procedures done in the field]. Current metropolitan guidelines mandate that all such patients must be transported to a hospital unless they refuse this service. It has been proposed that some patients with minor medical conditions could be better served by treatment in the field by paramedics and referred to a clinic or hospital for early follow-up care. It is proposed that this approach would save costs and improve paramedic availability for patients with more serious conditions.

OBJECTIVE

To evaluate the feasibility and safety of implementing such a program by identifying high-volume, low-complexity groupings of cases. Such high-volume, low-complexity cases would serve as the topics for curriculum development for paramedic training in field treatment and referral.

METHODS

Data were obtained from ambulance run sheets and emergency department (ED) records for all patients transported by the HCMC ambulance service in 1996 who were covered by the Metropolitan Health Plan (MHP) and who were categorized for billing purposes as "ALS minor" transports. The data included demographic information, vital signs, presenting problem, diagnoses in the ED, and procedures, laboratory studies, or x-rays done in the ED. Patients were classified as "potentially treatable" in the field if they were treated and discharged from the ED without undergoing any procedures or diagnostic studies. Patients who required more extensive evaluation in the ED, or who were admitted, were classified as likely too "complex" to be treated at the scene and then referred for early follow-up. The data were analyzed to find the most common presenting problems and the numbers, characteristics, and dispositions of "potentially treatable" and "complex" patients in each group. This information was used to determine what, if any, types of patients could potentially be treated safely and effectively according to this scheme.

RESULTS

The study group comprised 1,103 patients, representing 127 different presenting medical problems. There were 523 (47%) "potentially treatable" patients and 580 (53%) "complex" patients. The 127 medical problems were grouped and the 15 most common presenting problem groups were identified. Within these groups there was no single medical problem with high volume. Each of these 15 most common problem groups contained a substantial proportion of "complex" patients, ranging from 24% to 100%.

CONCLUSIONS

None of the 15 most frequently encountered problem groups consisted of a high enough proportion of "potentially treatable" cases to serve as a high-volume, low-complexity category for paramedic treatment in the field with early follow-up. Without any identified high-volume, low-complexity categories, a treatment and referral program as proposed in this article would require a substantial investment in development of appropriate criteria and in training paramedics to apply the criteria for numerous clinical entities. This would limit any cost saving, and require great care to avoid compromising patient safety accompanied by substantial professional liability exposure.