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Cheetham A, Babcock L, Hartwell V, Schwartz H, Bensman R, Lee SH, Riney L, Semenova O, Zhang Y, Pomerantz WJ. Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Services and Police: Trends and Interventions. Acad Pediatr 2024:S1876-2859(24)00157-8. [PMID: 38754700 DOI: 10.1016/j.acap.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/02/2024] [Accepted: 05/11/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE We aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported. METHODS This retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends. RESULTS Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% (confidence interval) CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001). CONCLUSIONS Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.
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Affiliation(s)
- Alexandra Cheetham
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio.
| | - Lynn Babcock
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
| | - Victoria Hartwell
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
| | - Hamilton Schwartz
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
| | - Rachel Bensman
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
| | - Sang Hoon Lee
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
| | - Lauren Riney
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
| | - Olga Semenova
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology (Y Zhang), Cincinnati Children's Hospital Medical Center, Ohio
| | - Wendy J Pomerantz
- Division of Pediatric Emergency Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, O Semenova, and WJ Pomerantz), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (A Cheetham, L Babcock, V Hartwell, H Schwartz, R Bensman, SH Lee, L Riney, and WJ Pomerantz), Ohio
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Cheung EH, Whitfield DA, Kipust A, Tadeo R, Gausche-Hill M. Advancing Emergency Medical Services' (EMS) Response Capability for Behavioral Health Emergencies: Los Angeles County's Performance Improvement Initiative. PREHOSP EMERG CARE 2024:1-11. [PMID: 38526711 DOI: 10.1080/10903127.2024.2333494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/05/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION Behavioral health emergencies (BHEs) are a common patient encounter for emergency medical services (EMS) clinicians and other first responders, in particular law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices. In 2016, the Los Angeles County EMS Agency's Commission initiated a comprehensive evaluation of the 9-1-1 response for BHEs and developed a plan for improving the quality of care and safety for patients and first responders. METHODS A Behavioral Health Initiative Committee was assembled with broad representation from EMS, LE, health agencies, and the public. Committee objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement. RESULTS The committee generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities' capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, develop alternate destination for EMS transport. CONCLUSION This paper describes a comprehensive performance improvement initiative in LAC-EMSA's 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs.
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Affiliation(s)
- Erick H Cheung
- David Geffen School of Medicine, Department of Psychiatry, University of California Los Angeles (UCLA), Los Angeles, California
- UCLA Resnick Neuropsychiatric Hospital, Los Angeles, California
| | - Denise A Whitfield
- Los Angeles County Emergency Medical Services Agency, Los Angeles, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
- The Lundquist Institute, Los Angeles, California
| | | | - Richard Tadeo
- Los Angeles County Emergency Medical Services Agency, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency, Los Angeles, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
- The Lundquist Institute, Los Angeles, California
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Glomb NW, Trivedi T, Grupp‐Phelan J, Schriger DL, Sporer K. Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County. J Am Coll Emerg Physicians Open 2023; 4:e12930. [PMID: 37051504 PMCID: PMC10083547 DOI: 10.1002/emp2.12930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/10/2023] [Accepted: 02/24/2023] [Indexed: 04/14/2023] Open
Abstract
Background Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol. Methods A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE. Results There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter. Conclusion Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.
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Affiliation(s)
- Nicolaus W. Glomb
- Division of Emergency MedicineUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Tarak Trivedi
- Department of Emergency MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Jacqueline Grupp‐Phelan
- Division of Emergency MedicineUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - David L. Schriger
- Department of Emergency MedicineUniversity of California, Los AngelesLos AngelesCaliforniaUSA
| | - Karl Sporer
- Division of Emergency MedicineUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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Kirchner H, Schaefer M, Ullrich H, Hulsmans N, Juckel G, Brzoska P, Pajonk FGB. Factors predicting admission of psychiatric emergency contacts after presenting to the emergency department: results of a regression analysis. Ann Gen Psychiatry 2022; 21:42. [PMID: 36352413 PMCID: PMC9647959 DOI: 10.1186/s12991-022-00421-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychiatric emergency patients have great relevance in the interdisciplinary emergency department. Emergency physicians in this setting often have to make decisions under time pressure based on incomplete information regarding the patient's further treatment. The aim of this study was to identify possible predictors associated with an increased likelihood of inpatient psychiatric admission. METHODS A retrospective cross-sectional study of all psychiatric emergency contacts in an interdisciplinary emergency department (ED) of a general hospital in a large German city was conducted for 2015. A binary regression analysis was performed to identify possible predictors. RESULTS In 2015, a total of 21421 patient contacts were reported in the emergency department, of which 1733 were psychiatric emergencies. Psychiatric emergency was the fourth most common cause presenting to the ED. The most common diagnosis given was mental and behavioral disorders due to the use of psychotropic substances (F1). Factors associated with an increased probability of inpatient psychiatric admission were previously known patients, patients under a legal care order (guardianship), and previous outpatient medical contact. No association for gender or age was found. Data demonstrated a negative relationship between a neurotic, stress-related and somatoform disorder diagnosis and admission. CONCLUSIONS The present study shows some significant characteristics associated with an increased likelihood of emergency admission. Independent of the health care system, the predictors found seem to be relevant with regard to the probability of admission, when compared internationally. To improve the treatment of patients in emergency units, these factors should be taken into account.
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Affiliation(s)
- Heribert Kirchner
- Faculty of Health, School of Medicine, University of Witten/Herdecke, Witten, Germany.
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy, Psychosomatics and Addiction Medicine, Evang. Kliniken Essen-Mitte, Essen, Germany.,Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
| | - Heiko Ullrich
- Department of Psychiatry, Psychotherapy and Psychosomatics, Kreisklinikum Siegen, Hospital, Siegen, Germany
| | - Nik Hulsmans
- Department of Psychology, University of Siegen, Siegen, Germany
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Patrick Brzoska
- Faculty of Health, School of Medicine, University of Witten/Herdecke, Witten, Germany
| | - Frank-Gerald Bernhard Pajonk
- Zentrum Isartal Am Kloster Schäftlarn, Schäftlarn, Germany.,Department. of Psychiatry and Psychotherapy, Technical University Munich, Munich, Germany
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Davis BT, Chen Z, Islam MB, Timken ME, Procissi D, Schwulst SJ. POSTINJURY FECAL MICROBIOME TRANSPLANT DECREASES LESION SIZE AND NEUROINFLAMMATION IN TRAUMATIC BRAIN INJURY. Shock 2022; 58:287-294. [PMID: 36256625 PMCID: PMC9586470 DOI: 10.1097/shk.0000000000001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACT Background: Traumatic brain injury (TBI) is an underrecognized public health threat. The constitutive activation of microglia after TBI has been linked to long-term neurocognitive deficits and the progression of neurodegenerative disease. Evolving evidence indicates a critical role for the gut-brain axis in this process. Specifically, TBI has been shown to induce the depletion of commensal gut bacteria. The resulting gut dysbiosis is associated with neuroinflammation and disease. Hypothesis: We hypothesized that fecal microbiota transplantation would attenuate microglial activation and improve neuropathology after TBI. Methods: C57Bl/6 mice were subjected to severe TBI (n = 10) or sham injury (n = 10) via an open-head controlled cortical impact. The mice underwent fecal microbiota transplantation (FMT) or vehicle alone via oral gavage once weekly for 4 weeks after injury. At 59 days after TBI, mice underwent three-dimensional, contrast-enhanced magnetic resonance imaging. Following imaging, mice were killed, brains harvested at 60 DPI, and CD45+ cells isolated via florescence-activated cell sorting. cDNA libraries were prepared using the 10x Genomics Chromium Single Cell 3' Reagent kit followed by sequencing on a HiSeq4000 instrument, and computational analysis was performed. Results: Fecal microbiota transplantation resulted in a >marked reduction of ventriculomegaly (P < 0.002) and preservation of white matter connectivity at 59 days after TBI (P < 0.0001). In addition, microglia from FMT-treated mice significantly reduced inflammatory gene expression and enriched pathways involving the heat-shock response compared with mice treated with vehicle alone. Conclusions: We hypothesized that restoring gut microbial community structure via FMT would attenuate microglial activation and reduce neuropathology after TBI. Our data demonstrated significant preservation of cortical volume and white matter connectivity after an injury compared with mice treated with vehicle alone. This preservation of neuroanatomy after TBI was associated with a marked reduction in inflammatory gene expression within the microglia of FMT-treated mice. Microglia from FMT-treated mice enriched pathways in the heat-shock response, which is known to play a neuroprotective role in TBI and other neurodegenerative disease processes.
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Affiliation(s)
- Booker T Davis
- Department of Surgery, Division of Trauma and Critical Care, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Zhangying Chen
- Department of Surgery, Division of Trauma and Critical Care, Northwestern University Feinberg School of Medicine, Chicago IL
- Driskill Graduate Program in Life Science, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Mecca B.A.R. Islam
- Department of Surgery, Division of Trauma and Critical Care, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Madeline E. Timken
- Department of Surgery, Division of Trauma and Critical Care, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Daniele Procissi
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, USA
- Center for Translational Pain Research Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Steven J. Schwulst
- Department of Surgery, Division of Trauma and Critical Care, Northwestern University Feinberg School of Medicine, Chicago IL
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Moore HE, Siriwardena AN, Gussy M, Spaight R. Mental health emergencies attended by ambulances in the United Kingdom and the implications for health service delivery: A cross-sectional study. J Health Serv Res Policy 2022; 28:138-146. [PMID: 35975884 DOI: 10.1177/13558196221119913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In the context of increasing demand for ambulance services, emergency mental health cases are among the most difficult for ambulance clinicians to attend, partly because the cases often involve referring patients to other services. We describe the characteristics of mental health emergencies in the East Midlands region of the United Kingdom. We explore the association between 999 (i.e. emergency) call records, the clinical impressions of ambulance clinicians attending emergencies and the outcomes of ambulance attendance. We consider the implications of our results for optimizing patient care and ambulance service delivery. METHODS We conducted a retrospective observational study of records of all patients experiencing mental health emergencies attended by ambulances between 1 January 2018 and 31 July 2020. The records comprised details of 103,801 '999' calls (Dispatch), the preliminary diagnoses by ambulance clinicians on-scene (Primary Clinical Impression) and the outcomes of ambulance attendance for patients (Outcome). RESULTS A multinomial regression analysis found that model fit with Outcome data was improved with the addition of Dispatch and Primary Clinical Impression categories compared to the fit for the model containing only the intercept and Outcome categories (Chi-square = 18,357.56, df = 180, p < 0.01). Dispatch was a poor predictor of Primary Clinical impression. The most common predictors of Outcome care pathways other than 'Treated and transported' were records of respiratory conditions at Dispatch and anxiety reported by clinicians on-scene. CONCLUSIONS Drawing on the expertise of mental health specialists may help '999' dispatchers distinguish between physical and mental health emergencies and refer patients to appropriate services earlier in the response cycle. Further investigation is needed to determine if training Dispatch operatives for early triage and referral can be appropriately managed without compromising patient safety.
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Affiliation(s)
| | - Aloysius Niroshan Siriwardena
- Professor of Primary and Pre-hospital Healthcare, Community and Health Research Unit, School of Health and Social Care, 4547University of Lincoln, Lincoln, UK
| | - Mark Gussy
- Global Professor of Rural Health and Social Care, Lincoln Institute of Rural Health, 4547University of Lincoln, Lincoln, UK
| | - Robert Spaight
- Head of Clinical Research and Audit, 9819East Midlands Ambulance NHS Trust, Nottinghamshire, UK
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Jain N, Sahu MRK, Singh AR, Sharma P. A decision framework model for hospital selection in COVID-19 pandemic: A FIS approach. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2095839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Naveen Jain
- Department of Mechanical Engineering, Shri Shankaracharya Institute of Professional Management and Technology, Raipur, India
| | - Manish R. K. Sahu
- Department of Mechanical Engineering, Shri Shankaracharya Institute of Professional Management and Technology, Raipur, India
| | - A. R. Singh
- Department of Mechanical Engineering, National Institute of Technology, Raipur, India
| | - Prateek Sharma
- Department of Mechanical Engineering, Shri Shankaracharya Institute of Professional Management and Technology, Raipur, India
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Faheem S, Smith A, Doeh E, Dunne R, Gorelick D. Strengthening Behavioral Health Services Through Partnerships and Data Integration. Cureus 2022; 14:e24929. [PMID: 35706737 PMCID: PMC9187841 DOI: 10.7759/cureus.24929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 11/05/2022] Open
Abstract
Background There has been an increase in emergency medical service (EMS) use for behavioral health reasons. Detroit Wayne Integrated Health Network (DWIHN) and Detroit East Medical Control Authority (DEMCA) collaborated to study the rising number of behavioral health (mental disorders and substance use disorders) calls to EMS. Methodology To examine the trend, DWIHN and DEMCA partnered on a data-sharing project and identified that a high volume of EMS runs (responses by EMS as a result of an emergency call) involved individuals served by DWIHN. Results Over a period of 2.5 years, an average of one-third (33.73%) of EMS runs involved individuals who receive behavioral health services through DWIHN. Conclusions DWIHN used the data to create interventions and internal process improvements that can help coordinate medical and behavioral healthcare for individuals who have been using EMS increasingly. The findings were also used to develop prevention efforts to decrease the occurrence of such crises and to avoid unwarranted member involvement with the justice system. We suggest that other comparable organizations consider similar partnerships, especially given the increasingly high EMS and Emergency Department use for behavioral health reasons.
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Bailey K, Lowder EM, Grommon E, Rising S, Ray BR. Evaluation of a Police-Mental Health Co-response Team Relative to Traditional Police Response in Indianapolis. Psychiatr Serv 2022; 73:366-373. [PMID: 34433289 DOI: 10.1176/appi.ps.202000864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Criminal justice and emergency medical service (EMS) outcomes were compared for individuals experiencing a behavioral health crisis who received a response from a co-response team (CRT) or a usual response from the police after a 911 call. METHODS A prospective, quasi-experimental design was used to examine outcomes of a CRT pilot tested in Indianapolis (August-December 2017). Weighted multivariable models examined effects of study condition (CRT group, N=313; usual-response group, N=315) on immediate booking, emergency detention, and subsequent jail bookings and EMS encounters. Sensitivity of outcomes to follow-up by a behavioral health unit (BHU) was also examined. RESULTS Individuals in the CRT group were less likely than those in the usual-police-response group to be arrested immediately following the 911 incident (odds ratio [OR]=0.48, 95% confidence interval [CI]=0.25-0.92) and were more likely to experience any EMS encounter at 6- and 12-month follow-up (OR range=1.71-1.85, p≤0.015 for all). Response type was not associated with jail bookings at 6 or 12 months. Follow-up BHU services did not reduce bookings or EMS encounters. CRT recipients with BHU follow-up were more likely than those without BHU follow-up to have a subsequent EMS contact (OR range=2.35-3.12, p≤0.001 for all). These findings differed by racial group. CONCLUSIONS CRT responses may reduce short-term incarceration risk but not long-term EMS demand or risk of justice involvement. Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.
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Affiliation(s)
- Katie Bailey
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, Detroit (Bailey, Ray); Department of Criminology, Law and Society, College of Humanities and Social Sciences, George Mason University, Fairfax, Virginia (Lowder); School of Public and Environmental Affairs, Indiana University-Purdue University Indianapolis, Indianapolis (Grommon); Center for Health and Justice Research, Public Policy Institute, Indiana University, Indianapolis (Rising)
| | - Evan M Lowder
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, Detroit (Bailey, Ray); Department of Criminology, Law and Society, College of Humanities and Social Sciences, George Mason University, Fairfax, Virginia (Lowder); School of Public and Environmental Affairs, Indiana University-Purdue University Indianapolis, Indianapolis (Grommon); Center for Health and Justice Research, Public Policy Institute, Indiana University, Indianapolis (Rising)
| | - Eric Grommon
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, Detroit (Bailey, Ray); Department of Criminology, Law and Society, College of Humanities and Social Sciences, George Mason University, Fairfax, Virginia (Lowder); School of Public and Environmental Affairs, Indiana University-Purdue University Indianapolis, Indianapolis (Grommon); Center for Health and Justice Research, Public Policy Institute, Indiana University, Indianapolis (Rising)
| | - Staci Rising
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, Detroit (Bailey, Ray); Department of Criminology, Law and Society, College of Humanities and Social Sciences, George Mason University, Fairfax, Virginia (Lowder); School of Public and Environmental Affairs, Indiana University-Purdue University Indianapolis, Indianapolis (Grommon); Center for Health and Justice Research, Public Policy Institute, Indiana University, Indianapolis (Rising)
| | - Bradley R Ray
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, Detroit (Bailey, Ray); Department of Criminology, Law and Society, College of Humanities and Social Sciences, George Mason University, Fairfax, Virginia (Lowder); School of Public and Environmental Affairs, Indiana University-Purdue University Indianapolis, Indianapolis (Grommon); Center for Health and Justice Research, Public Policy Institute, Indiana University, Indianapolis (Rising)
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Rivard MK, Cash RE, Chrzan K, Powell J, Kaye G, Salsberry P, Panchal AR. Public Health Surveillance of Behavioral Health Emergencies through Emergency Medical Services Data. PREHOSP EMERG CARE 2021; 26:792-800. [PMID: 34469269 DOI: 10.1080/10903127.2021.1973626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To identify the demographic, clinical and EMS characteristics of events documented as behavioral health emergencies (BHE) by EMS. Methods: This was a cross-sectional study using the 2018 National Emergency Medical Services Information System (NEMSIS) Version 3 dataset. All events that had patient care provided with a documented impression (field diagnosis) of ICD-10 codes F01-F99 (i.e., mental, behavioral, and neurodevelopmental disorders) were labeled a BHE and included. Descriptive statistics were calculated. Results: A total of 1,594,821 (7.3%) EMS calls had a BHE impression. The most common was mental and behavioral disorders due to psychoactive substance use (42.3%). More males than females had BHEs (54.6% vs. 45.4%), and most patients were ages 18-34 (31.5%). Most BHE occurred in urban settings (89.6%). Almost half (47.9%) were dispatched with a complaint unrelated to behavioral health. Conclusion: BHEs were noted in 7.3% of NEMSIS events, and the majority were associated with substance use disorders. EMS professionals need comprehensive training on best practices for BHE. Stakeholders should have information on prevalence of BHEs to ensure proper educational standards, training practices, and resource allocation.
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Vorstellung psychiatrischer Notfallpatienten in der Notaufnahme durch Notarzt und Rettungsdienst – Charakterisierung, Versorgung und Verbleib. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00917-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sills MR, Ozkaynak M, Jang H. Predicting hospitalization of pediatric asthma patients in emergency departments using machine learning. Int J Med Inform 2021; 151:104468. [PMID: 33940479 DOI: 10.1016/j.ijmedinf.2021.104468] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
MOTIVATION The timely identification of patients for hospitalization in emergency departments (EDs) can facilitate efficient use of hospital resources. Machine learning can help the early prediction of ED disposition; however, application of machine learning models requires both computer science skills and domain knowledge. This presents a barrier for those who want to apply machine learning to real-world settings. OBJECTIVES The objective of this study was to construct a competitive predictive model with a minimal amount of human effort to facilitate decisions regarding hospitalization of patients. METHODS This study used the electronic health record data from five EDs in a single healthcare system, including an academic urban children's hospital ED, from January 2009 to December 2013. We constructed two machine learning models by using automated machine learning algorithm (autoML) which allows non-experts to use machine learning model: one with data only available at ED triage, the other adding information available one hour into the ED visit. Random forest and logistic regression were employed as bench-marking models. The ratio of the training dataset to the test dataset was 8:2, and the area under the receiver operating characteristic curve (AUC), accuracy, and F1 were calculated to assess the quality of the models. RESULTS Of the 9,069 ED visits analyzed, the study population was made up of males (62.7 %), median (IQR) age was 6 (4, 10) years, and public insurance coverage (66.0 %). The majority had an Emergency Severity Index score of 3 (52.9 %). The prevalence of hospitalization was 22.5 %. The AUCs were 0.914 and 0.942. AUCs were 0.831 and 0.886 for random forests, and 0.795 and 0.823 for logistic regression. Among the predictors, an outcome at a prior visit, ESI level, time to first medication, and time to triage were the most important features for the prediction of the need for hospitalization. CONCLUSIONS In comparison with the conventional approaches, the use of autoML improved the predictive ability for the need for hospitalization. The findings can optimize ED management, hospital-level resource utilization and improve quality. Furthermore, this approach can support the design of a more effective patient ED flow for pediatric asthma care.
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Affiliation(s)
- Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Hoon Jang
- College of Global Business, Korea University, 2511 Sejong-ro, Sejong, Republic of Korea.
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Jang H, Ozkaynak M, Ayer T, Sills MR. Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma. Pediatr Emerg Care 2021; 37:e42-e47. [PMID: 30281550 DOI: 10.1097/pec.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. METHODS This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). RESULTS Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. CONCLUSIONS Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.
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Affiliation(s)
- Hoon Jang
- From the Science and Technology Policy Institute, Sejong, South Korea
| | - Mustafa Ozkaynak
- School of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Turgay Ayer
- Georgia Institute of Technology, Atlanta, GA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
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14
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Patel AM, Carroll NV, Wheeler DC, Rose SR, Nadpara PA, Pakyz AL, Ijioma SC. Economic burden of pediatric prescription opioid poisonings in the United States. J Manag Care Spec Pharm 2020; 27:16-26. [PMID: 33377438 PMCID: PMC10391177 DOI: 10.18553/jmcp.2021.27.1.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Among the different drugs involved in pediatric exposures and poisonings, opioids are the most important, given their rise in nonmedical use. Opioid poisonings in children can result in serious symptoms or complications, including respiratory disorders such as apnea, respiratory failure, and respiratory depression; psychiatric or nervous system disorders such as agitation, seizures, and coma; and cardiac disorders such as tachycardia, bradycardia, and cardiac arrest. Opioid poisonings in children can have delayed onset of symptoms as well as severe and prolonged toxic effects. Many studies have examined the economic burden of opioid poisoning in the general population, but very little is known about the pediatric population. OBJECTIVE: To estimate the economic burden associated with pediatric prescription opioid poisonings. METHODS: This study examined opioid poisonings in pediatric patients, defined as patients aged less than 18 years, for the 2012 base year. Costs were estimated using the 2012 Nationwide Emergency Department Sample (NEDS), Kids' Inpatient Database (KID), Multiple Cause-of-Death (MCOD) file, and other published sources, while applying a societal perspective. The Bottom Up approach was used to estimate the total cost of pediatric prescription opioid poisonings. Direct costs included costs associated with emergency department (ED) visits, hospitalizations, and ambulance transports. Indirect costs were estimated using the human capital method and included productivity costs due to caregivers' absenteeism and premature mortality among children. Descriptive statistics were employed in calculating costs. RESULTS: The total costs of pediatric prescription opioid poisonings and exposure in the United States were $230.8 million in 2012. Total direct costs were estimated to be over $21.1 million, the majority resulting from prescription opioid poisoning-related inpatient stays. Total indirect (productivity) costs were calculated at $209.7 million, and 98.6% of these costs were attributed to opioid poisoning-related mortality. Pediatric prescription opioid poisoning-related ED visits, inpatient stays, and deaths were most common in patients aged 13-17 years and those in mid to large urban areas. Most were unintentional. CONCLUSIONS: Pediatric prescription opioid poisonings resulted in direct and indirect costs of $230.8 million in 2012. While these costs are low in comparison with the costs of prescription opioid poisoning in the general population, the number of pediatric poisonings represents only a small fraction of total poisonings. Quantified costs associated with pediatric prescription opioid poisonings can help decision makers to understand the economic trade-offs in planning interventions. DISCLOSURES: This research had no external funding but was funded by an unrestricted research grant made to the Department of Pharmacotherapy & Outcomes Science by kaléo Pharma, maker of a naloxone product. The authors declare no conflicts of interest or financial interests. Portions of this study were presented as an abstract at the 22nd Annual ISPOR Meeting; May 22, 2017; Boston, MA.
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Affiliation(s)
- Anisha M Patel
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond
| | - Norman V Carroll
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond
| | - David C Wheeler
- Department of Biostatistics, Virginia Commonwealth University, Richmond
| | - S Rutherfoord Rose
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Pramit A Nadpara
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond
| | - Amy L Pakyz
- Department of Pharmacotherapy & Outcomes Science (deceased), Virginia Commonwealth University, Richmond
| | - Stephen C Ijioma
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond
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Katayama Y, Kitamura T, Hirose T, Kiyohara K, Ishida K, Tachino J, Nakao S, Kiguchi T, Umemura Y, Noda T, Tai S, Tsujino J, Masui J, Mizobata Y, Shimazu T. Characteristics and outcome of patients triaged by telephone and transported by ambulance: a population-based study in Osaka, Japan. Acute Med Surg 2020; 7:e609. [PMID: 33282318 PMCID: PMC7700103 DOI: 10.1002/ams2.609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 12/22/2022] Open
Abstract
Aim Details such as diagnosis and outcome of patients transported by ambulance after telephone triage have not been fully revealed. The aim of this study was to reveal profile and outcome about patients transported by ambulance via telephone triage with dataset of telephone triage and population‐based registry for emergency patients. Methods This retrospective descriptive study with a one‐year study period from January 1, 2016 to December 31, 2016 included patients selected from the telephone triage dataset who were transported by ambulance. Key parameters such as age, sex and date and time of ambulance dispatch were used to identify patient data from the ORION registry. We assessed the profile and outcome of the patients in a descriptive epidemiological analysis. Results We included 4,293 patients in the selected datasets whose data were merged, of whom 2,998 patients (69.8%) returned home from the emergency department, 1,255 (29.2%) were hospitalized, 32 (0.7%) were transferred to other hospitals, and 8 (0.2%) died. The most common diagnosis in the emergency departments was “infectious gastroenteritis and colitis, unspecified [A09] (219, 5.1%)”. Among the 1,255 hospitalized patients, 905 patients (72.1%) were discharged home, 254 patients (20.2%) remained hospitalized, 52 patients (4.1%) were transferred to other hospitals, 38 patients (3.0%) died, and 5 patients (0.5%) had missing data. The most common diagnosis was “cerebral infarction [I63.0‐I63.9] (138, 11.0%)”. Conclusion This study revealed the profile and outcome of patients transported by ambulance after telephone triage.
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Affiliation(s)
- Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Kosuke Kiyohara
- Department of Food Science Faculty of Home Economics Otsuma Women's University Tokyo Japan
| | - Kenichiro Ishida
- Department of Acute Medicine and Critical Care Medical Center Osaka National Hospital National Hospital Organization Osaka Japan
| | - Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Takeyuki Kiguchi
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan.,Kyoto University Health Services Kyoto Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan.,Kyoto University Health Services Kyoto Japan
| | - Tomohiro Noda
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | | | | | - Jun Masui
- Osaka Prefectural Government Osaka Japan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
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16
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Ray B, Bailey K, Huynh P, Carl A, Alton M. Arrest and emergency medical services events among participants from one of the first mental health courts. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 73:101644. [PMID: 33246223 DOI: 10.1016/j.ijlp.2020.101644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This study looked at, in addition to subsequent arrest, emergency medical services (EMS) events as an outcome of participation in mental health court (MHC). METHODS We linked information from participants of a MHC in Marion County, Indiana with jail booking and EMS services data. To understand programmatic impact, we looked at differences in jail bookings and EMS events within one year prior to and one year after MHC participation. We ran paired t-tests to understand whether correlations were significant. We also considered differences in outcomes between those who successfully completed MHC versus those who did not. RESULTS MHC participation was significantly associated with a reduction in jail bookings and EMS events in the 12 months after program participation compared to the 12 months before. When comparing MHC participant groups, a significant reduction in jail bookings is found consistently whereas a significant reduction in EMS events was found in only some participant groups: the entire MHC group and the misdemeanor-level court (PAIR) participants when they successfully completed the program. CONCLUSIONS EMS utilization should be an outcome of consideration in evaluating the success and cost savings of MHCs. Where MHCs do not result in significantly reduced EMS events, communities should consider what individual-level and community-level factors contribute to this and adjust accordingly.
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Affiliation(s)
- Bradley Ray
- Center for Behavioral Health and Justice, Wayne State University School of Social Work, 5201 Cass Avenue, Prentis, Suite 226, Detroit, MI 48202, USA.
| | - Katie Bailey
- Center for Behavioral Health and Justice, Wayne State University School of Social Work, 5201 Cass Avenue, Prentis, Suite 226, Detroit, MI 48202, USA
| | - Philip Huynh
- Center for Behavioral Health and Justice, Wayne State University School of Social Work, 5201 Cass Avenue, Prentis, Suite 226, Detroit, MI 48202, USA
| | - Alexis Carl
- Center for Behavioral Health and Justice, Wayne State University School of Social Work, 5201 Cass Avenue, Prentis, Suite 226, Detroit, MI 48202, USA
| | - Madison Alton
- Indiana University, School of Medicine, 340 West 10(th) Street, Fairbanks Hall, Suite 6200, Indianapolis, IN 46202-3082, USA
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17
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DeCou CR, Huppert T, Kume K, Veras P, Comtois KA, Rea T. Prehospital Patient Care Protocols for Suicidality in Washington State. PREHOSP EMERG CARE 2020; 25:432-437. [PMID: 32420776 DOI: 10.1080/10903127.2020.1771489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with suicidal thoughts and behavior represent a growing proportion of patients who present for Emergency Department care. Many of these patients arrive via ambulance. Several brief suicide- or self-harm-specific interventions have been developed for implementation in the Emergency Department setting. However, there is a dearth of training resources, patient care guidelines, and policy guidance to assist prehospital care providers in the treatment of EMS patients who are suicidal. We evaluated prehospital patient care protocols in Washington State to assess for the presence-absence of any suicide and/or self-harm specific protocols, as well as the inclusion of procedures above and beyond conventional approaches to scene safety and transport to the Emergency Department. METHODS Prehospital patient care protocols were obtained for all counties in Washington State. Researchers rated protocols across seven domains, including the mention of any suicide- or self-harm-specific procedures. RESULTS Approximately one-third of counties had any suicide- or self-harm-specific content in prehospital patient care protocols. There was no association between county-level rurality-urbanicity and the presence-absence of suicide- or self-harm-specific care. CONCLUSION These findings demonstrated that little guidance exists for EMS providers in Washington State with regard to the screening or treatment of suicidal patients, above and beyond scene safety and transportation to hospital-based care. Development of guidelines for prehospital suicide care, as well as enhanced screening, assessment, and collaboration with on-call crisis resources has the potential to expand the scope of prehospital treatment for suicidal patients, and reduce burdens on patients, EMS providers, and Emergency Departments.
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18
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Moskovitz J, Sapadin J, Guttenberg M. Interfacility ambulance transport of mental health patients. J Am Coll Emerg Physicians Open 2020; 1:173-182. [PMID: 33000032 PMCID: PMC7493513 DOI: 10.1002/emp2.12012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 11/21/2022] Open
Abstract
The transportation of mental health patients between facilities by emergency medical services personnel poses a unique risk to both patients and their providers. Increasingly, common injuries are occurring and difficulties are arising during this transition in care. Proximal causes exist that could be addressed to help mitigate many of the complexities that occur during this shift in care. Patient safety, quality of care, and provider safety are all at risk if improvements are not made and problems not identified or rectified.
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Affiliation(s)
- Joshua Moskovitz
- Albert Einstein College of MedicineBronxNew YorkUSA
- Hofstra School of Health and Human ServicesHempsteadNew YorkUSA
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19
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Sanko S, Kashani S, Ito T, Guggenheim A, Fei S, Eckstein M. Advanced Practice Providers in the Field: Implementation of the Los Angeles Fire Department Advanced Provider Response Unit. PREHOSP EMERG CARE 2019; 24:693-703. [PMID: 31621447 DOI: 10.1080/10903127.2019.1666199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: To address the growing number of low-acuity patients in the 911-EMS system, the Los Angeles Fire Department (LAFD) launched a pilot program placing an Advanced Provider Response Unit (APRU) in the field so that a prehospital nurse practitioner (NP) could offer patients treatment/release on scene, alternative destination transport, and linkage with social services. Objective: To describe the initial 18-month experience implementing this new APRU. Methods: This is a retrospective, descriptive review of all APRU-attended patients from January 2016 to June 2017. The APRU was an ambulance staffed by an NP and a firefighter/paramedic, equipped with basic point-of-care testing capability, and linked to incidents by either being summoned by on-scene first responders or by monitoring EMS radio traffic. Descriptive statistics were used and outcome measures included counts of clients attended, treat/release rates, impact on total time in service for other LAFD resources, patient need for subsequent re-use of 911 and self-reported experience of care. Results: During its first 18 months in service, the APRU attended 812 patients, including 792 911-patient incidents. 400 of these 911-patients (50.5%) were treated and released on scene or medically cleared and transported to an alternative site for specialty care. This included 76 patients with primary psychiatric complaints who were medically-cleared and transported directly to a mental health urgent care center. An additional 18 high utilizers of 911 were attended by the APRU and connected with a social work organization, and 12 of 18 (66.7%) decreased their use of EMS in the 90-days following APRU evaluation and referral. Of the 400 911-patients that did not go to the emergency department (ED), 26 (6.5%) re-contacted 911 within 3 days: all were transported to the ED with normal vital signs and without prehospital intervention, and all were ultimately discharged home from the ED. As a result of APRU intervention, 458 other LAFD field resources were quickly placed back in service and made available for the next time-critical call. Conclusions: Advanced practice providers such as nurse practitioners can be incorporated into the prehospital setting to address a growing subset of 911-patients whose needs can be met outside of the ED.
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20
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Wilfond BS, Zabrowski J, Johnson LM. A Pragmatic Trial of Suicide Risk Assessment and Ambulance Transport Decision Making Among Emergency Medical Services Providers: Implications for Patient Consent. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:97-98. [PMID: 31557089 DOI: 10.1080/15265161.2019.1654024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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21
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Courtemanche C, Friedson A, Koller AP, Rees DI. The affordable care act and ambulance response times. JOURNAL OF HEALTH ECONOMICS 2019; 67:102213. [PMID: 31362143 DOI: 10.1016/j.jhealeco.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 11/18/2018] [Accepted: 05/30/2019] [Indexed: 06/10/2023]
Abstract
This study contributes to the literature on the capacity challenges faced by health care providers after insurance expansions by examining the Affordable Care Act (ACA) and ambulance response times. Exploiting temporal and geographic variation in the implementation of the ACA as well as pre-treatment differences in uninsured rates, we estimate that the expansions of private and Medicaid coverage under the ACA combined to slow ambulance response times by an average of 24%. We conclude that, through extending coverage to individuals who, in its absence, would not have availed themselves of emergency medical services, the ACA added strain to emergency response systems.
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Affiliation(s)
| | | | | | - Daniel I Rees
- University of Colorado Denver, NBER and IZA, United States
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22
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Wilson MP, Shenvi C, Rives L, Nordstrom K, Schneider S, Gerardi M. Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology. West J Emerg Med 2019; 20:380-385. [PMID: 30881561 PMCID: PMC6404701 DOI: 10.5811/westjem.2019.1.39260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction Despite the ever-increasing numbers of mental health patients presenting to United States emergency departments, there are large gaps in knowledge about acute care of the behavioral health patient. To address this important problem, the Coalition on Psychiatric Emergencies convened a research consensus conference in December 2016 consisting of clinical researchers, clinicians from emergency medicine, psychiatry and psychology, and representatives from governmental agencies and patient advocacy groups. Methods Participants used a standardized methodology to select and rank research questions in the order of importance to both researchers and patients. Results Three working groups (geriatrics, substance use disorders, and psychosis) reached consensus on 26 questions within their respective domains. These questions are summarized in this document. Conclusion The research consensus conference is the first of its kind to include non-clinicians in helping identify knowledge gaps in behavioral emergencies. It is hoped that these questions will prove useful to prioritize future research within the specialty.
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Affiliation(s)
- Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Christina Shenvi
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Loren Rives
- American College of Emergency Physicians, Irving, Texas
| | - Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Psychiatry, Denver, Colorado
| | - Sandra Schneider
- American College of Emergency Physicians, Irving, Texas.,John Peter Smith Hospital, Department of Emergency Medicine, Fort Worth, Texas.,Hofstra Northwell School of Medicine, Hempstead, New York
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23
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Fishe JN, Lynch S. Pediatric Behavioral Health-Related EMS Encounters: A Statewide Analysis. PREHOSP EMERG CARE 2019; 23:654-662. [PMID: 30612501 DOI: 10.1080/10903127.2019.1566423] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: Pediatric behavioral health disorders and related emergency department visits are increasing, but effects on emergency medical services (EMS) are unknown. This study's objective was to describe the statewide epidemiology of pediatric behavioral health-related EMS encounters in Florida, including mental health and substance use. Methods: This analysis is a retrospective study of pediatric behavioral health-related EMS encounters from Florida's statewide EMS Tracking and Reporting Systems Database from 2011 to 2016. Demographic, clinical, EMS, and geographic characteristics are described. We also compared characteristics between patients who did and did not receive an acute EMS behavioral/psychiatric intervention. Results: There were 22,254 pediatric behavioral health-related EMS encounters during the study period, one-quarter of which were noted to have suspected or confirmed ingestion/substance use. The median age was 16 and the majority of patients were female and white. A total of 946 patients (4%) had an acute EMS behavioral/psychiatric intervention. EMS scene, ED turnaround, and total EMS time were significantly longer for intervention patients. Of the 14 counties in the top quartile of percentages of intervention patients, 7 were rural, 10 did not have any hospitals with child/adolescent psychiatric services, and 7 did not have any child psychiatrists. Conclusions: Pediatric behavioral-health related EMS encounters had a significant proportion of suspected ingestions/substance use, and we found disproportionate effects on rural agencies. Increases in EMS resource utilization (including longer EMS times) occurred in certain settings with limited behavioral health infrastructure. Those findings suggest an opportunity for community paramedicine to alleviate EMS utilization and decrease the frequency of pediatric behavioral health emergencies.
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Abstract
There are 240 million 9-1-1 calls in the United States every year. The burden of managing these emergencies until first responders can arrive is on the dispatchers working in the 5806 public safety answering points, more commonly known as dispatch centers. They are the first link in the chain of survival between the public and the remainder of the health care system. Dispatchers play a critical role in the early identification of emergencies, assignment of appropriate emergency resources, and provision of life-sustaining interventions like dispatcher-assisted cardiopulmonary resuscitation and disaster management.
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Affiliation(s)
- Saman Kashani
- Los Angeles Fire Department, EMS Bureau, 200 North Main Street, Suite 1860, Los Angeles, CA 90012, USA; Division of Emergency Medical Services, Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State Street, Room 1011, Los Angeles, CA 90033, USA.
| | - Stephen Sanko
- Los Angeles Fire Department, EMS Bureau, 200 North Main Street, Suite 1860, Los Angeles, CA 90012, USA; Division of Emergency Medical Services, Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State Street, Room 1011, Los Angeles, CA 90033, USA
| | - Marc Eckstein
- Los Angeles Fire Department, EMS Bureau, 200 North Main Street, Suite 1860, Los Angeles, CA 90012, USA; Division of Emergency Medical Services, Department of Emergency Medicine, Keck School of Medicine of USC, 1200 North State Street, Room 1011, Los Angeles, CA 90033, USA
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Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016. Ann Emerg Med 2018; 73:42-51. [PMID: 30274946 DOI: 10.1016/j.annemergmed.2018.08.422] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/30/2018] [Accepted: 08/13/2018] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Patients with acute psychiatric emergencies who receive an involuntary hold often spend hours in the emergency department (ED) because of a deficit in inpatient psychiatric beds. One solution to address the lack of prompt psychiatric evaluation in the ED has been to establish regional stand-alone psychiatric emergency services. However, patients receiving involuntary holds still need to be screened and evaluated to ensure that their behavior is not caused by an underlying and life-threatening nonpsychiatric illness. Although traditional regional emergency medical services (EMS) systems depend on the medical ED for this function, a field-screening protocol can allow EMS to directly transport a substantial portion of patients to a stand-alone psychiatric emergency service. The purpose of this investigation is to describe overall EMS use for patients receiving involuntary holds, compare patients receiving involuntary holds with all EMS patients, and evaluate the safety of field medical clearance of an established field-screening protocol in Alameda County, CA. METHODS We obtained data for all EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County's standardized data set. After unique patient identification, we describe the data at the patient level and at the encounter level. At the patient level, we compare "involuntary hold patients" (≥1 involuntary hold during the study period) with those who were "never held." Additionally, we assess the safety of out-of-hospital medical clearance by calculating the rate of failed diversion, defined as retransport of a patient to a medical ED within 12 hours of transport to the psychiatric emergency services by EMS. RESULTS Of the 541,731 total EMS encounters in Alameda County during the study period, 10% (N=53,887) were identified as involuntary hold encounters. Of these involuntary hold patient encounters, 41% (N=22,074) resulted in direct transport of the patient to the stand-alone psychiatric emergency service for evaluation; 0.3% (N=60) failed diversion and required retransport within 12 hours. At the patient level, Alameda County EMS encountered 257,625 unique patients, and 10% (N=26,283) had at least one encounter for an involuntary hold during the study period. These "involuntary hold patients" were substantially younger, more likely to be men, and less likely to be insured. Additionally, they had higher overall EMS use: "involuntary hold patients" accounted for 24% of all encounters (N=128,003); 53,887 of these encounters were for involuntary holds, whereas an additional 74,116 were for other reasons. Similarly, 4% of "involuntary hold patients" had 20 or more encounters, whereas only 0.4% of "never held" patients were in this category. Last, the 7% of "involuntary hold patients" (N=1,907) who received greater than or equal to 5 involuntary holds during the study period accounted for 39% of all involuntary holds and 9% of all EMS encounters. CONCLUSION Ten percent of all EMS encounters were for involuntary psychiatric holds. With an EMS-directed screening protocol, 41% of all such patient encounters resulted in direct transport of the patient to the psychiatric emergency service, bypassing medical clearance in the ED. Overall, only 0.3% of these patients required retransport to a medical ED within 12 hours of arrival to psychiatric emergency services. We found that 24% of all EMS encounters in Alameda County were attributable to "involuntary hold patients," reinforcing the importance of the effects of mental illness on EMS use.
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Affiliation(s)
- Tarak K Trivedi
- National Clinical Scholars Program, University of California-Los Angeles, Los Angeles, CA; Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA; Veterans Administration, Greater Los Angeles Healthcare System, Los Angeles, CA.
| | - Melody Glenn
- Alameda Health System-Highland Hospital, Oakland, CA
| | - Gene Hern
- Alameda Health System-Highland Hospital, Oakland, CA; Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - David L Schriger
- National Clinical Scholars Program, University of California-Los Angeles, Los Angeles, CA; Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Karl A Sporer
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA; Alameda County EMS Agency, Oakland, CA
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Emond K, O'Meara P, Bish M. Paramedic management of mental health related presentations: a scoping review. J Ment Health 2018; 28:89-96. [PMID: 30269628 DOI: 10.1080/09638237.2018.1487534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Mental illness is a recognised global health issue and is a major burden of disease that health systems have failed to adequately address. National reforms in Australia to improve mental health service delivery propose building the knowledge and skills of service providers, such as paramedics, to ensure that they appropriately respond to the needs of people experiencing mental health issues. There is a paucity of literature on the role of paramedics in managing mental health presentations despite becoming an increasingly significant part of mental health care in the pre-hospital context. AIMS This scoping review examined the available literature on the paramedic management of mental health related presentations. METHODS The five stages of Arksey and O'Malley's methodological framework was used: (1) identifying the research question; (2) identifying relevant studies; (3) study section; (4) charting the data; and (5) collating, summarizing and reporting of results. Relevant databases were searched. RESULTS Fourteen peer-reviewed articles met the inclusion criteria. Three themes were identified and structured the findings. These were education and training, organizational factors, and clinical decision making. CONCLUSION The authors recommend that future research address these areas, as high quality evidence will support planning in this complex area of health care delivery.
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Affiliation(s)
- Kate Emond
- a La Trobe Rural Health School La Trobe University , Bendigo , Victoria , Australia
| | - Peter O'Meara
- a La Trobe Rural Health School La Trobe University , Bendigo , Victoria , Australia
| | - Melanie Bish
- a La Trobe Rural Health School La Trobe University , Bendigo , Victoria , Australia
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Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department. Jt Comm J Qual Patient Saf 2018; 44:279-292. [PMID: 29759261 DOI: 10.1016/j.jcjq.2017.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. METHODS A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management. RESULTS Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes. CONCLUSION Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.
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Roggenkamp R, Andrew E, Nehme Z, Cox S, Smith K. Descriptive Analysis Of Mental Health-Related Presentations To Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:399-405. [DOI: 10.1080/10903127.2017.1399181] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ford-Jones PC, Chaufan C. A Critical Analysis of Debates Around Mental Health Calls in the Prehospital Setting. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017704608. [PMID: 28466658 PMCID: PMC5798668 DOI: 10.1177/0046958017704608] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Paramedics, health care workers who assess and manage health concerns in the prehospital setting, are increasingly providing psychosocial care in response to a rise in mental health call volume. Observers have construed this fact as “misuse” of paramedic services, and proposed as solutions better triaging of patients, better mental health training of paramedics, and a greater number of community mental health services. In this commentary, we argue that despite the ostensibly well-intentioned nature of these solutions, they shift attention and accountability away from relevant public policies, as well as from broader economic, social, and political determinants of mental health, while placing responsibility on those requiring services or, at best, on the health care system. We also argue that the perspective of paramedics, who are exposed to, and interact with, individuals in their everyday environments, has the potential to inform a better, structural and critical, understanding of the factors driving the rise in psychosocial crises in the first place. Finally, we suggest that a greater engagement with the political and social determinants of mental health would lead to preventing, rather than primarily reacting to, these crises after the fact.
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Affiliation(s)
- Polly Christine Ford-Jones
- York University, Toronto, Ontario, Canada
- Polly Christine Ford-Jones, York University, 4700 Keele St, Toronto, Ontario, Canada M3J 1P3.
| | - Claudia Chaufan
- York University, Toronto, Ontario, Canada
- University of California, San Francisco, USA
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Hanchate AD, Paasche-Orlow MK, Dyer KS, Baker WE, Feng C, Feldman J. Geographic Variation in Use of Ambulance Transport to the Emergency Department. Ann Emerg Med 2017; 70:533-543.e7. [PMID: 28559039 DOI: 10.1016/j.annemergmed.2017.03.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 02/23/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Evidence on variability in emergency medical services use is limited. We obtain national evidence on geographic variation in the use of ambulance transport to the emergency department (ED) among Medicare enrollees and assess the role of health status, socioeconomic status, and provider availability. METHODS We used 2010 Medicare claims data for a random sample of 999,999 enrollees aged 66 years and older, and identified ambulance transport and ED use. The main outcome measures were number of ambulance transports to the ED per 100 person-years (ambulance transport rate) and proportion (percentage) of ED visits by ambulance transport by hospital referral regions. RESULTS The national ambulance transport rate was 22.2 and the overall proportion of ED visits by ambulance was 36.7%. Relative to hospital referral regions in the lowest rate quartile, those in the highest quartile had a 75% higher ambulance transport rate (incidence rate ratio [IRR] 1.75; 95% confidence interval [CI] 1.69 to 1.81) and a 15.5% higher proportion of ED visits by ambulance (IRR 1.155; 95% CI 1.146 to 1.164). Adjusting for health status, socioeconomic status, and provider availability reduced quartile 1 versus quartile 4 difference in ambulance transport rate by 43% (IRR 1.43; 95% CI 1.38 to 1.48) and proportion of ED visits by ambulance by 7% (IRR 1.145; 95% CI 1.135 to 1.155). Among the 3 covariate domains, health status was associated with the largest variability in ambulance transport rate (30.1%), followed by socioeconomic status (12.8%) and provider availability (2.9%). CONCLUSION Geographic variability in ambulance use is large and associated with variation in patient health status and socioeconomic status.
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Affiliation(s)
- Amresh D Hanchate
- VA Boston Healthcare System, Boston, MA; Section of General Internal Medicine, Boston University School of Medicine, Boston, MA.
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
| | - K Sophia Dyer
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA; Boston EMS, City of Boston, Boston, MA
| | - William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
| | - Chen Feng
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - James Feldman
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
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Hamilton JE, Desai PV, Hoot NR, Gearing RE, Jeong S, Meyer TD, Soares JC, Begley CE. Factors Associated With the Likelihood of Hospitalization Following Emergency Department Visits for Behavioral Health Conditions. Acad Emerg Med 2016; 23:1257-1266. [PMID: 27385617 DOI: 10.1111/acem.13044] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/23/2016] [Accepted: 06/29/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States. METHODS Using Andersen's Behavioral Model of Health Service Use for guidance, the study examined the relationship between predisposing (characteristics of the individual, i.e., age, sex, race/ethnicity), enabling (system or structural factors affecting healthcare access), and need (clinical) factors and the likelihood of hospitalization following ED visits for behavioral health conditions (n = 28,716 ED visits). In the adjusted analysis, a logistic fixed-effects model with blockwise entry was used to estimate the relative importance of predisposing, enabling, and need variables added separately as blocks while controlling for variation in unobserved hospital-specific practices across hospitals and time in years. RESULTS Significant predisposing factors associated with an increased likelihood of hospitalization following an ED visit included increasing age, while African American race was associated with a lower likelihood of hospitalization. Among enabling factors, arrival by emergency transport and a longer ED LOS were associated with a greater likelihood of hospitalization while being uninsured and the availability of community-based behavioral health services within 5 miles of the ED were associated with lower odds. Among need factors, having a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, dementia, or an impulse control disorder as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit. CONCLUSION The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness.
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Affiliation(s)
- Jane E. Hamilton
- McGovern Medical School; Department of Psychiatry and Behavioral Sciences; University of Texas, Health Science Center at Houston; Houston TX
| | - Pratikkumar V. Desai
- McGovern Medical School; Department of Psychiatry and Behavioral Sciences; University of Texas, Health Science Center at Houston; Houston TX
| | - Nathan R. Hoot
- McGovern Medical School, Department of Emergency Medicine; University of Texas, Health Science Center at Houston; Houston TX
| | - Robin E. Gearing
- Graduate College of Social Work; University of Houston; Houston TX
| | - Shin Jeong
- Department of Management, Policy and Community Health; University of Texas School of Public Health; Houston TX
| | - Thomas D. Meyer
- McGovern Medical School; Department of Psychiatry and Behavioral Sciences; University of Texas, Health Science Center at Houston; Houston TX
| | - Jair C. Soares
- McGovern Medical School; Department of Psychiatry and Behavioral Sciences; University of Texas, Health Science Center at Houston; Houston TX
| | - Charles E. Begley
- Department of Management, Policy and Community Health; University of Texas School of Public Health; Houston TX
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The HOME Team: Evaluating the Effect of an EMS-based Outreach Team to Decrease the Frequency of 911 Use Among High Utilizers of EMS. Prehosp Disaster Med 2016; 31:603-607. [PMID: 27640612 DOI: 10.1017/s1049023x16000790] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The San Francisco Fire Department's (SFFD; San Francisco, California USA) Homeless Outreach and Medical Emergency (HOME) Team is the United States' first Emergency Medical Services (EMS)-based outreach effort using a specially trained paramedic to redirect frequent users of EMS to other types of services. The effectiveness of this program at reducing repeat use of emergency services during the first seven months of the team's existence was examined. METHODS A retrospective analysis of EMS use frequency and demographic characteristics of frequent users was conducted. Clients that used emergency services at least four times per month from March 2004 through May 2005 were contacted for intervention. Patterns for each frequent user before and after intervention were analyzed. Changes in EMS use during the 15-month study interval was the primary outcome measurement. RESULTS A total of 59 clients were included. The target population had a median age of 55.1 years and was 68% male. Additionally, 38.0% of the target population was homeless, 43.4% had no primary care, 88.9% had a substance abuse disorder at time of contact, and 83.0% had a history of psychiatric disorder. The HOME Team undertook 320 distinct contacts with 65 frequent users during the study period. The average EMS use prior to HOME Team contact was 18.72 responses per month (SD=19.40), and after the first contact with the HOME Team, use dropped to 8.61 (SD=10.84), P<.001. CONCLUSION Frequent users of EMS suffer from disproportionate comorbidities, particularly substance abuse and psychiatric disorders. This population responds well to the intervention of a specially trained paramedic as measured by EMS usage. Tangherlini N , Villar J , Brown J , Rodriguez RM , Yeh C , Friedman BT , Wada P . The HOME Team: evaluating the effect of an EMS-based outreach team to decrease the frequency of 911 use among high utilizers of EMS. Prehosp Disaster Med. 2016;31(6):603-607.
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Booker MJ, Shaw ARG, Purdy S. Why do patients with 'primary care sensitive' problems access ambulance services? A systematic mapping review of the literature. BMJ Open 2015; 5:e007726. [PMID: 25991458 PMCID: PMC4442240 DOI: 10.1136/bmjopen-2015-007726] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Emergency ambulance use for problems that could be managed in primary care continues to rise owing to complex reasons that are poorly understood. The objective of this systematic review is to draw together published evidence across a variety of study methodologies and settings to gain a better understanding of why patients seek help from ambulance services for these problems. DESIGN Systematic searches were undertaken across the MEDLINE, EMBASE, PsychINFO, CINAHL, Health Management Information Consortium and Health Management Information Service publication databases. Google Scholar, Web of Science, OpenSigle, EThOS and DART databases were also systematically searched for reports, proceedings, book chapters and theses, along with hand-searching of grey literature sources. Studies were included if they reported on findings examining patient, carer, health professional or service management interactions with ambulance services for primary care problems. All study methodologies and perspectives were of interest. Data were extracted, quality assessed and systematically mapped according to key findings through generation of an iterative framework. RESULTS A total of 31 studies met inclusion criteria. Findings were summarised across 5 broad categories: factors associated with individual patients; actions of care-givers and bystanders; population-level factors; health infrastructure factors; challenges faced by health professionals. A number of subcategories were developed to explore these factors in more detail. CONCLUSIONS This review reports important factors that may impact on ambulance use for primary care problems across a global setting, including demographic measures associated with deprivation, minority status and individual social circumstances. Categorising ambulance calls for primary care problems as 'inappropriate' is context dependant and may be unhelpful. Potential implications for triage and risk management strategies are discussed.
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Affiliation(s)
- Matthew J Booker
- Centre for Academic Primary Care, School of Social and Community Medicine University of Bristol, Bristol, UK
| | - Ali R G Shaw
- Centre for Academic Primary Care, School of Social and Community Medicine University of Bristol, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, School of Social and Community Medicine University of Bristol, Bristol, UK
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Assessing pediatric and young adult substance use through analysis of prehospital data. Prehosp Disaster Med 2014; 29:468-72. [PMID: 25088538 DOI: 10.1017/s1049023x1400079x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Substance use in young adults is a significant and growing problem. Emergency Medical Services (EMS) personnel often encounter this problem, yet the use of prehospital data to evaluate the prevalence and magnitude of substance abuse has been limited. HYPOTHESIS/PROBLEM This study evaluated drug and alcohol use through the use of prehospital and EMS data in one suburban county in Maryland (USA). The primary hypothesis was that the type of drug being abused is associated with age. The secondary hypothesis was substance abuse incidence is associated with location. The tertiary hypothesis was that substance abuse is associated with a history of mental illness. METHODS Deidentified patient care reports (PCRs) were obtained during a 24-month period from October 2010 through September 2012 for patients 0 through 25 years of age. Inclusion criteria included chief complaint of alcohol overdose, drug overdose, or the use of naloxone. RESULTS The primary hypothesis was supported that age was associated with drug category (P < .001). Younger adolescents were more likely to use household items, prescription drugs, or over-the-counter drugs, whereas older adolescents were more likely to use illicit drugs. The secondary hypothesis was supported that both alcohol (P < .001) and drugs (P < .001) were associated with location of call. Calls involving alcohol were more likely to be at a home or business, whereas calls involving drugs were more likely to be at home or at a public venue. The tertiary hypothesis was supported that both alcohol (P = .001) and drug use (P < .001) were associated with history of mental illness. Older adolescents were more likely to report a history of mental illness. Chi-squared tests indicated there were significant differences between genders and drug category (P = .002) and gender and current suicide attempt (P = .004). Females were more likely to use prescription drugs, whereas males were more likely to use illicit drugs. Calls involving younger adolescents under 18 were more likely to be at school or the mall, whereas calls involving older adolescents were likely to be at a prison, public venue, or a business. CONCLUSION All three hypotheses were supported: the type of substance being abused was associated with both age and location, and substance abuse was associated with a history of mental illness. This research has important implications for understanding how EMS resources are utilized for substance use. This information is valuable in not only the education and training of prehospital care providers, but also for the targeting of future public health interventions.
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Knowlton A, Weir BW, Hughes BS, Southerland RJH, Schultz CW, Sarpatwari R, Wissow L, Links J, Fields J, McWilliams J, Gaasch W. Patient demographic and health factors associated with frequent use of emergency medical services in a midsized city. Acad Emerg Med 2013; 20:1101-11. [PMID: 24238312 DOI: 10.1111/acem.12253] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 05/10/2013] [Accepted: 08/09/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health. METHODS The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users. RESULTS Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse-related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher. CONCLUSIONS The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions.
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Affiliation(s)
- Amy Knowlton
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Brian W. Weir
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Brenna S. Hughes
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | | | - Cody W. Schultz
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | - Ravi Sarpatwari
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | - Lawrence Wissow
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Departments of Psychiatry and Pediatrics; Johns Hopkins School of Medicine; Baltimore MD
| | - Jonathan Links
- The Department of Environmental Health Sciences; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore MD
| | - Julie Fields
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore MD
| | - Junette McWilliams
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Wade Gaasch
- The Department of Emergency Medicine; University of Maryland School of Medicine; Baltimore MD
- The Baltimore City Fire Department; Baltimore MD
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Inocencio TJ, Carroll NV, Read EJ, Holdford DA. The economic burden of opioid-related poisoning in the United States. PAIN MEDICINE 2013; 14:1534-47. [PMID: 23841538 DOI: 10.1111/pme.12183] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To estimate the yearly economic burden of opioid-related poisoning in the United States. BACKGROUND Rates of opioid poisoning and related mortality have increased substantially over the past decade. Although previous studies have measured the costs of misuse and abuse, costs related specifically to opioid poisoning have not been quantified. This study quantifies the economic burden of opioid poisoning in the United States to help evaluate the economic case for efforts to reverse or prevent opioid poisoning and its associated morbidity and mortality. METHODS Mean costs and prevalence estimates were estimated using publically available datasets. A societal perspective was assumed and accordingly estimated direct medical and productivity costs. Direct medical costs included treatment for opioid poisoning in the emergency department (ED) and inpatient settings, along with emergency transport and drug costs. Productivity costs were estimated using the human capital method and included lost wages due to mortality and absenteeism costs from ED visits and hospitalizations. All costs were inflated to 2011 U.S. dollars. RESULTS In 2009, total costs were estimated at approximately $20.4 billion with indirect costs constituting 89% of the total. Direct medical costs were approximately $2.2 billion. ED costs and inpatient costs were estimated to be $800 million and $1.3 billion, respectively. Absenteeism costs were $335 million and lost future earnings due to mortality were $18.2 billion. CONCLUSION Opioid-related poisoning causes a substantial burden to the United States each year. Costs related to mortality account for the majority of costs. Interventions designed to prevent or reverse opioid-related poisoning can have significant impacts on cost, especially where death is prevented.
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Tippett VC, Toloo GS, Eeles D, Ting JYS, Aitken PJ, Fitzgerald GJ. Universal access to ambulance does not increase overall demand for ambulance services in Queensland, Australia. AUST HEALTH REV 2013; 37:121-6. [PMID: 23237427 DOI: 10.1071/ah12141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 07/26/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the impact of the introduction of universal access to ambulance services via the implementation of the Community Ambulance Cover (CAC) program in Queensland in 2003-04. METHOD The study involved a 10-year (2000-01 to 2009-10) retrospective analysis of routinely collected data reported by the Queensland Ambulance Service (QAS) and by the Council of Ambulance Authorities. The data were analysed for the impact of policy changes that resulted in universal access to ambulance services in Queensland. RESULTS QAS is a statewide, publically funded ambulance service. In Queensland, ambulance utilisation rate (AUR) per 1000 persons grew by 41% over the decade or 3.9% per annum (10-year mean=149.8, 95% CI: 137.3-162.3). The AUR mean after CAC was significantly higher for urgent incidents than for non-urgent ones. However projection modelling demonstrates that URs after the introduction of CAC were significantly lower than the projected utilisation for the same period. CONCLUSIONS The introduction of universal access under the Community Ambulance Cover program in Queensland has not had any significant independent long-term impact on demand overall. There has been a reduction in the long-term growth rate, which may have been contributed to by an 'appropriate use' public awareness program.
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Affiliation(s)
- Vivienne C Tippett
- School of Clinical Sciences, Victoria Park Road, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia.
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Willems A, Waxman B, Bacon AK, Smith J, Kitto S. Interprofessional non-technical skills for surgeons in disaster response: a literature review. J Interprof Care 2013; 27:380-6. [DOI: 10.3109/13561820.2013.791670] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Toloo GS, FitzGerald GJ, Aitken PJ, Ting JYS, McKenzie K, Rego J, Enraght-Moony E. Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions. Acad Emerg Med 2013; 20:576-83. [PMID: 23758304 DOI: 10.1111/acem.12149] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/29/2012] [Accepted: 12/14/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to study the role and effect of patients' perceptions on reasons for using ambulance services in Queensland, Australia. METHODS A cross-sectional survey was conducted of patients (n = 911) presenting via ambulance or self-transport at eight public hospital emergency departments (EDs). The survey included perceived illness severity, attitudes toward ambulance, and reasons for using ambulance. A theoretical framework was developed to inform this study. RESULTS Ambulance users had significantly higher self-rated perceived seriousness, urgency, and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions. In compared to self-transports, likelihood of using an ambulance increased by 26% for every unit increase in perceived seriousness; and patients who had not used an ambulance in the 6 months prior to the survey were 66% less likely to arrive by ambulance. Patients who had presented via ambulance stated they considered the urgency (87%) or severity (84%) of their conditions as reasons for calling the ambulance. Other reasons included requiring special care (76%), getting higher priority at the ED (34%), not having a car (34%), and financial concerns (17%). CONCLUSIONS Understanding patients' perceptions is essential in explaining their actions and developing safe and effective health promotion programs. Individuals use ambulances for various reasons and justifications according to their beliefs, attitudes, and sociodemographic conditions. Policies to reduce and manage demand for such services need to address both general opinions and specific attitudes toward emergency health services to be effective.
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Affiliation(s)
- Ghasem Sam Toloo
- School of Public Health and Social Work; Queensland University of Technology; Brisbane; QLD
| | - Gerry J. FitzGerald
- School of Public Health and Social Work; Queensland University of Technology; Brisbane; QLD
| | - Peter J. Aitken
- Emergency Department; The Townsville Hospital, and Anton Breinl Centre for Public Health and Tropical Medicine; James Cook University; Townsville; QLD
| | - Joseph Y. S. Ting
- Mater Health Services; Careflight Medical Services Qld, and University of Queensland Medical School; Brisbane; QLD
| | - Kirsten McKenzie
- Centre for Accident Research and Road Safety Queensland; School of Psychology and Counseling, and National Centre for Health Information Research and Training; School of Public Health; Queensland University of Technology; Brisbane; QLD
| | - Joanna Rego
- School of Public Health and Social Work; Queensland University of Technology; Brisbane; QLD
| | - Emma Enraght-Moony
- Clinical Performance & Service Improvement Unit; Queensland Ambulance Service; Brisbane; QLD; Australia
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Wang HE, Mann NC, Jacobson KE, Ms MD, Mears G, Smyrski K, Yealy DM. National characteristics of emergency medical services responses in the United States. PREHOSP EMERG CARE 2012; 17:8-14. [PMID: 23072355 DOI: 10.3109/10903127.2012.722178] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Despite its long history and current prominence in U.S. communities, only limited data describe the national characteristics of emergency medical services (EMS) care in the United States. We sought to characterize out-of-hospital EMS care in the United States. METHODS We conducted an analysis of the 2010 National Emergency Medical Services Information System (NEMSIS) research data set, encompassing EMS emergency response data from 29 states. From these data, we estimated the national number and incidence of EMS responses. We also characterized EMS responses and the patients receiving care. RESULTS There were 7,563,843 submitted EMS responses, corresponding to an estimated national incidence of 17.4 million EMS emergency responses per year (56 per 1,000 person-years). The EMS response incidence varied by U.S. Census region (South 137.4 per 1,000 population per year, Northeast 85.2, West 39.7, and Midwest 33.3). The use of lights and sirens varied across Census regions (Northeast 90.3%, South 76.7%, West 68.8%, and Midwest 67.5%). The percentage of responses resulting in patient contact varied across Census regions (range 78.4% to 95.7%). The EMS time intervals were similar between Census regions; response median 5 minutes (interquartile range [IQR] 3-9), scene 14 minutes (10-20), and transport 11 minutes (7-19). Underserved populations (the elderly, minorities, rural residents, and the uninsured) were large users of EMS resources. CONCLUSION These data highlight the breadth and diversity of EMS demand and care in the United States.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, USA.
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Jacobsen RC, Toy S, Bonham AJ, Salomone J, Ruthstrom J, Gratton M. Anaphylaxis Knowledge Among Paramedics: Results of a National Survey. PREHOSP EMERG CARE 2012; 16:527-34. [DOI: 10.3109/10903127.2012.689931] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Durant E, Fahimi J. Factors associated with ambulance use among patients with low-acuity conditions. PREHOSP EMERG CARE 2012; 16:329-37. [PMID: 22494108 DOI: 10.3109/10903127.2012.670688] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The use of ambulances for low-acuity medical complaints depletes emergency medical services (EMS) resources that could be used for higher-acuity conditions and contributes to emergency department (ED) overcrowding and ambulance diversion. Objective. We sought to understand the characteristics of patients who use ambulances for low-acuity conditions. We hypothesized that patients who arrive to the ED by ambulance for low-acuity conditions are more likely to be members of vulnerable populations. METHODS A secondary analysis was performed on the National Hospital Ambulatory Medical Care Survey (NHAMCS). We included only patients aged 18 years or older who were triaged to the "nonurgent" category upon presentation to the ED. To compare patients who arrived by ambulance with those who arrived by all other modes, multivariate logistic regression was performed using a generalized linear model, and adjusted relative risks (ARRs) were calculated. RESULTS A total of 16,109 records from 1997 to 2008 (excluding 2001-2002) were included in the analysis. Significantly higher rates of ambulance use for low-acuity conditions were associated with: 1) older age (ARR 1.30, 95% confidence interval [CI]: 1.18-1.43; per 10 years); 2) Medicare or Medicaid insurance (ARR 1.81, 95% CI: 1.36-2.41, and ARR 1.46, 95% CI: 1.12-1.91, respectively); 3) homelessness (ARR 3.30, 95% CI: 1.61-6.78); 4) arrival between 11 pm and 6:59 am (ARR 1.80, 95% CI: 1.43-2.27); and 5) certain chief complaint categories: psychiatric (ARR 1.78, 95% CI: 1.03-3.07), toxicologic/poisoning (ARR 3.26, 95% CI: 1.85-5.76), and neurologic/psychological (ARR 1.71, 95% CI: 1.34-2.18). Patients who arrived by ambulance were more likely than nonambulance patients to receive laboratory diagnostic tests (ARR 3.50, 95% CI: 2.80-4.39), radiographic imaging (ARR 2.26, 95% CI: 1.91-2.68), and admission to the hospital (ARR 3.99, 95% CI: 3.03-5.27). CONCLUSION Our study builds on a body of work highlighting the factors associated with ambulance transport to EDs, confirms that certain vulnerable populations disproportionately use ambulances, and may inform interventions aimed at increasing access to nonambulance transportation and urgent care for these patients.
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Affiliation(s)
- Edward Durant
- School of Public Health, University of California-Berkeley, USA.
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Meisel ZF, Pines JM, Polsky D, Metlay JP, Neuman MD, Branas CC. Variations in ambulance use in the United States: the role of health insurance. Acad Emerg Med 2011; 18:1036-44. [PMID: 21996068 PMCID: PMC3196627 DOI: 10.1111/j.1553-2712.2011.01163.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The purpose of this study was to describe the associations between individual health insurance and ambulance utilization using a national sample of patients who receive emergency department (ED) care. METHODS The data source was the National Hospital Ambulatory Medical Care Survey, years 2004 through 2006. Noninstitutionalized patients between ages 18 and 65 years were included. The primary dependent variable was ambulance use. Multivariable logistic regression methods were used to assess the associations between health insurance status and ambulance use and to adjust for confounders. RESULTS A total of 61,013 ED visits were included, representing a national sample of approximately 70 million annual ED visits over 3 years. Ambulance transport was used in 11% of private insurance visits, 16% of Medicaid visits, and 13% of uninsured visits. In the adjusted model, visits by patients with Medicaid (adjusted odds ratio [aOR] = 1.60, 99% confidence interval (CI) = 1.37 to 1.86) and the uninsured (aOR = 1.43, 99% CI = 1.23 to 1.66) were more likely to arrive by ambulance than visits by patients with private insurance. Ambulance use among the uninsured was most pronounced in metropolitan areas. CONCLUSIONS Ambulance use varies by health insurance status. Medicaid coverage and lack of insurance are each independently associated with increased odds of ambulance use, suggesting a disproportionate role for emergency medical services (EMS) in the care of patients with limited financial resources.
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Affiliation(s)
- Zachary F Meisel
- Robert Wood Johnson Foundation Clinical Scholars Program, the Leonard Davis Institute of Health Economics, the Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
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Lowthian JA, Cameron PA, Stoelwinder JU, Curtis A, Currell A, Cooke MW, McNeil JJ. Increasing utilisation of emergency ambulances. AUST HEALTH REV 2011; 35:63-9. [PMID: 21367333 DOI: 10.1071/ah09866] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Accepted: 05/18/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied. AIMS To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase. METHOD A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken. FINDINGS Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed. CONCLUSION The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes. A variety of factors may contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand.
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Affiliation(s)
- Judy A Lowthian
- Ambulance Victoria, 375 Manningham Road, Doncaster, VIC 3108, Australia.
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Migdole S, Tondora J, Silva MA, Barry AD, Milligan JC, Mattison E, Rutledge W, Powsner S. Exploring New Frontiers: Recovery-Oriented Peer Support Programming in a Psychiatric ED. AMERICAN JOURNAL OF PSYCHIATRIC REHABILITATION 2011. [DOI: 10.1080/15487768.2011.546274] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Squire BT, Tamayo A, Tamayo-Sarver JH. At-risk populations and the critically ill rely disproportionately on ambulance transport to emergency departments. Ann Emerg Med 2010; 56:341-7. [PMID: 20554351 DOI: 10.1016/j.annemergmed.2010.04.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 03/31/2010] [Accepted: 04/19/2010] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) crowding increases ambulance diversion. Ambulance diversion disproportionately affects individuals who rely on ambulance transport. The purpose of this study is to determine which populations rely most on ambulance transport. METHODS We queried the National Hospital Ambulatory Medical Care Survey database for 1997 to 2000 and 2003 to 2005 for patients who arrived by ambulance or personal transport. We performed bivariate analysis to assess the extent to which all patients and a subset of critically ill patients use ambulance transport relative to self-transport. RESULTS In our sample, 30,455 (15%; 95% confidence interval [CI] 15% to 16%) patients arrived by ambulance and 162,091 (85%; 95% CI 84% to 85%) arrived by walk-in/self-transport. Overall, patients with Medicare insurance were more likely to rely on ambulance transport, at 34% (95% CI 33% to 35%), than the privately insured, at 11% (95% CI 10% to 11%). Among the critically ill, privately insured patients were less likely to rely on ambulance transport, at 47% (95% CI 42% to 52%), than those with Medicare insurance (61%; 95% CI 58% to 65%), the publicly insured (60%; 95% CI 52% to 67%), or the uninsured (57%; 95% CI 49% to 64%). Among the critically ill, patients aged 15 to 24 years and those older than 74 years were most likely to rely on ambulance transport, at 63% (95% CI 53% to 72%) and 67% (95% CI 62% to 71%), respectively. Fifty-seven percent (95% CI 54% to 59%) of the critically ill used ambulance versus 15% (95% CI 14% to 15%) of noncritical patients. CONCLUSION Patients with Medicare insurance or public insurance, the uninsured, the elderly, and the critically ill disproportionately rely on ambulance transport to the ED. Ambulance diversion may disproportionately affect these populations.
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Affiliation(s)
- Benjamin T Squire
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.
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Abstract
OBJECTIVE Alcohol misuse by college students places resource demands on colleges and universities, including the provision of medical services for intoxicated students. We harvested archival data to document the prevalence of alcohol-related ambulance utilization and to explore factors associated with ambulance use. METHODS We reviewed 2 years of university ambulance records and determined which trips were alcohol related and their demographic, descriptive, and medical correlates. RESULTS Alcohol use was associated with 17 and 16 percent of all university-based ambulance trips in 2005 and 2006, respectively. When alcohol was involved, patients were more likely to be younger than 21 years, less alert, and more likely to receive advanced life support. Alcohol-related ambulance trips were more likely to occur on weekends, to involve transport from a residence hall, and to a hospital. CONCLUSION Alcohol misuse is associated with one out of every six campus-based ambulance runs, a hidden cost of student alcohol misuse.
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Larkin GL, Beautrais AL, Spirito A, Kirrane BM, Lippmann MJ, Milzman DP. Mental health and emergency medicine: a research agenda. Acad Emerg Med 2009; 16:1110-9. [PMID: 20053230 DOI: 10.1111/j.1553-2712.2009.00545.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.
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Affiliation(s)
- Gregory Luke Larkin
- Department of Surgery, Emergency Medicine Division, Yale University School of Medicine, New Haven, CT, USA.
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