Risk Factors Associated With Emergency Department Return Visits Following Trauma System Discharge

Evaluating Health Literacy in Families of Injured Children: A Prospective Observational Cohort Study at a Level One Pediatric Trauma Center

BACKGROUND

Low health literacy (HL) has been associated with poor health outcomes in children. Optimal recovery after pediatric injury requires caregiver participation in complicated rehabilitative and medical aftercare. We aimed to quantify HL among guardians of injured children and identify factors associated with low HL of guardians.

METHODS

A prospective observational cohort study was conducted to evaluate the HL using the Newest Vital Sign™ of guardians of injured children (≤18 years) admitted to a level 1 pediatric trauma center. Patient and guardian characteristics were compared across levels of HL using univariate statistics. We conducted multivariable logistic regression to identify factors independently-associated with low HL.

RESULTS

A sample of 95 guardian-child dyads were enrolled. The majority of guardians had low HL (n = 52, 55%), followed by moderate HL (n = 36, 38%) and high HL (n = 7, 7%). Many families received public benefits (n = 47, 49%) and 12 guardians (13%) had both housing and employment insecurity. Guardians with low HL were significantly more likely to have insecure housing and not have completed any college.

CONCLUSION

The majority of injured children had a primary guardian with low HL. Pediatric trauma centers should consider screening for low HL to ensure that families have adequate post-discharge support.

LEVEL OF EVIDENCE

Level 3.

Emergency department visit patterns in the recently discharged, violently injured patient: Retrospective cohort review

BACKGROUND

Analysis of the costs associated with emergency department (ED) visits after discharge for violent injury could highlight subgroups for the development of cost-effective interventions to support healing and prevent treatment failures in violently injured patients.

METHODS

A retrospective cohort review was conducted of all patients with return ED visits within 90 days of discharge after treatment for a violent injury occurring between July 1, 2016, and June 30, 2018. Hospital costs were calculated for each incidence and analyzed against demographic and injury type variables to identify trends.

RESULTS

218 return ED visits were identified. Hospital costs showed a high frequency of low-cost visits. For more complex visits, distinct cost patterns were observed for Black and LatinX males compared to White males as a function of age.

CONCLUSIONS

Analysis of hospital cost per visit identified trends among different subgroups. Underlying etiologies presumably vary between groups, but hypothesis-driven further investigation and needs assessment is required. Understanding the driving forces behind these cost trends may aid in developing effective interventions.

Social and structural determinants of emergency department use among Arab and Jewish patients in Jerusalem

Background

A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance.

Methods

A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days.

Results

There were differences between Jewish and Arab patients’ social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty.

Conclusion

The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.

Emergency department return visits and hospital admissions in trauma team assessed patients initially discharged from the emergency department: a population-based cohort study

BACKGROUND

Many injured patients are transported directly to trauma centers, found to be minimally injured, and discharged directly home from the emergency department (ED). Our objectives were to characterize the short-term outcomes in this discharged patient population and to identify patient factors predictive of ED return visits.

METHODS

We conducted a retrospective population-based cohort study using linked administrative datasets involving patients assessed at trauma centers in Ontario, Canada between April 1, 2009 and March 31, 2020. Patients who were assessed by a trauma team and discharged directly home from ED were included. The primary outcome was the percentage of patients with an ED return visit within 14-days. We used multivariate logistic regression analyses to identify patient characteristics predictive of at least one ED return visit.

RESULTS

There were 5550 patients included in the study. 1004 (18.1%) of patients had at least one ED return visit but only 100 patients (1.8%) were admitted to hospital following initial discharge. Common reasons for ED return visits included wound care concerns (17.2%), head injury complaints (15.6%), and substance misuse (6.8%). Rural residence (OR 1.83, 95% CI: 1.45 - 2.29), history of anxiety disorder (OR 2.05, 95% CI: 1.54 - 2.73), high baseline ED usage (OR 2.58, 95% CI: 2.03 - 3.28), penetrating injury (OR 1.42, 95% CI: 1.20 - 1.68), and extremity fracture (OR 1.52, 95% CI: 1.24 - 1.88) predicted return visits.

CONCLUSION

Patients discharged directly have high rates of ED return visits but low rates of hospital admission or delayed surgical intervention. Trauma services should expand quality assurance initiatives to capture return visits, understand any gaps in clinical service provision, and aim to minimize unnecessary ED return visits.

LEVEL OF EVIDENCE

Level VI prognostic study.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities

OBJECTIVES

In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language.

METHODS

A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test.

RESULTS

Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers.

CONCLUSIONS

Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

The impact of retained bullet fragments on outcomes in patients with gunshot wounds

BACKGROUND

Nationally, 115,000 non-fatal firearm injuries occurred in 2017, with many such victims possessing retained bullet fragments (RBFs); however, the impact of RBFs has not been well studied.

METHODS

An institutional trauma database from an urban, level one trauma center was queried for patients presenting with gunshot wounds (GSWs) to the ED in 2017. GSWs were stratified by the presence or absence of RBFs. Groups were compared using t-tests, chi-squared, and logistic regression.

RESULTS

Of 674 patients with GSWs who met inclusion criteria, 394 had RBFs versus 280 with no RBFs. Patients with RBFs were more likely admitted from the ED (57.4% vs. 41.8%, p < 0.001), had significantly higher rates of return to the ED within six months (30.7% vs. 18.6%, p < 0.001), and higher rates of subsequent GSW in the next year (5.1% vs. 1.8%, p = 0.03). On return to ED, 17.6% of those with a RBF had symptoms associated with their RBF.

CONCLUSION

RBFs may represent an unrecognized risk factor for both repeat ED visits and subsequent bullet injury.

A multicenter mixed-effects model for inference and prediction of 72-h return visits to the emergency department for adult patients with trauma-related diagnoses

Objective

Emergency department (ED) return visits within 72 h may be a sign of poor quality of care and entail unnecessary use of healthcare resources. In this study, we compare the performance of two leading statistical and machine learning classification algorithms, and we use the best performing approach to identify novel risk factors of ED return visits.

Methods

We analyzed 3.2 million ED encounters with at least one diagnosis under “injury, poisoning and certain other consequences of external causes” and “external causes of morbidity.” These encounters included patients 18 years or older from across 128 emergency room facilities in the USA. For each encounter, we calculated the 72-h ED return status and retrieved 57 features from demographics, diagnoses, procedures, and medications administered during the process of administration of medical care. We implemented a mixed-effects model to assess the effects of the covariates while accounting for the hierarchical structure of the data. Additionally, we investigated the predictive accuracy of the extreme gradient boosting tree ensemble approach and compared the performance of the two methods.

Results

The mixed-effects model indicates that certain blunt force and non-blunt trauma inflates the risk of a return visit. Notably, patients with trauma to the head and patients with burns and corrosions have elevated risks. This is in addition to 11 other classes of both blunt force and non-blunt force traumas. In addition, prior healthcare resource utilization, patients who have had one or more prior return visits within the last 6 months, prior ED visits, and the number of hospitalizations within the 6 months are associated with increased risk of returning to the ED after discharge. On the one hand, the area under the receiver characteristic curve (AUROC) of the mixed-effects model was 0.710 (0.707, 0.712). On the other hand, the gradient boosting tree ensemble had a lower AUROC of 0.698 CI (0.696, 0.700) on the independent test model.

Conclusions

The proposed mixed-effects model achieved the highest known AUC and resulted in the identification of novel risk factors. The model outperformed one of the leading machine learning ensemble classifiers, the extreme gradient boosting tree in terms of model performance. The risk factors we identified can assist emergency departments to decrease the number of unplanned return visits within 72 h.

A Discharge Vital Sign Documentation Improvement Initiative in the Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Vital signs are important data elements in the pediatric emergency department (PED). The presence of unexplained tachycardia at discharge has been associated with patient return to the PED and subsequent admission. Our aim for this study was to increase the percentage of patients discharged with a complete set of vital signs, when indicated, from 22% to 95% by June 30, 2018.

METHODS

A multidisciplinary team developed key drivers, and data were collected by using a retrospective chart review. Outcome measures were the percentage of patients with discharge vital signs and 72-hour returns to the PED. Balancing measures included PED length of stay (LOS) and hospital admissions. Data were compiled from a chart review 7 times monthly; all charts were of patients presenting to the PED during the days being reviewed. An annotated p-chart was used to analyze the data.

RESULTS

Data were collected for 18 months, including baseline data from July to September 2017, during which time 22% of patients had discharge vital signs. Targeted quality improvement methodology initially improved discharge vital signs to 41%, and then to 85%, which has been sustained for 7 months. There was no change in 72-hour return PED visits or LOS. Although absolute hospitalizations remained stable, the percentage of patients admitted increased.

CONCLUSIONS

Targeted quality improvement methodology is associated with sustained improvement of indicated discharge vital signs for patients discharged from the PED. This improvement was not associated with reduced return PED visits, prolonged LOS, or increased hospitalization.

Community Need Index (CNI): a simple tool to predict emergency department utilization after hospital discharge from the trauma service

Background

Emergency department (ED) visits after hospital discharge may reflect failure of transition of care to the outpatient setting. Reduction of postdischarge ED utilization represents an opportunity for quality improvement and cost reduction. The Community Need Index (CNI) is a Zip code-based score that accounts for a community's unmet needs with respect to healthcare and is publicly accessible via the internet. The purpose of this study was to determine if patient CNI score is associated with postdischarge ED utilization among hospitalized trauma patients.

Methods

Level 1 trauma patient admitted between January 2014 and June 2016 were stratified by 30-day postdischarge ED utilization (yes/no). CNI is a nationwide Zip code-based score (1.0-5.0) and was determined per patient from the CNI website. Higher scores indicate greater barriers to healthcare per aggregate socioeconomic factors. Patients with 30-day postdischarge ED visits were compared with those without, evaluating for differences in CNI score and clinical and demographic characteristics.

Results

309 of 3245 patients (9.5%) used the ED. The ED utilization group was older (38.3±15.7 vs. 36.3±16.4 years, p=0.034), more injured (Injury Severity Score 10.4±8.7 vs. 7.7±8.0, p<0.001), and more likely to have had in-hospital complications (17.5% vs. 5.4%, p<0.001). Adjusted for patient age, injury severity, gender, race/ethnicity, penetrating versus blunt injury, alcohol above the legal limit, illicit drug use, the presence of one or more complications and comorbidities, hospital length of stay, and insurance category, CNI score ≥4 was associated with increased utilization (OR 2.0 [95% CI 1.4 to 2.9, p<0.001]).

Discussion

CNI is an easily accessible score that independently predicts postdischarge ED utilization in trauma patients. Patients with CNI score ≥4 are at significantly increased risk. Targeted intervention concerning discharge planning for these patients represents an opportunity to decrease postdischarge ED utilization.

Level of evidence

III, Prognostic and Epidemiological.