Identifying Frequent Users of an Urban Emergency Medical Service Using Descriptive Statistics and Regression Analyses

Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study

BACKGROUND

Substance misuse poses a significant public health challenge, characterized by premature morbidity and mortality, and heightened healthcare utilization. While studies have demonstrated that previous hospitalizations and emergency department visits are associated with increased mortality in patients with substance misuse, it is unknown whether prior utilization of emergency medical service (EMS) is similarly associated with poor outcomes among this population. The objective of this study is to determine the association between EMS utilization in the 30 days before a hospitalization or emergency department visit and in-hospital outcomes among patients with substance misuse.

METHODS

We conducted a retrospective analysis of adult emergency department visits and hospitalizations (referred to as a hospital encounter) between 2017 and 2021 within the Substance Misuse Data Commons, which maintains electronic health records from substance misuse patients seen at two University of Wisconsin hospitals, linked with state agency, claims, and socioeconomic datasets. Using regression models, we examined the association between EMS use and the outcomes of in-hospital death, hospital length of stay, intensive care unit (ICU) admission, and critical illness events, defined by invasive mechanical ventilation or vasoactive drug administration. Models were adjusted for age, comorbidities, initial severity of illness, substance misuse type, and socioeconomic status.

RESULTS

Among 19,402 encounters, individuals with substance misuse who had at least one EMS incident within 30 days of a hospital encounter experienced a higher likelihood of in-hospital mortality (OR 1.52, 95% CI [1.05 - 2.14]) compared to those without prior EMS use, after adjusting for confounders. Using EMS in the 30 days prior to an encounter was associated with a small increase in hospital length of stay but was not associated with ICU admission or critical illness events.

CONCLUSIONS

Individuals with substance misuse who have used EMS in the month preceding a hospital encounter are at an increased risk of in-hospital mortality. Enhanced monitoring of EMS users in this population could improve overall patient outcomes.

Characteristics of consecutive versus non-consecutive frequent emergency medical services transport to a single emergency department

OBJECTIVE

This study was to examine characteristics concerning frequent users of emergency medical services (EMS) transport by comparing patients who used EMS transport frequently for one year and those who used EMS transport for more than two years consecutively.

METHODS

A retrospective review for frequent use of EMS transport was conducted. The patients from the fire stations that transported more than 70% of all EMS transport to the study hospital emergency department (ED) were included. The study subjects were divided into consecutive group (frequent EMS transport for ≥ two years consecutively) and non-consecutive group (frequent EMS transport for only one year). Characteristics of patients who were frequent users of EMS transport and those of all cases with EMS transport were examined.

RESULTS

Of the total 205 patients and 1204 cases of frequent EMS transport, 85 (42%) patients and 755 (63%) cases were in the consecutive group. Patients in the consecutive group were more likely to have risky alcohol use, unemployed state, and medical aid type of payment for ED treatment than those in the non-consecutive group. More patients had previous experience of EMS transport to the study hospital ED in the consecutive group and the number of cases with alcohol ingestion was higher in the consecutive group. Elapsed time from EMS call to ED arrival was longer for the consecutive group.

CONCLUSION

Risky alcohol use, unemployed state, and previous experience of EMS transport were associated with consecutive and frequent use of EMS transport in frequent users of EMS transport.

Managing High Frequency of Ambulance Calls in Hospitals: A Systematic Review

Background

This study addresses the critical issue of high-volume emergency calls in hospitals, focusing on the strain caused by frequent caller patients on ambulance services. The aim was to synthesize various management methods for handling high-frequency hospital calls.

Methods

The systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines and guided by the Cochrane Handbook for systematic reviews. Inclusion criteria encompassed studies focusing on the management of emergency departments in hospitals, exploring various medical conditions requiring ambulance attention, and reporting on the impact of a high volume of ambulance calls on hospitals. Databases including PubMed, Web of Science, and Google Scholar were searched from January 1, 2005, to May 1, 2022. The quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) Checklist.

Results

Out of 2390 identified citations, 18 studies met the inclusion criteria. These studies, from 12 countries, presented diverse methods categorized into country policy-based management, modeling approaches, and general strategies. Key findings included the effectiveness of risk stratification models and community-based interventions in managing high call frequencies and improving patient care. Our review identified effective strategies such as risk stratification models and community-based interventions, which have shown significant impacts in managing high call frequencies, aligning closely with our objective. These approaches have been pivotal in reducing the burden on emergency services and improving patient care.

Conclusion

The study synthesizes effective management methods for high-frequency ambulance calls, including predictive modeling and community interventions. It highlights the need for multi-faceted management strategies in different healthcare settings and underscores the importance of continued research and implementation of these methods to improve emergency service efficiency.

[Black box: Attenders with psychosocial needs in the emergency department]

OBJECTIVES

The aims are (a) assessment of the prevalence of psychosocial emergencies in the emergency department (ED), (b) determination of the proportion of cases not coded as diagnosis (unreported cases), and (c) characterization of identified patients.

METHODS

In a retrospective study, psychosocial emergencies in one week were identified from routine documentation of the central ED of the Charité - Universitätsmedizin Berlin, Charité Campus Mitte (CCM). After exclusion of planned admitted cases, 862 patients were included in the study. The identified psychosocial emergencies were descriptively analyzed with regard to their sociodemographic and clinical characteristics and compared with other emergencies.

RESULTS

The prevalence of psychosocial emergencies in the reported period was 11.9% (n = 103). A large proportion of psychosocial emergencies were not coded (35.9%) or not fully coded (20.4%) as an ICD diagnosis (unreported cases). There was a statistically relevant difference in gender distribution with a significantly higher proportion of males among psychosocial emergencies (70.9%) compared to other emergencies (50.7%; p < 0.0001). The two most common treatment causes among psychosocial emergencies were substance abuse (66.0%) and homelessness (20.4%).

CONCLUSIONS

This study shows a relevant proportion of psychosocial emergencies among all treatments in ED routine data and a high proportion of cases not captured in the coded diagnoses. EDs thus represent an important point of contact for vulnerable patient groups but standardized screening and identification are still lacking.

Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations

BACKGROUND

High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1.

OBJECTIVE

The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse.

METHODS

A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed.

RESULTS

We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors.

CONCLUSIONS

This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.

Paediatric frequent use of emergency medical services: a systematic review

BACKGROUND

Frequent use of emergency medical services (EMS) is recognised to be a global phenomenon, although paediatric frequent use is poorly understood. This systematic review aimed to understand how paediatric frequent use of EMS is currently defined, identify factors associated with paediatric frequent use of EMS and determine effectiveness of interventions for paediatric patients who frequently use EMS.

METHODS

Four electronic databases (Medline, CINAHL, Web of Science and PsycINFO) were searched to September 2022 for primary, peer-reviewed research studies published in English from January 2000. Studies were included that examined frequent use (>1 contact during study period) of EMS or other services with arrival via EMS. Paediatric patients were defined as <18 years of age or otherwise defined by study authors as paediatric/adolescent/children. Data were extracted using a structured proforma, and quality was assessed using the Standard Quality Assessment Criteria for Quantitative Studies but did not influence inclusion decisions. Data were presented using narrative synthesis.

RESULTS

The search resulted in 4172 unique references, with 12 papers included in the review from 7 countries. Four were EMS studies, and eight Emergency Department with arrival via EMS. All studies used retrospective designs, with no interventional studies identified. Paediatric frequent EMS users were more likely to use services for medical reasons rather than trauma, including respiratory complaints, mental health and seizures, but data on gender and ethnicity were inconclusive and silent on socioeconomic status. There was no consistency in definitions of either a paediatric patient or of frequent use.

CONCLUSION

The broad range of reasons for frequent use suggests that a single intervention is unlikely to be effective at addressing the causes of frequent use. There is a need for further research to better identify the underlying reasons for frequent EMS use among paediatric patients and to develop interventions in this population.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders

Introduction: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. Methods: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. Results: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. Conclusion: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Frequent Emergency Department Use by Children

OBJECTIVES

Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization.

METHODS

The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics.

RESULTS

Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency.

CONCLUSIONS

Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

BACKGROUND

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

METHODS

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

RESULTS

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95% CI 3.21-3.30; OROFF 3.18, 95% CI 3.04-3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9-47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6-79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

CONCLUSIONS

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

[Use of emergency rooms by so-called multiple users: results of a prospective study with special consideration of the migration status]

Fragestellung

Welche prädiktiven Faktoren lassen sich für die Gruppe der sog. Mehrfachnutzer (MFN; 4 und mehr Inanspruchnahmen einer Notaufnahme [NA] in den letzten 12 Monaten) finden? Sind Personen mit Migrationshintergrund häufiger in die Gruppe der MFN einzuordnen?

Methodik

Konsekutive Patienten, die von Juli 2017 bis Juli 2018 drei Klinik-NA in Berlin aufsuchten. Mittels Fragebogen Erfassung von Erkrankungen, Gründen für den NA-Besuch und sozioökonomischen Faktoren. Die Unterschiede zwischen Migranten (1. Generation), ihren Nachkommen (2. Generation) und Nichtmigranten wurden mithilfe der logistischen Regression bewertet.

Ergebnisse

2339 Patienten konnten in die Auswertung einbezogen werden (Rücklaufrate 56 %), davon hatten 901 einen Migrationshintergrund. Bei jungen Frauen (<30 Jahre), chronisch Kranken, Schwangeren, Patientinnen und Patienten mit starken Beschwerden und Personen mit (selbsteingeschätzter) mittlerer und schlechter „Gesundheitsqualität“ sowie solchen ohne ärztliche Zuweisung war die Chance für eine Mehrfachnutzung der NA größer.

Schlussfolgerung

MFN belasten das ohnehin zunehmende Patientenvolumen von NA. Sie stellen jedoch eine heterogene Patientengruppe dar, unter der Menschen mit Migrationshintergrund nicht häufiger vertreten sind. Weitere Untersuchungen sind erforderlich, um die Faktoren, die zu einer häufigen Inanspruchnahme führen, besser zu verstehen und wirksame Strategien zu entwickeln, um den komplexen Gesundheitsbedürfnissen von MFN gerecht zu werden.

EMS utilization predictors in a Mobile Integrated Health (MIH) program

BACKGROUND

The provision of unnecessary Emergency Medical Services care remains a challenge throughout the US and contributes to Emergency Department overcrowding, delayed services and lower quality of care. New EMS models of care have shown promise in improving access to health services for patients who do not need urgent care. The goals of this study were (1) to identify factors associated with EMS utilization (911) and (2) their effects on total EMS calls and transports in an MIH program.

METHODS

The study sample included 110 MIH patients referred to the program or considered high-users of EMS services between November 2016 and September 2018. The study employed descriptive statistics and Poisson regressions to estimate the effects of covariates on total EMS calls and transports.

RESULTS

The typical enrollee is a 60-year-old single Black male living with two other individuals. He has a PCP, takes 12 medications and is compliant with his treatment. The likelihood of calling and/or being transported by EMS was higher for males, patients at high risk for falls, patients with asthma/COPD, psychiatric or behavioral illnesses, and longer travel times to a PCP. Each prescribed medication increased the risk for EMS calls or transports by 4%. The program achieved clear reductions in 911 calls and transports and savings of more than 140,000 USD in the first month.

CONCLUSIONS

This study shows that age, marital status, high fall risk scores, the number of medications, psychiatric/behavioral illness, asthma/COPD, CHF, CVA/stroke and medication compliance may be good predictors of EMS use in an MIH setting. MIH programs can help control utilization of EMS care and reduce both EMS calls and transports.

Tracing frequent users of regional care services using emergency medical services data: a networked approach

OBJECTIVES

This study shows how a networked approach relying on 'real-world' emergency medical services (EMS) records might contribute to tracing frequent users of care services on a regional scale. Their tracing is considered of importance for policy-makers and clinicians, since they represent a considerable workload and use of scarce resources. While existing approaches for data collection on frequent users tend to limit scope to individual or associated care providers, the proposed approach exploits the role of EMS as the network's 'ferryman' overseeing and recording patient calls made to an entire network of care providers.

DESIGN

A retrospective study was performed analysing 2012-2017 EMS calls in the province of Drenthe, the Netherlands. Using EMS data, benefits of the networked approach versus existing approaches are assessed by quantifying the number of frequent users and their associated calls for various categories of care providers. Main categories considered are hospitals, nursing homes and EMS.

SETTING

EMS in the province of Drenthe, the Netherlands, serving a population of 491 867.

PARTICIPANTS

Analyses are based on secondary patient data from EMS records, entailing 212 967 transports and 126 758 patients, over 6 years (2012-2017).

RESULTS

Use of the networked approach for analysing calls made to hospitals in Drenthe resulted in a 20% average increase of frequent users traced. Extending the analysis by including hospitals outside Drenthe increased ascertainment by 28%. Extending to all categories of care providers, inside Drenthe, and subsequently, irrespective of their location, resulted in an average increase of 132% and 152% of frequent users identified, respectively.

CONCLUSIONS

Many frequent users of care services are network users relying on multiple regional care providers, possibly representing inefficient use of scarce resources. Network users are effectively and efficiently traced by using EMS records offering high coverage of calls made to regional care providers.

Statistical tools used for analyses of frequent users of emergency department: a scoping review

OBJECTIVE

Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user.

METHODS

We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis.

RESULTS

We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used.

CONCLUSIONS

This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.

It was not a hip fracture - you were lucky this time - or perhaps not! A prospective study of clinical outcomes in patients with low-energy pelvic fractures and hip contusions

INTRODUCTION

Prehospital and hospital emergency care guidelines have been developed for patients with suspected hip fracture. Initial radiography can identify a number of patients with other injuries, generally pelvic fractures and hip contusions. Little is known about the prognosis for these patients. The aim of this study is twofold: i) to investigate the injury pattern of patients assessed in prehospital emergency care as suffering from a suspected hip fracture and ii) to compare clinical outcomes between patients with verified hip fracture (HF) and those with other hip injuries (OHI).

METHOD

The study design was prospective. Older patients with suspected HF after low-energy trauma were identified in prehospital emergency care. Injury type was determined by radiological imaging. Comparisons of length of stay, adverse events, repeated prehospital emergency care and mortality were made between verified HF and OHI cases.

RESULTS

449 patients were included, 400 in the HF and 149 in the OHI group (86 hip contusions, 46 pelvic fractures and 17 other injuries/diseases). The HF group had a significantly longer hospital stay (9.5 days vs. 6.3 for the OHI group; p < 0.001) and more adverse events while in hospital (34% vs. 19%; p < 0.001). We found no evidence that the groups differed with regard to other outcomes: mortality during hospital stay (4% vs. 2%, p = 0.42), at 4 (16% vs. 13%; p = 0.35) and 12 months (21 vs. 23%; p = 0.64), the proportion that experienced an adverse event (24% vs. 22%; p = 0.65) and the proportion that required another ambulance transport within 6 months after discharge (40% vs. 34%; p = 0.16). The results were not strongly affected by adjustments for possible confounders.

CONCLUSION

Older patients who suffer a low-energy pelvic fracture or a hip contusion are common in prehospital and hospital emergency care. These patients need attention as they have poor outcomes in terms of adverse events, mortality and recurrent need for ambulance transport after discharge from hospital. While individualized multidisciplinary care is recommended for hip fracture patients, it might also be suitable for other geriatric hip injuries.

Diagnosis Prevalence and Comorbidity in a Population of Mobile Integrated Community Health Care Patients

INTRODUCTION

Frequent calls to 911 and requests for emergency services by individuals place a costly burden on emergency response systems and emergency departments (EDs) in the United States. Many of the calls by these individuals are non-emergent exacerbations of chronic conditions and could be treated more effectively and cost efficiently through another health care service. Mobile integrated community health (MICH) programs present a possible partial solution to the over-utilization of emergency services by addressing factors which contribute to a patient's likelihood of frequent Emergency Medical Services (EMS) use. To provide effective care to eligible individuals, MICH providers must have a working understanding of the common conditions they will encounter.

OBJECTIVE

The purpose of this descriptive study was to evaluate the diagnosis prevalence and comorbidity among participants in the Queen Anne's County (Maryland USA) MICH Program. This fundamental knowledge of the most common medical conditions within the MICH Program will inform future mobile integrated health programs and providers.

METHODS

This study examined preliminary data from the MICH Program, as well as 2017 Maryland census data. It involved secondary analysis of de-identified patient records and descriptive statistical analysis of the disease prevalence, degree of comorbidity, insurance coverage, and demographic characteristics among 97 program participants. Diagnoses were grouped by their ICD-9 classification codes to determine the most common categories of medical conditions. Multiple linear regression models and chi-squared tests were used to assess the association between age, sex, race, ICD-9 diagnosis groups, and comorbidity among program enrollees.

RESULTS

Results indicated the most prevalent diagnoses included hypertension, high cholesterol, esophageal reflux, and diabetes mellitus. Additionally, 94.85% of MICH patients were comorbid; the number of comorbidities per patient ranged from one to 13 conditions, with a mean of 5.88 diagnoses per patient (SD=2.74).

CONCLUSION

Overall, patients in the MICH Program are decidedly medically complex and may be well-suited to additional community intervention to better manage their many conditions. The potential for MICH programs to simultaneously improve patient outcomes and reduce health care costs by expanding into larger public health and addressing the needs of the most vulnerable citizens warrants further study.ScharfBM, BissellRA, TrevittJL, JenkinsJL.Diagnosis prevalence and comorbidity in a population of mobile integrated community health care patients.Prehosp Disaster Med. 2019;34(1):46-55.

Frequent presentations to emergency departments and the collaborative community and emergency response

Purpose

Patient dependence on an emergency department (ED) for ongoing, non-urgent health care is a complex issue related to poor mental and physical health, disability, previous trauma, social disadvantage and lack of social supports. Working Together to Connect Care is an innovative program that provides an assertive community case management approach coupled with an ED management plan to support people who frequently attend the Royal Brisbane and Women’s Hospital ED. The program, which is yet to be fully evaluated, currently helps to manage a large number of patients with a wide variety of complex needs. To demonstrate the scope and capabilities of the program, the purpose of this paper is to present a series of case studies of patients who frequently attended the ED and subsequently became program participants.

Design/methodology/approach

A series of five case studies is used to illustrate the variety of patient characteristics and available management pathways. Outcomes, including rates of ED attendance, at five months after program commencement are also described.

Findings

The variety of characteristics and experiences of the patients in the case studies is representative of the program cohort as a whole. Program participation has resulted in improved patient outcomes as demonstrated by crisis resolution, housing stability, engagement with primary health care and reduced frequency of ED presentations.

Originality/value

A personalized, integrated-care management approach is both flexible and effective in responding to the complex needs of five patients who frequently attend EDs.

Difficult Patients in the Emergency Department: Personality Disorders and Beyond

Physician-patient encounters in clinical settings, especially in the emergency department, can be of varying degrees of difficulty. Medically complicated, challenging cases can be paradoxically rewarding, whereas psychologically driven difficulty is frustrating and counterproductive for patient care. This article presents 3 different complementary perspectives on difficult patients: clinical presentations, manifestations of personality traits and disorders in clinical settings, and how physician feelings may affect care. Management strategies are discussed.

The effect of brief case management on emergency department use of frequent users in mental health: Findings of a randomized controlled trial

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64–1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59–2.29), physical (1.50, 95% CI -2.15–5.15) or mental (-3.97, 95% CI -8.13–0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30–1.49), alcohol (0.053 95% -0.017–0.12) or drug (-0.0027, 95% CI -0.0028–0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

Contributing factors of frequent use of the emergency department: A synthesis

INTRODUCTION

Overcrowding in emergency departments is an issue that has a negative impact worldwide. As attendance in emergency departments has increased, the ability to provide critical services to patients suffering from actual medical emergencies in a timely manner has decreased as these departments are many times at or over capacity. One patient population whose negative influence has been researched with regard to their impact on the overcrowding issue is that of the frequent user.

METHODS

A search of two electronic databases was conducted to identify factors that frequent users state as their reasoning for using an emergency department. Peer reviewed articles in English were searched for in CINAHL Plus and PubMed, as well as a review of reference lists.

RESULTS

A review of the literature identified two predominant factors related to frequent users in the emergency department: a lack of awareness of medical necessity and issues of access.

DISCUSSION

To address the frequent users in emergency departments, implications for practice need to be explored and implemented. Implications for practice include education of medical necessity for the frequent users, expansion of the pre-hospital role in primary care and inappropriate use prevention, and improvement of access to alternative healthcare services.

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database

STUDY OBJECTIVE

The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region.

METHODS

Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport.

RESULTS

During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14).

CONCLUSION

More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.

Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid

OBJECTIVE

To assess the impact of chronic conditions on children's emergency department (ED) use.

STUDY DESIGN

Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates.

RESULTS

The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees).

CONCLUSIONS

The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.