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Background: The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown., Methods: This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission-accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention., Results: Of 1,148 hospitals, 346 (30.1%) responded. The majority (n = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (n = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (n = 128 [37.0%)] or made follow-up contact with patients (n = 105 [30.3%]), and approximately a quarter (n = 97 [28.0%]) developed a plan for lethal means safety. Very few (n = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge., Conclusion: The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Over 30 instruments are in current, active use for delirium identification. In a recent systematic review, we recommended 4 commonly used and well-validated instruments for clinical and research use. The goal of this study is to harmonize the four instruments on the same metric using modern methods in psychometrics., Design: Secondary data analysis from 3 studies, and a simulation study based on the observed data., Setting: Hospitalized (non-ICU) adults over 65 years old in the United States, Ireland, and Belgium., Participants: The total sample comprised 600 participants, contributing 1,623 assessments., Measurements: Confusion Assessment Method (long-form and short-form), Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98 (DRS-R-98) (total and severity scores), and Memorial Delirium Assessment Scale., Results: Using item response theory, we linked scores across instruments, placing all four instruments and their separate scorings on the same metric (the propensity to delirium). Kappa statistics comparing agreement in delirium identification among the instruments ranged from 0.37 to 0.75, with the highest agreement between the DRS-R-98 total score and MDAS. After linking scores, we created a harmonized item bank, called the Delirium Item Bank (DEL-IB), consisting of 50 items. The DEL-IB allowed us to create six crosswalks, to allow scores to be translated across instruments., Conclusions: With our results, individual instrument scores can be directly compared to aid in clinical decision-making, and quantitatively combined in meta-analyses., (Copyright © 2021 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Brief interventions for suicide risk among patients treated in acute care settings like the emergency department are needed. The Safety Planning Intervention is a promising approach but has yet to undergo a high quality, individual level randomized controlled trial., Purpose: This paper describes the methods associated with an individual level randomized controlled trial of the Safety Planning Intervention compared to a control condition comprised of reviewing risk factors and warning signs., Methods: The sample comprised patients 18 years and older presenting to one of three different emergency departments with suicide related emergencies (target n = 484). Eligible patients were approached, consented, and randomized to the intervention (Safety Planning Intervention) or control (risk factors and warning signs). They were assessed at 1, 3 and 6 months after their index visit. The primary outcome is suicidal behavior. The study also assessed mechanisms of action. Data analyses are pending., Conclusions: We identified and addressed key challenges to studying suicidal patients in the emergency department, including difficulty enrolling during the emergency department visit, ascertaining outcomes in patients that are historically very difficult to follow, and addressing the ambiguity of suicidal behavior. ClinicalTrials.gov Identifier: NCT03227991., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Few brief suicide risk screening instruments are validated for use in both adult and pediatric medical populations. Using the pediatric Ask Suicide-Screening Questions (ASQ) development study as a model, this study aimed to determine whether the ASQ is a valid suicide risk-screening instrument for use among adults medical patients, as well as to evaluate a set of other potential screening questions for use in adults., Methods: Adult patients hospitalized on inpatient medical/surgical units from 4 hospitals were recruited to participate in a cross-sectional instrument-validation study. The 4-item ASQ and other candidate items were compared against the 25-item, previously validated Adult Suicidal Ideation Questionnaire as the criterion standard., Results: A total of 727 adult medical inpatients completed the screening process. Compared with the Adult Suicidal Ideation Questionnaire, the ASQ performed best among the full set of candidate items, demonstrating strong psychometric properties, with a sensitivity of 100% (95% confidence interval = 90%-100%), a specificity of 89% (95% confidence interval = 86%-91%), and a negative predictive value of 100% (95% confidence interval = 99%-100%). A total of 4.8% (35/727) of the participants screened positive for suicide risk based on the standard criterion Adult Suicidal Ideation Questionnaire., Conclusions: The ASQ is a valid and brief suicide risk-screening tool for use among adults. Screening medical/surgical inpatients for suicide risk can be performed effectively for both adult and pediatric patients using this brief, primary screener., (Published by Elsevier Inc.)

Background: Connected interventions use data collected through mobile/wearable devices to trigger real-time interventions and have great potential to improve treatment for substance use disorder (SUD). This review aims to describe the current landscape, effectiveness and usability of connected interventions for SUD., Methods: A systematic review was conducted to identify articles evaluating connected health interventions for SUD in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed, IEEE, and Scopus) were searched over a five-year period. Included articles described a connected health intervention targeting SUD and provided outcomes data. Data were extracted using a standardized reporting tool., Results: A total of 1676 unique articles were identified during the initial search, with 32 articles included in the final analysis. Seven articles of the 32 were derived from two large studies. The most commonly studied SUD was alcohol use disorder. Sixteen articles reported at least one statistically significant result with respect to reduced craving and/or substance use. The majority of articles used ecological momentary assessment to trigger interventions, while four used biologic/physiologic data. Two articles used a wearable device. Common intervention types included craving management, coping assistance, and tailored feedback. Twenty-three articles measured usability factors, and acceptability was generally reported as high., Conclusion: Identified themes included a focus on AUD, use of smart phones, use of EMA for intervention delivery, positive effects on SUD related outcomes, and overall high acceptability. Wearables that directly monitor biologic data and predictive analytics using integrated data streams represent understudied opportunities for new research., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Emergency departments (EDs) are important for preventing suicide. Historically, many patients with suicide risk are not detected during routine clinical care, and those who are often do not receive suicide-specific intervention. The original Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE 1) study examined the implementation of universal suicide risk screening and a multi-component ED-initiated suicide prevention intervention., Purpose: The ED-SAFE 2 aims to study the impact of using a continuous quality improvement approach (CQI) to improve suicide related care, with a focus on improving universal suicide risk screening in adult ED patients and evaluating implementation of a new brief intervention called the Safety Planning Intervention (SPI) into routine clinical practice. CQI is a quality management process that uses data and collaboration to drive incremental, iterative improvements. The SPI is a personalized approach that focuses on early identification of warning signs and execution of systematic steps to manage suicidal thoughts. ED-SAFE 2 will provide data on the effectiveness of CQI procedures in improving suicide-related care processes, as well as the impact of these improvements on reducing suicide-related outcomes., Methods: Using a stepped wedge design, eight EDs collected data cross three study phases: Baseline (retrospective), Implementation (12 months), and Maintenance (12 months). Lean methods, a specific approach to pursuing CQI which focuses on increasing value and eliminating waste, were used to evaluate and improve suicide-related care., Conclusions: The results will build upon the success of the ED-SAFE 1 and will have a broad public health impact through promoting better suicide-related care processes and improved suicide prevention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Validated secondary screeners are needed to stratify suicide risk among those with nonnegligible risk. This study tested the predictive utility of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Secondary Screener (ESS), one of the screeners listed by The Joint Commission's Patient Safety Goal 15 resources as a potential secondary screener for acute care settings., Methods: The researchers performed secondary analyses of data collected for the ED-SAFE study. Data were collected during an emergency department (ED) visit for 1,376 patients who endorsed active suicide ideation or a suicide attempt in the past week. Participants were followed for 12 months using telephone-based assessments, review of health care records, and National Death Index query. The study examined the predictive validity of the individual items, total score, and a scoring algorithm using the total score and critical items. Bivariable analyses, multivariable logistic regression, and test operating characteristics were calculated., Results: Of the 1,376 patients enrolled, most were positive for at least one indicator. Four of the indicators were significantly associated with several outcomes. Based on score and critical items, the patients were trichotomized: The three strata were associated with significantly different rates of prospective suicidal behavior, with 52% of the high-risk group engaging in suicidal behavior within 12 months., Conclusion: The ESS possesses adequate operating characteristics for triage purposes. The researchers recommend validation in new samples to confirm its operating characteristics and potentially reduce its length by removing the substance and agitation items, which offered little predictive utility in this study., Competing Interests: Conflicts of Interest All authors report no conflicts of interest., (Copyright © 2020 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Objective: The MHADRO assesses psychosocial and medical needs, provides tailored feedback reports, and connects patients to mental health providers. This study examined the MHADRO's effect on patient outcomes, health care utilization, and oncology provider documentation and behaviors., Methods: 836 patients were part of a multi-site RCT and assessments were conducted at baseline, 2, 6 and 12 months., Results: The intervention group engaged in less emergency calls to providers. There were no differences in psychosocial outcomes at follow up assessments. Providers of patients in the intervention group were more likely to: document psychosocial symptoms and history; refer to psychosocial services; encourage support groups; seek psychological evaluations during visits. Patients who agreed to a mental health referral had decreased hospitalizations, increased mental health care interactions, and stronger ratings of counseling potential benefits. This group also reported increased psychosocial distress at all follow-up assessments., Conclusion: The MHADRO may increase access to mental health care, lessen utilization, and improve providers' management of psychosocial needs, but does not appear to impact overall functioning over time., Practice Implications: Providers are encouraged to consider incorporating programs, like the MHADRO, into patient care as they may have the potential to impact screening and management of patients' psychosocial needs., (Published by Elsevier B.V.)

Background: Although research suggests that crisis hotlines are an effective means of mitigating suicide risk, lack of empirical evidence may limit the use of this method as a research safety protocol., Purpose: This study describes the use of a crisis hotline to provide clinical backup for research assessments., Methods: Data were analyzed from participants in the Emergency Department Safety and Follow-up Evaluation (ED-SAFE) study (n=874). Socio-demographics, call completion data, and data available on suicide attempts occurring in relation to the crisis counseling call were analyzed. Pearson chi-squared statistic for differences in proportions were conducted to compare characteristics of patients receiving versus not receiving crisis counseling. P<0.05 was considered statistically significant., Results: Overall, there were 163 counseling calls (6% of total assessment calls) from 135 (16%) of the enrolled subjects who were transferred to the crisis line because of suicide risk identified during the research assessment. For those transferred to the crisis line, the median age was 40 years (interquartile range 27-48) with 67% female, 80% white, and 11% Hispanic., Conclusions: Increasing demand for suicide interventions in diverse healthcare settings warrants consideration of crisis hotlines as a safety protocol mechanism. Our findings provide background on how a crisis hotline was implemented as a safety measure, as well as the type of patients who may utilize this safety protocol., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Screening, brief intervention, and referral to treatment (SBIRT) is effective for reducing risky alcohol use across a variety of medical settings. However, most programs have been unsustainable because of cost and time demands. Telehealth may alleviate on-site clinician burden. This exploratory study examines the feasibility of a new Remote Brief Intervention and Referral to Treatment (R-BIRT) model., Methods: Eligible emergency department (ED) patients were enrolled into one of five models. (1) Warm Handoff: clinician-facilitated phone call during ED visit. (2) Patient Direct: patient-initiated call during visit. (3) Electronic Referral: patient contacted by R-BIRT personnel post visit. (4) Patient Choice: choice of models 1-3. (5) Modified Patient Choice: choice of models 1-2, Electronic Referral offered if 1-2 were declined. Once connected, a health coach offered assessment, counseling, and referral to treatment. Follow up assessments were conducted at 1 and 3 months. Primary outcomes measured were acceptance, satisfaction, and completion rates., Results: Of 125 eligible patients, 50 were enrolled, for an acceptance rate of 40%. Feedback and satisfaction ratings were generally positive. Completion rates were 58% overall, with patients enrolled into a model wherein the consultation occurred during the ED visit, as opposed to after the visit, much more likely to complete a consultation, 90% vs. 10%, χ(2) (4, N=50)=34.8, p<0.001., Conclusions: The R-BIRT offers a feasible alternative to in-person alcohol SBIRT and should be studied further. The public health impact of having accessible, sustainable, evidence-based SBIRT for substance use across a range of medical settings could be considerable., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention., Purpose: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes., Methods: This paper summarizes the ED-SAFE's study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1440 suicidal individuals, from 8 general ED's nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12 months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment., Conclusions: While 'classic' randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multi-phase, quasi-experimental design embedded in 'real world' clinical settings., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The Health Evaluation and Referral Assistant (HERA) is a web-based program designed to facilitate screening, brief intervention, and referral to treatment (SBIRT) for tobacco, alcohol, and drug abuse. After the patient completes a computerized substance abuse assessment, the HERA produces a summary report with evidence-based recommended clinical actions for the healthcare provider (the Healthcare Provider Report) and a report for the patient (the Patient Feedback Report) that provides education regarding the consequences of use, personally tailored motivational messages, and a tailored substance abuse treatment referral list. For those who provide authorization, the HERA faxes the individual's contact information to a substance abuse treatment provider matched to the individual's substance use severity and personal characteristics, like insurance and location of residence (dynamic referral). This paper summarizes the methods used for a randomized controlled trial to evaluate the HERA's efficacy in leading to increased treatment initiation and reduced substance use. The study was performed in four emergency departments. Individual patients were randomized into one of two conditions: the HERA or assessment only. A total of 4269 patients were screened and 1006 participants enrolled. The sample was comprised of 427 tobacco users, 212 risky alcohol users, and 367 illicit drug users. Forty-two percent used more than one substance class. The enrolled sample was similar to the eligible patient population. The study should enhance understanding of whether computer-facilitated SBIRT can impact process of care variables, such as promoting substance abuse treatment initiation, as well as its effect on subsequent substance abuse and related outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The National Cancer Coalition Network, National Cancer Institute, and American College of Surgeons all emphasize the need for oncology providers to identify, address, and monitor psychosocial needs of their patients. The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a patient-driven, computerized, psychosocial assessment that identifies, addresses, and monitors physical, psychological, and social issues faced by oncology patients. This paper presents the methodology of a randomized controlled trial (RCT) that tested the impact of the MHADRO on patient outcomes at 2, 6, and 12 months. Patient outcomes including overall psychological distress, depression, anxiety, functional disability, and use of psychosocial resources will be presented in future publications after all follow-up data is gathered. Eight hundred and thirty six cancer patients with heterogeneous diagnoses, across three comprehensive cancer centers in different parts of the United States, were randomized to the MHADRO (intervention) or an assessment-only control group. Patients in the intervention group were provided detailed, personalized reports and, when needed, referrals to mental health services; their oncology provider received detailed reports designed to foster clinical decision making. Those patients who demonstrated high levels of psychosocial problems were given the option to authorize that a copy of their report be sent electronically to a "best match" mental health professional. Demographic and patient cancer-related data as well as comparisons between patients who were enrolled and those who declined enrollment are presented. Challenges encountered during the RCT and strategies used to address them are discussed., (Published by Elsevier Inc.)

Background: Many consider heroin abuse a problem of the inner city, but suburban patients may also be at risk., Objective: To characterize the demographics and purchase/use patterns of heroin users in an inner-city emergency department (ED)., Methods: The study was conducted in one of the most impoverished and crime-ridden cities in the United States. Demographics and substance use habits of ED patients were prospectively collected. Patients who were<18 years of age, cognitively impaired, or did not speak English were excluded. Participants were further categorized as homeless, inner-city, and suburban residents., Results: Of 3947 participants, 608 (15%) used an illicit substance in the past year, with marijuana (9%) and cocaine (6%) the most commonly used. Heroin ranked third, used by 180 (5%) participants, with 61% male, 31% black, and 20% Hispanic. There were 64 homeless, 60 suburban, and 56 inner-city heroin users. The most common route of use was injection (68%), with the highest rate in the homeless (84%). The majority of homeless and inner-city users bought (73%, both groups) and used (homeless 74%, inner city 88%) in the inner city. Of suburban users, 58% purchased and 61% used heroin in the inner city. Prescription narcotic use was more common in homeless (20%) and suburban (23%) heroin users than in inner-city users (9%) (p<0.001)., Conclusions: Heroin is the third most commonly used illicit substance by ED patients, and a significant amount of inner-city purchase and use activity is conducted by suburban heroin users., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To determine whether receipt of smoking cessation counseling affects satisfaction scores in adult emergency department (ED) smokers., Methods: Secondary analysis of data collected at eight US EDs in 2006. Eligible patients were age 18 years or older, every- or some-day smokers, English or Spanish speaking, able to provide written informed consent, and not actively psychotic., Results: There were 1168 patients interviewed, median age 41 years (interquartile range 29-50), 48.5% female. Receiving a tobacco control intervention was strongly and consistently associated with higher satisfaction scores. Satisfaction scores improved as the number of tobacco control interventions recalled by the patient increased. In multivariate analysis, the number of tobacco control interventions recalled was the only variable associated with higher patient satisfaction (odds ratio 1.24, 95% confidence interval 1.04-1.49)., Conclusion: ED patients who report having received a tobacco control intervention are more likely to be satisfied with their care. There is a dose-response relationship between the number of patient-reported tobacco interventions received and the global satisfaction score. Of all providers, only physicians' performance of tobacco control was associated with improved satisfaction scores. Routine screening, intervention, and referral of ED patients for smoking will not harm, and may improve, satisfaction scores. The mechanism underlying this effect is unknown., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

The Dynamic Assessment and Referral System for Substance Abuse (DARSSA) conducts a computerized substance abuse assessment; prints personalized summary reports that include tailored substance abuse treatment referral lists; and, for individuals who provide authorization, automatically faxes their contact information to a "best match" substance abuse treatment provider (dynamic referral). After piloting the program and resolving problems that were noted, we enrolled a sample of 85 medical patients. The DARSSA identified 48 (56%) participants who were risky substance users, many of whom had not been identified during their routine medical assessment. Mean satisfaction scores for all domains ranged between "Good" to "Excellent" across patients, nurses, doctors, and substance abuse treatment providers. The median completion time was 13min. Of the 48 risky substance using participants, 20 (42%) chose to receive a dynamic referral. The DARSSA provides a user-friendly, desirable service for patients and providers. It has the potential to improve identification of substance abuse in medical settings and to provide referrals that would not routinely be provided. Future studies are planned to establish its efficacy at promoting treatment initiation and abstinence.

Our objective was to study the role of race/ethnicity and socioeconomic status (SES) in the use of the emergency department (ED) as a source of routine healthcare. Adult patients presenting to an urban ED were surveyed. We assessed demographics, race/ethnicity, SES, and perceptional factors related to choosing the ED for the current visit. Stepwise logistic regression analyses were used to explore whether SES accounted for racial/ethnic trends in ED use. Of 1375 patients, 936 (68%) were enrolled. After controlling for insurance status, income, employment status, and education, neither race nor ethnicity remained a strong predictor of routine ED use. Race/ethnicity-based disparities in routine ED use were due to the confounding effects of SES. Programs to reduce inappropriate ED use must be sensitive to an array of complex socioeconomic issues and may necessitate a substantial paradigm shift in how acute care is provided in low SES communities.

This study examined the relationship between throughput times, expectations, and patient satisfaction using the Disconfirmation Paradigm (DP), which proposes that dissatisfaction arises when service expectations are not met. Before discharge or admission, adult emergency department (ED) patients estimated how long they waited for three intervals (Perceived Times): triage to patient care area, patient care area placement to physician evaluation, and physician evaluation to disposition. Acceptable waiting times and satisfaction for the same intervals were then provided by the subject (Acceptable Times and Throughput Time Satisfaction, respectively). Perceived Times were subtracted from Acceptable Times to yield an index of Expectancy Disconfirmation. There were 1118 (72%) of 1550 eligible patients interviewed. Throughput Time Satisfaction predicted overall satisfaction (r = 0.56 to 0.62, p < 0.001). In turn, Expectancy Disconfirmation predicted Wait Time Satisfaction (r = 0.42 to 0.64, p < 0.001). Consistent with the DP, when throughput times exceeded expectations, dissatisfaction with those throughput times arose, leading to general dissatisfaction with the ED visit.

Objective: Emergency department (ED) visits for asthma are frequent and may indicate increased morbidity and poor primary care access. Our objective was to compare the effect of two interventions on primary care follow-up after ED treatment for asthma exacerbations., Methods: We performed a randomized controlled trial of patients 2 to 54 years old who were judged safe for discharge receiving prednisone, and who were available for contact at 2 days and 30 days. Patients were excluded if they were previously enrolled or did not speak English. Patients received usual discharge care (group A); free prednisone, vouchers for transport to and from a primary care visit, and either a telephone reminder to schedule a visit (group B); or a prior scheduled appointment (group C). Follow-up with a primary care provider for asthma within 30 days was the main outcome. Secondary outcomes were recurrent ED visits, subsequent hospitalizations, quality of life, and use of inhaled corticosteroids 1 year later., Results: Three hundred eighty-four patients were enrolled. Baseline demographics, chronic asthma severity, and access to care were similar across groups. Primary care follow-up was higher in group C (65%) vs group A (42%) or group B (48%) [p = 0.002]. Group C intervention remained significant (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.1) when adjusted for other factors influencing follow-up (prior primary care relationship, insurance status). There were no differences in ED, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year after the index ED visit., Conclusion: An intervention including free medication, transportation vouchers, and appointment assistance significantly increased the likelihood that discharged asthma patients obtained primary care follow-up but did not impact long-term outcomes.

This article reviews the empirical literature on patient satisfaction in the Emergency Department (ED). It explores the implications for clinical practice, discusses limitations and weaknesses of the literature, and provides direction for future research. Articles resulting from a comprehensive electronic search were obtained, their references examined, and all other relevant articles not already discovered via the electronic search were acquired and reviewed. Articles were included if: 1) the stated goal of the study was to investigate satisfaction with at least one aspect of ED care, 2) the study was conducted in the United States, 3) it provided enough information on the study methods, design, and statistical analyses to conduct a critical review, and 4) it used quantitative methods. Fifty studies met the above criteria. Based on the multivariate predictive studies, the most robust predictor of global satisfaction is the quality of interpersonal interactions with the ED provider. Perceived waiting times are more closely associated with satisfaction than actual waiting times. Several methods for improving satisfaction have shown promise, but none has garnered sufficient support to recommend unequivocally. Promising interventions include: providing information on how the ED functions through visual media, improving ED processes through performance improvement methodologies, and improving the interpersonal skills of providers. Interventions designed to reduce actual waiting times have not been sufficiently studied, but results from several well-designed studies suggest that such a strategy is unlikely to have as great an impact as those targeting perceived waiting times. To advance this area of research, investigators must use: 1) larger, more representative samples; 2) reliable and valid assessment instruments; 3) theory-driven hypothesis testing; and 4) randomized, controlled trials.

Objectives: To investigate racial/ethnic differences in acute asthma among adults presenting to the emergency department (ED), and to determine whether observed differences are attributable to socioeconomic status (SES)., Design: Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the ED and by telephone 2 weeks after hospital discharge., Participants: Sixty-four North American EDs., Results: A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma patients had a history of more hospitalizations than did whites (ever-hospitalized patients: black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year: black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%; Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ based on race/ethnicity. After accounting for several confounding variables, blacks and Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks, 24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors, the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were markedly reduced., Conclusion: Despite significant racial/ethnic differences in chronic asthma severity, initial PEFR at ED presentation, and posthospital discharge outcome, ED management during the index visit was fairly similar for all racial groups. SES appears to account for most of the observed acute asthma differences, although hospital admission rates were higher among black and Hispanic patients after adjustment for confounding factors. Despite asthma treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and policymakers might specifically target the ED as a place to initiate interventions designed to reduce race-based disparities in health.

Study Objectives: The emergency department (ED) is an important focal point for asthmatic individuals with uncontrolled illness. Anecdotally, many adults presenting to the ED with acute asthma are active cigarette smokers. The present study determined the prevalence of cigarette smoking among adults presenting to the ED with acute asthma and identified the factors associated with current smoking status., Design: A prospective cohort study conducted as part of the Multicenter Airway Research Collaboration., Patients: A structured interview was performed in 1,847 patients, ages 18 to 54 years, who presented to the ED with acute asthma., Setting: Sixty-four EDs in 21 US states and 4 Canadian provinces., Results: Thirty-five percent of the enrolled asthmatic patients were current smokers with a median of 10 pack-years (interquartile range, 4 to 20 pack-years), while 23% were former smokers, and 42% were never-smokers. Current smokers comprised 33% of asthmatic patients aged 18 to 29 years, 40% for ages 30 to 39 years, and 33% for ages 40 to 54 (p < 0.001). In a multivariate analysis, the factors independently associated with current smoking status (p < 0.05) were as follows: age 30 to 39 years; white race/ethnicity; non-high school graduate; lower household income; lack of private insurance; no recent inhaled steroid usage; and no history of systemic steroid usage. Although 50% of current smokers admitted that smoking worsens their asthma symptoms, only 4% stated that smoking was responsible for their current exacerbation., Conclusions: Although cigarette smoke is generally recognized as a respiratory irritant, cigarette smoking is common among adults presenting to the ED with acute asthma. The ED visit may provide an opportunity for patients to be targeted for smoking cessation efforts.