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Purpose: The objective of this study is to examine the association between an academic medical center and free clinic referral partnership and subsequent hospital utilization and costs for uninsured patients discharged from the academic medical center's emergency department (ED) or inpatient hospital., Methods: This retrospective, cross-sectional study included 6014 uninsured patients age 18 and older who were discharged from the academic medical center's ED or inpatient hospital between July 2016 and June 2017 and were followed for 90 days in the organization's electronic medical record to identify the occurrence and cost of subsequent same-hospital ED visits and hospital admissions. The occurrence of any subsequent ED visits or hospital admissions and the cost of subsequent hospital care were compared by free clinic referral status after inverse probability of treatment weighting., Results: Overall, 330 (5.5%) of uninsured patients were referred to the free clinic. Compared with patients referred to the free clinic, patients not referred had greater odds of any subsequent ED visits or hospital admissions within 90 days (odds ratio, 1.8; 95% confidence interval: 1.7-2.0). For patients with any subsequent ED visits or hospital admissions, the mean cost of care for those who were not referred to the free clinic was 2.3 times higher (95% confidence interval: 2.0-2.7) compared to referred patients., Conclusion: An academic medical center-free clinic partnership for follow-up care after discharge from the ED or hospital admission is a promising approach for improving access to care for uninsured patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Importance: Cannabis hyperemesis syndrome is an emerging clinical issue associated with cannabis use. Legalization of cannabis has led to an increase in vomiting-related illnesses in health care settings., Objective: To examine whether legalization of cannabis in Colorado has been associated with increases in vomiting-related emergency department (ED) visits., Design, Setting, and Participants: A cross-sectional design was used to assess the increase in ED claims for vomiting reported to the Colorado Hospital Association between January 1, 2013, and December 31, 2018, in counties that had no prior cannabis dispensaries before legalization compared with those that did. A total of 820 778 patients seeking care through Colorado EDs were included in the analysis., Exposures: The number of medical and recreational cannabis dispensaries per county per quarter., Main Outcomes and Measures: County per capita rate of vomiting-related ED claims per quarter., Results: Vomiting-related ED health care encounters increased from 119 312 in 2013 to 153 699 in 2018 (29% increase). Over this period, 203 861 patients (25%) were aged 0 to 18 years; 114 201 (14%) were aged 19 to 25 years, and 502 771 (61%) were aged 26 years or older; 510 584 patients (62%) were female. Additional recreational dispensaries were associated with increased vomiting-related ED visits (incidence rate ratio, 1.03; 95% CI, 1.01-1.05), but counties with high baseline medical dispensary exposure experienced smaller increases in vomiting-related ED visits than counties with no baseline medical dispensary exposure (incidence rate ratio, 0.97; 95% CI, 0.95-0.99). Counties with a high number of medical marijuana dispensaries had increases at a 5.8% slower rate than counties with none., Conclusions and Relevance: The findings of this study suggest that cannabis legalization in Colorado is associated with an increase in annual vomiting-related health care encounters with regard to exposure to these markets. It may be useful for health care clinicians to be aware of cannabis hyperemesis syndrome and inquire about cannabis use when appropriate.

Background: Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied., Objectives: To assess the association between patient wait time and utilization of self-check-in kiosks in EDs. To investigate a series of other patient-, ED-, and hospital-level predictors of wait time in EDs., Methods: Using data from the 2015 and 2016 National Hospital Ambulatory Medical Care Survey, we analyzed 40,528 ED visits by constructing a multivariable linear regression model of the log-transformed wait time data as an outcome, then computing percent changes in wait times., Results: During the study period, about 9% of EDs in the United States implemented kiosks. In our linear regression model, the wait time in EDs with kiosk self-check-in services was 56.8% shorter (95% confidence interval ̶ 130% to ̶ 6.4%, p < 0.05) compared with EDs without kiosk services. In addition to kiosks, patients' day of visit, arrival time, triage assessment, arrival by ambulance, chronic medical conditions, ED boarding, hospitals' full-capacity protocol, and hospitals' location were significant predictors of wait time., Conclusions: Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Irregular migrants (IMM) are excluded from the National health insurance in most developed countries and may use the emergency department (ED) as a source for medical care. This study aims to compare the use of ED by IM with that of Israeli citizens (IC) in a large urban hospital in Tel Aviv, including socio-demographic characteristics, hospitalization proportion and medical conditions on admission., Methods: This cross-sectional study included all IM and IC patients older than 18 years who attended the ED between 2007 and 2011, and compared their socio-demographic characteristics, the administrative details of the visit and clinical variables upon admission. Hospitalization proportion was calculated by dividing the number of patients who were admitted to the hospital ward by the number of all patients who attended the ED., Results: IM who attended the ED were younger compared to IC (mean 39 ± 17 versus 52 ± 22 years, respectively), mostly males (1.4 Male/Female ratio) and mainly originated from developing countries. IM were more commonly self-referred, more likely to attend the ED during evening hours and weekends, complained of occupational injuries and frequented the surgical rather the medical ward of the ED compared with IC. IM stayed at the ED for longer periods than IC, yet the proportion of their hospitalization was lower than that of IC (19.4% versus 23.5%, respectively)., Conclusion: IM stayed in the ED for longer periods and were less likely to be admitted to the hospital wards, suggesting presentation of non-severe medical conditions or possible barriers in ensuring care continuity in the community following discharge. Minimizing the barriers of IM to primary care in the community can reduce unnecessary referrals to the ED. Additionally, hospitals managements should respond to the high-volume of IM by shifting staff to busy hours and improving the communication with IM.

Background: The Affordable Care Act (ACA) was enacted to enhance access to care primarily among nonelderly and low-income populations; however, several provisions addressed key determinants of emergency department (ED) and inpatient visits among Medicare beneficiaries over age 65 years. We take stock of the overall changes in these visits among older Medicare beneficiaries, focusing on those with multiple chronic conditions (MCCs), and provide a nationally representative post-reform update., Methods: We analyzed a sample of 32,919 older adults (65+) on Medicare from the 2006-2015 Medical Expenditure Panel Survey (MEPS). Using a survey-weighted two-part model, we examined changes in ED visits, inpatient visits, and length of stay (LOS) by MCC status, before (2006-2010), during (2011-2013), and after the ACA (2014-2015)., Results: Prior to the ACA, 18.1% of Medicare older adults had ≥1 ED visit, whereas 17.1% had ≥1 inpatient visits, with an average of 5.1 nights/visit. Following ACA reforms, among those with 2+ chronic conditions, the rate of ever having an ED visit increased by 4.3 percentage points [95% confidence intervals [CI]: 2.5, 6.1, p < 0.01], whereas the rate of inpatient visits decreased by 1.4 percentage points [95%CI: - 2.9, 0.2, p < 0.1], after multivariable adjustment., Conclusions: We found sizable increases in ED visits and nontrivial decreases in inpatient visits among older Medicare beneficiaries with MCCs, underscoring the continuing need for improving access to and quality of care among older adults with MCCs to decrease reliance on the ED and reduce preventable hospitalizations.

This article reports findings of a qualitative study describing how the US Department of Veterans Affairs cared for vulnerable veterans after Hurricane Sandy while medical center was closed for an extended period. This experience highlights how vulnerable patients continued to need care. Hospital preparedness planning efforts focus primarily on sheltering in place and evacuation. Research is needed to identify how hospitals provided temporary emergency services in alternative settings to inform practical guidance. Hospital planners should anticipate that their most vulnerable patients will continue to need emergency care. Viable solutions should be considered to meet immediate and long-term patient needs., (Published by Elsevier Inc.)

Background: The incidence of skin and soft-tissue infections (SSTIs), for which human immunodeficiency virus (HIV) is a significant risk factor, in United States emergency departments (EDs) increased dramatically after 2000 with the emergence of community-associated methicillin-resistant Staphylococcus aureus. Few studies have examined SSTI incidence among HIV-infected and non-HIV-infected patients in the United States after 2010., Methods: Data were obtained for patient encounters at all academic medical center EDs affiliated with the Vizient clinical data warehouse assigned an SSTI-associated code based on the International Classification of Diseases, Ninth Revision, between 1 January 2009 and 31 December 2014. The rate was calculated per 1000 ED encounters by year and stratified by SSTI, HIV infection, or both, and by age group, race, payer type, and region of care. Poisson regression was used to assess temporal change over the study period., Results: In 2009-2014, a total of 47317 HIV-associated and 820440 SSTI-associated encounters were recorded among 25239781 ED patient encounters. The rate of SSTIs decreased by 8% among all patients and by 14.6%, among those with HIV infection. The SSTI incidence overall decreased from 32.0 to 29.7 per 1000 ED encounters between 2009 and 2014. HIV-infected patients had a significantly higher rate of SSTIs than HIV-uninfected patients (adjusted rate ratio, 1.91; 95% confidence interval, 1.84-1.99)., Conclusions: The decline in SSTI incidence in US EDs between 2009 and 2014 is a remarkable epidemiologic shift from the increase in SSTIs after 2000, and further research is necessary to assess reasons for this decrease.

This study examined disparities in emergency department (ED) wait time for patients with mental health and substance-related disorders (PwMHSDs), using data from the 2009-2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). Wait time was defined as the time between arrival at ED and being seen by an ED provider. Results from multivariable regression models show racial disparities, with non-Hispanic Black PwMHSDs experiencing longer ED wait time, compared to non-Hispanic White PwMHSDs. A temporal decline in ED wait time was also observed over the study period. The findings of this study have implications for informing the development of policies tailored at facilitating the delivery of equitable emergency care services to all PwMHSDs.

Introduction: In the emergency department setting, it is essential to rapidly and accurately confirm correct endotracheal tube (ETT) placement. Ultrasound is an increasingly studied modality for identifying ETT location. However, there has been significant variation in techniques between studies, with some using the dynamic technique, while others use a static approach. This study compared the static and dynamic techniques to determine which was more accurate for ETT identification., Methods: We performed this study in a cadaver lab using three different cadavers to represent variations in neck circumference. Cadavers were randomized to either tracheal or esophageal intubation in equal proportions. Blinded sonographers then assessed the location of the ETT using either static or dynamic sonography. We assessed accuracy of sonographer identification of ETT location, time to identification, and operator confidence., Results: A total of 120 intubations were performed: 62 tracheal intubations and 58 esophageal intubations. The static technique was 93.6% (95% confidence interval [CI] [84.3% to 98.2%]) sensitive and 98.3% specific (95% CI [90.8% to 99.9%]). The dynamic technique was 92.1% (95% CI [82.4% to 97.4%]) sensitive and 91.2% specific (95% CI [80.7% to 97.1%]). The mean time to identification was 6.72 seconds (95% CI [5.53 to 7.9] seconds) in the static technique and 6.4 seconds (95% CI [5.65 to 7.16] seconds) in the dynamic technique. Operator confidence was 4.9/5.0 (95% CI [4.83 to 4.97]) in the static technique and 4.86/5.0 (95% CI [4.78 to 4.94]) in the dynamic technique. There was no statistically significant difference between groups for any of the outcomes., Conclusion: This study demonstrated that both the static and dynamic sonography approaches were rapid and accurate for confirming ETT location with no statistically significant difference between modalities. Further studies are recommended to compare these techniques in ED patients and with more novice sonographers., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Introduction: Lethal means counseling of suicidal individuals in emergency departments has the potential to reduce suicide. This study examines the provision of lethal means counseling and the presence of written protocols in a region with high rates of both firearm ownership and suicide., Methods: In 2015-2016, emergency department nurse managers in hospital-based emergency departments throughout eight states were surveyed using an 80-item survey developed through qualitative interviews and pilot testing. Questions focused on discharge counseling with suicidal patients and the presence of written protocols. Using survey weights to adjust for nonresponse, relationships of protocols with counseling practices were examined., Results: Data were obtained from 52.3% of all 363 eligible hospital emergency departments in the region. Among facilities that discharge suicidal patients, 79.7% (95% CI=75.0%, 84.4%) reported asking about access to firearms and 68.9% (95% CI=62.9%, 74.8%) counsel about safe storage when patients reported access. Forty-four percent of emergency departments reported having written protocols for lethal means counseling. Presence of written protocols was associated with a higher rate of counseling for all suicidal patients even if they were not planning to use a gun (45.0% [95% CI=33.4%, 56.7%] in hospitals with protocols vs 21.5% [95% CI=14.9%, 29.0%] in facilities without protocols)., Conclusions: There are significant gaps in attention to lethal means counseling in emergency departments. This signals an opportunity to increase consistency and thoroughness of care for suicidal patients in the emergency department and for leadership from key professional organizations to advocate for protocols., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Emergency department (ED) visits and the number of adults with multiple chronic conditions (MCC) have been increasing over the last decade, but little is known about the trends in ED use for patients with MCC. This study examined national trends in ED use for those with MCC compared with one chronic condition and no chronic conditions and used data from the 2007-2012 National Emergency Department Sample, limited to patients 45 years old or older. ED visits for encounters with one chronic condition and MCC increased at significantly greater rates than for those with no chronic conditions both overall and for all subgroups examined.

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities., (Project HOPE—The People-to-People Health Foundation, Inc.)

Context: The United States (US) is the only developed country that does not guarantee short-term or longer-term paid sick leave., Objective: This study used a multiyear nationally representative database to examine the association between availability of paid sick leave and frequency of emergency department (ED) use among US private sector employees., Study Sample: We used the National Health Interview Survey data (2012-2014). The final study sample consists of 42,460 US adults between 18 and 64years of age and working in nongovernmental private sector., Results: Our results suggest that availability of paid sick leave is significantly associated with lower likelihood of ED use, for both moderate (1-3 times/year) and repeated users (4 or more times/year). After controlling for confounding factors, respondents with paid sick leave are 14% less likely to be moderate ED users (adjusted odds ratio, 0.86; 95% CI, 0.79-0.93) and 32% less likely to be repeated ED users (adjusted odds ratio, 0.68; 95% CI, 0.50-0.91)., Discussion: Although expansion of health insurance coverage under the Affordable Care Act has not been shown to reduce utilization of high cost health care services such as the ED, our study suggests other factors such as the availability of paid sick leave may do so, by allowing patients to seek care through other more cost-effective mechanisms (eg, primary care providers). To reduce ED utilization, health policymakers should consider alternative reforms including paid sick leave., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities., Methods: We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data., Results: Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients., Conclusions: This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: During the 1990s, Israel absorbed approximately 1 million immigrants. The entitlement to citizenship and social rights in a country with universal health care coverage makes the Israeli case of special interest concerning immigrants' utilization of health care services., Objectives: 1. To describe utilization patterns of emergency room and in-hospital services among recent immigrants to Israel. 2. To determine if and when there is convergence of health care utilization patterns on the part of recent immigrants with native-born and long-established immigrants to Israel., Methods: Data was obtained from Clalit Health Services computerized database and included sociodemographics, date of immigration,presence of chronic disease, emergency room visits, and hospitalization days among all covered residents.Descriptive analysis of the group characteristics, multivariate analyses to determine influential factors, and tests for trend were conducted., Results: Rates of emergency room and hospitalization were lower for immigrants, and remained so even after 10 years., Conclusions: Economic and cultural factors influence health care utilization among immigrants and may lead to inequity in health care delivery and consequent health outcomes. A better understanding is needed for the differences in health care utilization patterns between immigrants and veteran Israelis., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene-66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a 'semi-evacuation hospital'. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs.

This study investigated the effect of fine particulate matter (PM2.5) in ambient air on hospital admissions and emergency room (ER) visits among young children (0-3 yr) residing in 4 communities in southern Israel, within an area 5-25 km from the 2 power plants, which operate within 25 km of each other. Daily records of hospitalizations and ER visits for respiratory diseases at the 3 hospitals serving the region were examined for 9 mo, October 1, 2000-June 30, 2001. Mean PM2.5 concentrations for the four communities ranged from 11.6 to 28.1 microg/m3. Time series analysis revealed a statistically significant association (p < 0.05) between the numbers of hospitalizations and ER visits for respiratory symptoms and concentrations of PM2.5. This effect was evaluated for 0-3 lag days, directly, and for interactions with temperatures and seasonal parameters. The respiratory health of young children may be affected by 24 hr concentrations of PM2.5 < 60 microg/m3, the threshold proposed by both Israel and the United States.