Search

Background: In 2020, during the COVID-19 pandemic, Italy implemented two national lockdowns aimed at reducing virus transmission. We assessed whether these lockdowns affected anti-seizure medication (ASM) use and epilepsy-related access to emergency departments (ED) in the general population. Methods: We performed a population-based study using the healthcare administrative database of Tuscany. We defined the weekly time series of prevalence and incidence of ASM, along with the incidence of epilepsy-related ED access from 1 January 2018 to 27 December 2020 in the general population. An interrupted time-series analysis was used to assess the effect of lockdowns on the observed outcomes. Results: Compared to pre-lockdown, we observed a relevant reduction of ASM incidence (0.65; 95% Confidence Intervals: 0.59–0.72) and ED access (0.72; 0.64–0.82), and a slight decrease of ASM prevalence (0.95; 0.94–0.96). During the post-lockdown the ASM incidence reported higher values compared to pre-lockdown, whereas ASM prevalence and ED access remained lower. Results also indicate a lower impact of the second lockdown for both ASM prevalence (0.97; 0.96–0.98) and incidence (0.89; 0.80–0.99). Conclusion: The lockdowns implemented during the COVID-19 outbreaks significantly affected ASM use and epilepsy-related ED access. The potential consequences of these phenomenon are still unknown, although an increased incidence of epilepsy-related symptoms after the first lockdown has been observed. These findings emphasize the need of ensuring continuous care of epileptic patients in stressful conditions such as the COVID-19 pandemic.

Author(s): Carlson, Lucas C.; Baker, Olesya N.; Schuur, Jeremiah D. | Abstract: Introduction: Emergency departments (ED) are an important source of care for underserved populations and represent a significant part of the social safety net. In order to explore the effect of freestanding emergency departments (FSED) on access to care for urban underserved populations, we performed a geospatial analysis comparing the proximity of FSEDs and hospital EDs to public transit lines in three United States (U.S.) metropolitan areas: Houston, Denver, and Cleveland.Methods: We used publicly available U.S. Census data, public transportation maps obtained from regional transit authorities, and geocoded FSED and hospital ED locations. Euclidean distance from each FSED and hospital ED to the nearest public transit line was calculated in ArcGIS. We calculated the odds ratio (OR) of an FSED, relative to a hospital ED, being located within 0.5 miles (mi) of a public transit line using logistic regression, adjusting for population density and median household income and with error clustered at the metropolitan statistical area (MSA) level.Results: The median distance from FSEDs to public transit lines was significantly greater than from hospital EDs across all three markets. In Houston, Denver, and Cleveland, the median distance between FSEDs and public transit lines was greater than from hospital EDs by 1.0 mi, 0.2 mi, and 1.6 mi, respectively. The OR of a public transit line being located within 0.5 mi of an FSED, as compared with a hospital ED, across all three MSAs was 0.21 (95% confidence interval [CI], 0.13–0.34) unadjusted and 0.20 (95% CI, 0.11–0.40) adjusted for population density and median household income.Conclusion: In comparison with hospital EDs, FSEDs are located farther from public transit lines and are less likely to be within walking distance of public transportation. These findings suggest that FSEDs are unlikely to directly increase access to care for patients without private means of transportation. Further research is necessary to explore both the direct and indirect impact of FSEDs on access to care, potentially through effects on hospital ED crowding and overall healthcare expenditures, as well as the ultimate role and responsibility of FSEDs in improving access to care for underserved populations.

Background and objectives: the emergency department (ED) is frequently identified by patients as a possible solution for all healthcare problems, leading to a high rate of misuse of the ED, possibly causing overcrowding. The coronavirus disease 2019 (COVID-19) pandemic started in China, it then spread throughout Italy, with the first cases confirmed in Lombardy, Italy, in February 2020. This has totally changed the type of patients referred to EDs. The aim of this study was to analyze the reduction of ED admissions at a Second level urban teaching (Fondazione Policlinico Universitario Agostino Gemelli IRCCS) during the COVID-19 pandemic. Materials and Methods: in this retrospective observational cross-sectional study, we reviewed and compared clinical records of all the patients consecutively admitted to our ED over a 40-day period (21 February &ndash, 31 March) in the last three years (2018&ndash, 2019&ndash, 2020). Mean age, sex, triage urgency level, day/night admission, main presentation symptom, and final diagnosis, according to different medical specialties, hospitalization, and discharge rate, were analyzed. Results: we analyzed 16,281 patient clinical records. The overall reduction in ED admissions in 2020 was 37.6% compared to 2019. In 2020, we observed an increase in triage urgency levels for ED admissions (the main presentation symptom was a fever). We noticed a significant drop in admissions for cardio-thoracic, gastroenterological, urological, otolaryngologic/ophthalmologic, and traumatological diseases. Acute neurological conditions registered only a slight, but significant, reduction. Oncology admissions were stable. Admissions for infectious diseases were 30% in 2020, compared to 5% and 6% in 2018 and 2019, respectively. In 2020, the hospitalization rate increased to 42.9% compared to 27.7%, and 26.4% in previous years. Conclusions: the drastic reduction of ED admissions during the pandemic may be associated with fear of the virus, suggesting that patients with serious illnesses did not go to the emergency room. Moreover, there was possible misuse of the ED in the previous year. In particular, worrisome data emerged regarding a drop in cardiology and neurology admissions. Those patients postponed medical attention, possibly with fatal consequences, just for fear of exposure to COVID-19, leading to unnecessary morbidity and mortality.

Author(s): Goto, Tadahiro; Hasegawa, Kohei; Faridi, Mohammad K.; Sullivan, Ashley F.; Camargo, Carlos A. | Abstract: Introduction: Epidemiological surveillance data for emergency department (ED) visits by children areimperative to guide resource allocation and to develop health policies that advance pediatric emergencycare. However, there are sparse population-based data on patient-level information (e.g., the number ofchildren who present to the emergency department [ED]). In this context, we aimed to investigate boththe patient- and visit-level rates of ED utilization by children.Methods: This was a retrospective cohort study using population-based multipayer data – state EDdatabases (SEDD) and state inpatient databases (SID) – from six geographically-dispersed U.S. states(California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all childrenaged l18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visitrate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDDand SID data. We also repeated the analysis using the 2010 data to determine the consistency of theresults across different years.Results: In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states.At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of thesechildren, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across thestates (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At thevisit-level, 6.7 million ED visits were made by children in 2011 – 34 ED visits per 100 children annually.ED visits by children accounted for 22% of all ED visits (including both adults and children), with arelatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the2010 data gave similar results for the ED utilization by children.Conclusion: By using large population-based data, we found a substantial burden of ED visits at bothpatient- and visit-levels. These findings provide a strong foundation for policy makers and professionalorganizations to strengthen emergency care for children.

Author(s): Stryckman, Benoit; Walsh, Lauren; Carr, Brendan; Hupert, Nathaniel; Lurie, Nicole | Abstract: Introduction: National health security requires that healthcare facilities be prepared to provide rapid,effective emergency and trauma care to all patients affected by a catastrophic event. We sought toquantify changes in healthcare utilization patterns for an at-risk Medicare population before, during,and after Superstorm Sandy’s 2012 landfall in New Jersey (NJ).Methods: This study is a retrospective cohort study of Medicare beneficiaries impacted bySuperstorm Sandy. We compared hospital emergency department (ED) and healthcare facilityinpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20%random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012(N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay,service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission.Results: In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prioryear. In the post-storm week, ED visits increased by 14% statewide; of these additional “surge”patients, 20% were admitted to the hospital. The increase in ED demand was more than double thestatewide average in the most highly impacted coastal regions (35% versus 14%).Conclusion: Superstorm Sandy impacted both pre- and post-storm patient movement in NewJersey; post-landfall ED surge was associated with overall storm impact, which was greatest incoastal counties. A significant increase in the number and severity of pre-storm transfer patients,in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attentionto the importance of collaborative regional approaches to healthcare in large-scale events.

Introduction: Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs. Methods: We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews. Results: The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses. Conclusion: Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs’ capabilities, and enhancing EDs’ resources to care for older patients.

Introduction According to the National Alliance to End Homelessness, the national rate of homelessness has been cited as 17.7 homeless people/10,000 people in the general population, and 24.8 homeless veterans/10,000 veterans in the general population. However, it is unknown what the prevalence of homelessness is in the emergency department (ED) setting. We set out to determine the prevalence of homelessness or at risk for homelessness in the ED setting. Methods Using a five-question screening tool derived from the U.S. Department of Housing and Urban Development, Health and Human Services and the Veterans Administration definition for homelessness, we surveyed all patients meeting inclusion/exclusion criteria on scheduled shifts in one of three EDs in Northeastern Pennsylvania. To participate, subjects had to be a registered patient in the ED, be 18 years or older, speak English, have the capacity to answer survey questions, not be critically ill, be willing to participate, and not have taken the survey before. We selected two survey periods to represent seasonal variations. Results We included 4,395 subjects in the analysis. The mean age of those who screened positive for homelessness or at risk for homelessness was 43.1 (SD 16.6). Overall, 136 (3.1%) participants screened positive for at risk for homelessness and 309 (7.0%) screened positive for homelessness. A total of 103 subjects (9.8%) screened positive for homelessness or at risk for homelessness on weekends and 312 (10.3%) on weekdays (p=0.64). The proportion of those screening positive for homelessness or at risk for homelessness varied by site: 145 (7.5%) at the trauma center, 151(9.1%) at the suburban site, and 149 (18.7%) at the center city site, p

Author(s): Probst, Beatrice D.; Walls, Luther; Cirone, Michael; Markossian, Talar | Abstract: Introduction: The emergency department (ED) has long served as a safety net for the uninsured and those with limited access to routine healthcare. This study aimed to compare the characteristics and severity of ED visits in an Illinois academic medical center (AMC) and community hospital (CH) of a single health system before and after the implementation of the Affordable Care Act (ACA).Methods: This was a retrospective record review of 357,764 ED visits from January 1, 2011– December 31, 2016, of which 74% were at the AMC and 26% at the CH. We assessed the severity of ED visits by applying the previously validated Ballard algorithm, which classifies ED visits as non-emergent, intermediate, or emergent. Descriptive analyses were conducted to compare the characteristics of ED visits before and after the implementation of the ACA. We conducted multilevel logistic regression analysis to examine the odds of non-emergent compared to intermediate/emergent ED visits by the ACA implementation status controlling for patient demographic characteristics, insurance status, and multiple visits per patient.Results: ED visits for patients with Medicaid or other governmental coverages increased in the post-ACA compared to pre-ACA period (Pre: 33.2 % vs Post: 38.3% at the AMC, and Pre: 29.7% vs Post: 35.1% at the CH). A statistically significant decrease in ED visits for uninsured patients was observed at the AMC and CH in the post-ACA period compared to the pre-ACA period (Pre: 12.1% vs Post: 6.4%, and Pre: 13.9% vs Post: 9.8%, respectively). Results from the regression analysis showed a significant decreased odds of non-emergent vs intermediate/emergent ED visits during the post-ACA period compared to the pre-ACA period at the AMC (odds ratio [OR] 0.68; confidence interval [CI], 0.66-0.70). However, an increased odds of non-emergent vs. intermediate/emergent ED visits was observed at the CH (OR 1.09; CI, 1.04-1.14).Conclusion: Similar to other Medicaid expansion states, ED utilization for uninsured patients decreased at both the AMC and the CH in the post-ACA period. While Medicaid visits for children l 18 years declined in the post-ACA period, it increased for ages 21 to 65 years of age. Contrary to our hypothesis, the severity of emergent ED visits increased in the post-ACA period but not at the CH.

Author(s): Dorner, Stephen C.; Camargo, Jr., Carlos A.; Schuur, Jeremiah D.; Raja, Ali S. | Abstract: Introduction: Under regulations established by the Affordable Care Act, insurance plans must meet minimum standards in order to be sold through the federal Marketplace. These standards to become a qualified health plan (QHP) include maintaining a provider network sufficient to assure access to services. However, the complexity of emergency physician (EP) employment practices – in which the EPs frequently serve as independent contractors of emergency departments, independently establish insurance contracts, etc… – and regulations governing insurance repayment may hinder the application of network adequacy standards to emergency medicine. As such, we hypothesized the existence of QHPs without in-network access to EPs. The objective is to identify whether there are QHPs without in-network access to EPs using information available through the federal Marketplace and publicly available provider directories.Results: In a national sample of Marketplace plans, we found that one in five provider networks lacks identifiable in-network EPs. QHPs lacking EPs spanned nearly half (44%) of the 34 states using the federal Marketplace.Conclusion: Our data suggest that the present regulatory framework governing network adequacy is not generalizable to emergency care, representing a missed opportunity to protect patient access to in-network physicians. These findings and the current regulations governing insurance payment to EPs dis-incentivize the creation of adequate physician networks, incentivize the practice of balance billing, and shift the cost burden to patients.

Introduction: Previous studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States. Methods: We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18-54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge. Results: The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p

Introduction: Previous literature has shown gender disparities in the care of acute ischemic stroke. Compared to men, women wait longer for brain imaging and are less likely to receive intravenous (IV) tissue plasminogen activator (tPA). Emergency department (ED) triage is an important step in the rapid assessment of stroke patients and is a possible contributor to disparities. It is unknown whether gender differences exist in ED triage of acute stroke patients. Our primary objective was to determine whether gender disparities exist in the triage of acute stroke patients as defined by Emergency Severity Index (ESI) levels and use of ED critical care beds. Methods: This was a retrospective, observational study of both ischemic and hemorrhagic stroke patients age ≥18 years presenting to a large, urban, academic ED within six hours of symptom onset between January 2010, and December 2012. Primary outcomes were triage to a non-critical ED bed and Emergency Severity Index (ESI) level. Primary outcome data were extracted from electronic medical records by a blinded data manager; secondary outcome data and covariates were abstracted by trained research assistants. We performed bivariate and multivariate analyses. Logistic regression was performed using age, race, insurance status, mode of and time to arrival, National Institutes of Health Stroke Scale, and presence of atypical symptoms as covariates. Results: There were 537 patients included in this study. Women were older (75.6 vs. 69.5, p

Introduction: Research has described emergency department (ED) use patterns in detail. However, evidence is lacking on how, at the time a decision is made, patients decide if healthcare is required or where to seek care. Methods: Using community-based participatory research methods, we conducted a mixed-methods descriptive pilot study. Due to the exploratory, hypothesis-generating nature of this research, we did not perform power calculations, and financial constraints only allowed for 20 participants. Hypothetical vignettes for the 10 most common low acuity primary care complaints (cough, sore throat, back pain, etc.) were texted to patients twice daily over six weeks, none designed to influence the patient’s decision to seek care. We conducted focus groups to gain contextual information about participant decision-making. Descriptive statistics summarized responses to texts for each scenario. Qualitative analysis of open-ended text message responses and focus group discussions identified themes associated with decision-making for acute care needs. Results: We received text survey responses from 18/20 recruited participants who responded to 72% (1092/1512) of the texted vignettes. In 48% of the vignettes, participants reported they would do nothing, for 34% of the vignettes participants reported they would seek care with a primary care provider, and 18% of responses reported they would seek ED care. Participants were not more likely to visit an ED during “off-hours.” Our qualitative findings showed: 1) patients don’t understand when care is needed; 2) patients don’t understand where they should seek care. Conclusion: Participants were unclear when or where to seek care for common acute health problems, suggesting a need for patient education. Similar research is necessary in different populations and regarding the role of urgent care in acute care delivery. [West J Emerg Med. 2014;15(6):-0]

Introduction: Reducing non-urgent emergency department (ED) visits has been targeted as a method to produce cost savings. To better describe these visits, we sought to compare resource utilization of ED visits characterized as non-urgent at triage to immediate, emergent, or urgent (IEU) visits.Methods: We performed a retrospective, cross-sectional analysis of the 2006-2009 National Hospital Ambulatory Medical Care Survey. Urgency of visits was categorized using the assigned 5-level triage acuity score. We analyzed resource utilization, including diagnostic testing, treatment, and hospitalization within each acuity categorization.Results: From 2006-2009, 10.1% (95% confidence interval [CI], 9.2-11.2) of United States ED visits were categorized as non-urgent. Most (87.8% [95%CI, 86.3-89.2]) non-urgent visits had some diagnostic testing or treatment in the ED. Imaging was common in non-urgent visits (29.8% [95%CI, 27.8-31.8]), although not as frequent as for IEU visits (52.9% [95%CI, 51.6-54.2]). Similarly, procedures were performed less frequently for non-urgent (34.1% [95%CI, 31.8-36.4]) compared to IEU visits (56.3% [95%CI, 53.5-59.0]). Medication administration was similar between the 2 groups (80.6% [95%CI, 79.5-81.7] vs. 76.3% [95% CI, 74.7-77.8], respectively). The rate of hospital admission was 4.0% (95%CI, 3.3-4.8) vs. 19.8% (95%CI, 18.4-21.3) for IEU visits, with admission to a critical care setting for 0.5% of non-urgent visits (95%CI, 0.3-0.6) vs. 3.4% (95%CI, 3.1-3.8) of IEU visits.Conclusions: For most non-urgent ED visits, some diagnostic or therapeutic intervention was performed. Relatively low, but notable proportions of non-urgent ED visits were admitted to the hospital, sometimes to a critical care setting. These data call into question non-urgent ED visits being categorized as “unnecessary,” particularly in the setting of limited access to timely primary care for acute illness or injury. [West J Emerg Med.609-616.]

Introduction: To assess if families presenting to a pediatric emergency department (PED) with multiple children as patients require interventions at the same rate as families presenting with a single child. Methods: This is a retrospective chart review looking at PED encounters for families presenting with single children versus multiple children as patients. Patients presenting with siblings were retrospectively selected from the electronic tracking board, and we randomly selected age/gender matched single-patient controls from a comparable time period. The primary outcome was a comparison of visit acuity between families presenting with single versus multiple children, with the hypothesis that families presenting with multiple children as patients would require less utilization of services (as a surrogate for acuity). Admission, intravenous fluid administration (IVF), planned observation, subspecialty consultation, performance of procedures, laboratories and radiographs, administration of prescription medications, and prescription medications for home were all recorded and compared via chi-squared comparison. We considered 5 interventions (admission, subspecialty consultation, performance of procedures, IVF administration, and observation > 6 hours) “critical interventions” and compared them separately. Results: In our sample of 83 patients from 41 families registering multiple children and 248 singleton controls, we found a significant difference in the percentage of patients requiring critical interventions (4.8% versus 32.5%, P < 0.0001). Conclusion: Families presenting with multiple children concurrently to an ED require critical interventions at a much lower rate than children presenting as single patients. Many of these families could be well-served at an urgent care or primary care provider. [West J Emerg Med. 2013;14(5):525–528.]

Introduction: In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness. Methods: We extracted data from a Kaiser Permanente database for a single metropolitan community ED. We compared the number of visits due to respiratory illness at t ime intervals of 2 weeks before and during the time when the fires were burnin g. We counted the total number of patients with chief complaint of dyspnea, cough, and asthma and final international classification of disease 9 coding diagnosis of asthma, bronchitis, chronic obstructive pulmonary disease and respiratory syndrome, and analyzed data for both total number and proportion of ED visits. We evaluated the data using Early Aberration Reporting System software to determine significant single-visit increases compared to expected counts. We also analyzed the average length of ED stay. Data on air quality were extracted from the http:// www.airnow.gov site. Results: There were significant differences between pre-fire and fire period average visit counts for the chief complaints of dyspnea and asthma. Dypnea complaints increased by 3.2 visits per day. During the fire the diagnoses of asthma increased significantly by 2.6 patients per day. Air quality reached air quality index values of 300, indicating very unhealthy conditions. Average ED length of stay times remained unchanged during the fire period compared to the pre-fire period. Conclusion: The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur. [West J Emerg Med 2013;14(2):79-84.]

Introduction: The American College of Emergency Physicians (ACEP) Task Force on Boarding described high-impact initiatives to decrease crowding. Furthermore, some emergency departments (EDs) have implemented a novel initiative we term “vertical patient flow,” i.e. segmenting patients who can be safely evaluated, managed, admitted or discharged without occupying a traditional ED room. We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.). Methods: We surveyed the physician leadership of all U.S. academic EDs from March to May 2010 using a 2-minute online survey. Academic ED was defined by the primary site of an emergency residency program. Results: We had a response rate of 73% (106/145) and a completion rate of 71% (103/145). The most prevalent hospital-based initiative was inpatient discharge coordination (46% [47/103] of respondents) while the least fully initiated was surgical schedule smoothing (11% [11/103]). The most prevalent ED-based initiative was fast track (79% [81/103]) while the least initiated was physician triage (12% [12/103]). Vertical patient flow had been implemented in 29% (30/103) of responding EDs while an additional 41% (42/103) reported partial/in progress implementation. Conclusion: We found great variability in the extent academic EDs have implemented ACEP’s established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow. Future studies should examine barriers to implementing these crowding initiatives and how they affect outcomes such as patient safety, ED throughput and patient/provider satisfaction. [West J Emerg Med 2013;14(2):85-89.]

Introduction Emergency department (ED) crowding has been shown to negatively impact patient outcomes. Few studies have addressed the effect of ED crowding on patient satisfaction. Our objective was to evaluate the impact of ED crowding on patient satisfaction in patients discharged from the ED. Methods: We measured patient satisfaction using Press-Ganey surveys returned by patients that visited our ED between August 1, 2007 and March 31, 2008. We recorded all mean satisfaction scores and obtained mean ED occupancy rate, mean emergency department work index (EDWIN) score and hospital diversion status over each 8-hour shift from data archived in our electronic tracking board. Univariate and multivariate logistic regression analysis was calculated to determine the effect of ED crowding and hospital diversion status on the odds of achieving a mean satisfaction score ≥ 85, which was the patient satisfaction goal set forth by our ED administration. Results: A total of 1591 surveys were returned over the study period. Mean satisfaction score was 77.6 (standard deviation [SD] ±16) and mean occupancy rate was 1.23 (SD ± 0.31). The likelihood of failure to meet patient satisfaction goals was associated with an increase in average ED occupancy rate (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.17 to 0.59, P < 0.001) and an increase in EDWIN score (OR 0.05, 95% CI 0.004 to 0.55, P = 0.015). Hospital diversion resulted in lower mean satisfaction scores, but this was not statistically significant (OR 0.62, 95% CI 0.36 to 1.05). In multivariable analysis controlling for hospital diversion status and time of shift, ED occupancy rate remained a significant predictor of failure to meet patient satisfaction goals (OR 0.34, 95% CI 0.18 to 0.66, P = 0.001). Conclusion: Increased crowding, as measured by ED occupancy rate and EDWIN score, was significantly associated with reduced patient satisfaction. Although causative attribution was limited, our study suggested yet another negative impact resulting from ED crowding.

Introduction: The state of emergency department (ED) crowding in Pennsylvania has not previously been reported. Methods: We assessed perceptions of ED crowding by surveying medical directors/chairs from Pennsylvania EDs in the spring of 2008. Results: A total of 106 completed the questionnaire (68% response rate). A total of 83% (86/104) agreed that ED crowding was a problem; 26% (27/105) reported that at least half of admitted patients boarded for more than 4 hours. Ninety-eight percent (102/104) agreed that patient satisfaction suffers during crowding and 79% (84/106) stated that quality suffers. Sixty-five percent (68/105) reported that crowding had worsened during the past 2 years. Several hospital interventions were used to alleviate crowding: expediting discharges, 81% (86/106); prioritizing ED patients for inpatient beds, 79% (84/106); and ambulance diversion, 55% (57/105). Almost all respondents who had improved ED operations reported that it had reduced crowding. Conclusion: ED crowding is a common problem in Pennsylvania and is worsening in the majority of hospitals, despite the implementation of a variety of interventions.

Author(s): Parks, Ashley; Hoegh, Andy; Kuehl, Damon | Abstract: Introduction: Availability of timely access to ambulatory care for semi-urgent medical concerns in rural and suburban locales is unknown. Further distance to an emergency department (ED) may require rural clinics to serve as surrogate EDs in their region, and make it more likely for these clinics to offer timely appointments. We determined the availability of urgent (within 48 hours) access to ambulatory care for non-established visiting patients, and assessed the effect of insurance and ability to pay cash on a patient’s success in scheduling an appointment in rural and suburban Eastern United States. We also assessed how proximity to EDs and urgent care (UC) facilities influenced access to semi-urgent ambulatory appointments at primary care facilities.Methods: The Appalachian Trail (AT), which runs from Georgia to Maine, was used as a transect to select 190 rural and suburban primary care clinics located along its entire length. We calculated their location and distance to the nearest hospital-based ED or UC via Google Earth. A sham patient representing a non-established visiting patient called each clinic over a four-month period (2013), requesting an appointment in the next 48 hours for one of three scripted clinical vignettes representing common semi-urgent ambulatory concerns. We randomized the scenarios and insurance statuses (insured vs. uninsured). Each clinic was contacted twice, once with the caller representing an insured patient, once with the caller representing an uninsured patient. When the caller was representing an uninsured patient, any required upfront payment was requested from each clinic. One hundred dollars was used as a cutoff between the uninsured as a distinction between those able to afford substantial upfront sums and those who could not. To determine if proximity to other sources of care impacted a clinic’s ability to grant an appointment, distance to the nearest ED or UC was modeled as a dichotomous variable using 30 miles as the divider.Results: Of 380 requests, 96 (25.3%) resulted in appointments within 48 hours. Insured patients and uninsured patients able to pay a substantial amount upfront (g$100) were more likely to book an appointment (p-value=l0.001, OR 18, CI [5-154]). Of the 47 clinics that granted uninsured patients appointments 89.3% required some form of payment up front. Farther distances from an ED did not result in greater likelihood of an appointment (OR 1.7, CI [0.4-11.3]). Clinics located within 30 miles of an UC were more likely to grant an appointment (OR 2.45, CI [1.19-5.80]).Conclusion: Almost 75% of rural clinics were unable to grant a new appointment for a semi-urgent health complaint. Lack of insurance and large upfront charges appear to be significant barriers to rural ambulatory care appointments. Greater distance from an ED does not improve a clinic’s ability to see semi-urgent appointments. Clinics located near an UC were more likely to grant an appointment than clinics without close alternative outpatient healthcare options.

Introduction: When a psychiatric patient in the emergency department requires inpatient admission, but no bed is available, they may become a “boarder.” The psychiatric emergency service (PES) has been suggested as one means to reduce psychiatric boarding, but the frequency and characteristics of adult PES boarders have not been described. Methods: We electronically extracted electronic medical records for adult patients presenting to the PES in an urban county safety-net hospital over 12 months. Correlative analyses included Student’s t-tests and multivariate regression. Results: 521 of 5363 patient encounters (9.7%) resulted in boarding. Compared to non-boarding encounters, boarding patient encounters were associated with diagnoses of a primary psychotic, anxiety, or personality disorder, or a bipolar manic/mixed episode. Boarders were also more likely to be referred by family, friends or providers than self-referred; arrive in restraints; experience restraint/seclusion in the PES; or be referred for involuntary hospitalization. Boarders were more likely to present to the PES on the weekend. Substance use was common, but only tobacco use was more likely associated with boarding status in multivariate analysis. Conclusion: Boarding is common in the PES, and boarders have substantial psychiatric morbidity requiring treatment during extended PES stays. We question the appropriateness of PES boarding for seriously ill psychiatric patients. [West J Emerg Med. 2014;15(6):-0]

Introduction: The boarding of admitted patients in the emergency department (ED) is a major cause of crowding and access block. One solution is boarding admitted patients in inpatient ward (W) hallways. This study queried and compared ED and W nurses’ opinions toward ED and W boarding. It also assessed their preferred boarding location if they were patients. Methods: A survey administered to a convenience sample of ED and W nurses was performed in a 631-bed academic medical center (30,000 admissions/year) with a 68-bed ED (70,000 visits/ year). We identified nurses as ED or W, and if W, whether they had previously worked in the ED. The nurses were asked if there were any circumstances where admitted patients should be boarded in ED or W hallways. They were also asked their preferred location if they were admitted as a patient. Six clinical scenarios were then presented, and the nurses’ opinions on boarding based on each scenario were queried. Results: Ninety nurses completed the survey, with a response rate of 60%; 35 (39%) were current ED nurses (cED), 40 (44%) had previously worked in the ED (pED). For all nurses surveyed 46 (52%) believed admitted patients should board in the ED. Overall, 52 (58%) were opposed to W boarding, with 20% of cED versus 83% of current W (cW) nurses (P < 0.0001), and 28% of pED versus 85% of nurses never having worked in the ED (nED) were opposed (P < 0.001). If admitted as patients themselves, 43 (54%) of all nurses preferred W boarding, with 82% of cED versus 33% of cW nurses (P < 0.0001) and 74% of pED versus 34% nED nurses (P = 0.0007). The most commonly cited reasons for opposition to hallway boarding were lack of monitoring and patient privacy. For the 6 clinical scenarios, significant differences in opinion regarding W boarding existed in all but 2 cases: a patient with stable chronic obstructive pulmonary disease but requiring oxygen, and an intubated, unstable sepsis patient. Conclusion: Inpatient nurses and those who have never worked in the ED are more opposed to inpatient boarding than ED nurses and nurses who have worked previously in the ED. Primary nursing concerns about boarding are lack of monitoring and privacy in hallway beds. Nurses admitted as patients seemed to prefer not being boarded where they work. ED and inpatient nurses seemed to agree that unstable or potentially unstable patients should remain in the ED but disagreed on where more stable patients should board. [West J Emerg Med 2013;14(2):90-95.]

Introduction: Major health-care reforms have extended across all Australian public hospitals in recent years. Improving emergency department (ED) access has been a focus of these reforms. Objective: This study evaluates how the national reforms have led to improvement in ED access in a regional hospital in remote Australia. Methods: Assessing a complex scenario such as national reforms and the challenges faced by the regional hospital to implement these reforms requires in-depth analysis. A realist evaluation theory-based approach was employed, allowing investigation of what, how, why, and for whom change occurred. A case study mixed methods design was adopted within the realist framework to answer these questions about change. Results and Conclusion: The study identified moderate improvement in ED access as a result of the reforms (investment in infrastructure and workforce and the introduction of ED targets). Clinical leadership and support from management were essential for the improvement. Without ongoing investment and clinical redesign activities, however, sustainability of the improvement may prove difficult.

Introduction: Early antibiotic administration is recommended in newborns presenting with febrile illness to emergency departments (ED) to avert the sequelae of serious bacterial infection. Although ED crowding has been associated with delays in antibiotic administration in a dedicated pediatric ED, the majority of children that receive emergency medical care in the U.S. present to EDs that treat both adult and pediatric emergencies. The purpose of this study was to examine the relationship between time to antibiotic administration in febrile newborns and crowding in a general ED serving both an adult and pediatric population. Methods: We conducted a retrospective chart review of 159 newborns presenting to a general ED between 2005 and 2011 and analyzed the association between time to antibiotic administration and ED occupancy rate at the time of, prior to, and following infant presentation to the ED. Results: We observed delayed and variable time to antibiotic administration and found no association between time to antibiotic administration and occupancy rate prior to, at the time of, or following infant presentation (P > 0.05). ED time to antibiotic administration was not associated with hospital length of stay, and there was no inpatient mortality. Conclusion: Delayed and highly variable time to antibiotic treatment in febrile newborns was common but unrelated to ED crowding in the general ED study site. Guidelines for time to antibiotic administration in this population may reduce variability in ED practice patterns. [West J Emerg Med. 2013;14(5):518-524.]

Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department(ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness towait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. Methods: We conducted this survey-based study from March to July 2010 at an urban academicmedical center. After triage, patients were given a multiple-choice questionnaire, designed toascertain how long they would wait for medical care. We collected data including age, gender, race,insurance status, and triage acuity level. We looked at the association between willingness to waitand these variables, using stratified analysis and logistic regression. Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventyone(51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and110 (32%) would wait indefinitely. No association was found between willingness to wait and race,gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended tobe older than 25, have higher acuity, and prefer the study site ED. Conclusion: Many patients have a defined, limited period that they are willing to wait for emergencycare. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED withoutbeing seen. This result suggests that efforts to reduce the percentage of patients who LWBS mustfactor in time limits. [West J Emerg Med. 2012;13(6):463-467]

We analyze whether decreased emergency department access (measured by increased driving time to the nearest ED) results in adverse patient outcomes or changes in the patient health profile for patients suffering from acute myocardial infarction. Data soirces include 100% Medicare Provider Analysis and Review, AHA hospital annual surveys, Medicare hospital cost reports, and longitude and latitude information for 1995-2005. We define four ED access changes catagories and estimate a zip codes fixed-effects regression models on the following AMI outcomes: time-specific mortality rates, age, and probability of PTCA on the day of admission. We find a small increase in 30-day to 1-year mortality rates among patients in communities that experience 30-minute increases in driving times, we find a substantial increase in long-term mortality rates, a shift to younger ages (suggesting that the older ones die en route) and a higher probability of immediate PTCA. Most of the adverse effects disappear after the initial three-year transition window.

Advertising emergency department (ED) wait times has become a common practice in the United States. Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED. Opponents worry about the risk to the public health that arises from a patient with an emergent condition self-triaging to a further hospital, problems with inaccuracy and lack of standard definition of the reported time, and directing lower acuity patients to the higher cost ED setting instead to primary care. Three sample cases demonstrating the pitfalls of advertising ED wait times are discussed. Given the lack of rigorous evidence supporting the practice and potential adverse effects to the public health, caution about its use is advised. [West J Emerg Med 2013;14(2):77-78.]