Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge

Background

Monitoring unscheduled return visits to the Emergency Department (ED) is useful to identify medical errors.

Objective

To investigate the differences between unscheduled return visit admissions (URVA) and unscheduled return visit no admissions (URVNA) after ED discharge.

Methods

From January 1, 2008 to March 31, 2008, URVA and URVNA patients who returned within 3 days after ED discharge were enrolled in the study. We compared the clinical characteristics, underlying diseases, ED crowding indicators, staff experience at the patient's first visit, and several other risk factors. We used multivariate logistic regression to evaluate differences between the two groups and to identify predictors of admission from unscheduled return visits.

Results

The unscheduled return visit rate was 3.1%. Of the 413 patients included, 147 patients (36%) were admitted, and had a mortality rate of 4.1%. The most common reason for the return visit was an illness-based factor (47.9%). Compared to URVNA patients, unscheduled return visit admissions had higher prevalence rates for old age, non-ambulatory status, high-grade triage, and underlying diseases (e.g., malignancy, diabetes mellitus, hypertension, coronary artery disease, heart failure, and chronic obstructive pulmonary disease). The independent predictors for URVA were: age ≥ 65 years (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.5); high-grade triage (adjusted OR 2.1, 95% CI 1.3–3.2); and doctor-based factors (adjusted OR 3.5, 95% CI 2.0–6.1). More advanced staff experience (p = 0.490) and ED crowding were not significant predictors (p = 0.498 for whole-day number of patients, p = 0.095 for whole-shift number of patients).

Conclusion

Old age, high-grade triage, and doctor-based factors were found to be significant predictors for URVA, whereas advanced staff experience and ED crowding were not.     

The Prevalence of Quality Issues and Adverse Outcomes among 72-Hour Return Admissions in the Emergency Department

Background

Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues.

Objectives

We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome.

Methods

Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006–2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered “low quality.” Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality.

Results

Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1–2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2–0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2–6.1) and hospital 3 (OR 3.2, 95% CI 2.0–4.7) compared to hospital 2.

Conclusions

Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality.     

Who Comes Back? Characteristics and Predictors of Return to Emergency Department Services for Pediatric Mental Health Care

Objectives: The objective of this study was to investigate predictors of emergency department (ED) return visits for pediatric mental health care. The authors hypothesized that through the identification of clinical and health system variables that predict return ED visits, which children and adolescents would benefit from targeted interventions for persistent mental health needs could be determined. Methods: Data on 16,154 presentations by 12,589 pediatric patients (≤17 years old) were examined from 2002 to 2006, using the Ambulatory Care Classification System (ACCS), a provincewide database for Alberta, Canada. Multivariable logistic regressions identified predictors, while survival analyses estimated time to ED return. Results: In the multivariable analysis, there were four patient factors significantly associated with ED return. Male sex (odds ratio [OR] = 0.78; 99% confidence interval [CI] = 0.69 to 0.89) was associated with a lower rate of return, as was child age. The likelihood of ED return increased with age. Children ≤5 years (OR = 0.26; 99% CI = 0.14 to 0.46) and between ages 6 and 12 (OR = 0.64; 99% CI = 0.51 to 0.79) were less likely to return, compared to 13‐ to 17‐year‐olds. Patients with families receiving full assistance for covering government health care premiums were more likely to return compared to those with no assistance (OR = 1.59; 99% CI = 1.33 to 1.91). Patients were more likely to return if their initial presentation was for a mood disorder (OR = 1.72; 99% CI = 1.46 to 2.01) or psychotic‐related illness (OR = 2.53; 99% CI = 1.80 to 3.56). There were two modest health care system predictors in the model. The likelihood of return decreased for patients triaged as nonurgent (OR = 0.62; 99% CI = 0.45 to 0.87) versus those triaged as urgent (level 3 acuity) and increased for patients with visits to general (vs. pediatric) EDs (OR = 1.25; 99% CI = 1.03 to 1.52). ED region (urban vs. rural) did not predict return. Within 72 hours of discharge, 6.1 and 8.7% of patients diagnosed with a mood disorder and psychotic‐related illness, respectively, returned to the ED. Throughout the study period, 28.5 and 36.6% of these diagnostic populations, respectively, returned to the ED. Conclusions: Among children and adolescents who accessed the ED for mental health concerns, being female, older in age, in receipt of social assistance, and having an initial visit for a mood disorder or psychotic‐related illness were associated with return for further care. How patient presentations were triaged and whether visits were made to a pediatric or general ED also affected the likelihood of return. ACADEMIC EMERGENCY MEDICINE 2010; 17:177–186 © 2010 by the Society for Academic Emergency Medicine     

Cardiology clinic follow-up did not decrease return visits to the ED for chest pain patients

Background

We initiated a program to rapidly rule out myocardial infarction and make an appointment (with no co-payment) with a cardiologist within 72 hours for patients with low-risk chest pain.

Objective

The objectives of this study were to determine if the rate of return emergency department (ED) visits for chest pain decreased among patients who kept their appointments and to evaluate factors that impacted clinic no-show rates.

Methods

The study was conducted at a safety net facility with 65 000 adult patient visits per year. This study was a retrospective review of patients with chest pain discharged from the ED with a scheduled cardiology clinic appointment between October 2008 and December 2009. We compared those who kept their clinic appointment with those who did not for repeat ED visits for 6 months after the study period. Multivariate analysis evaluated factors associated with keeping appointments.

Results

Of 381 patients, 265 (70%) kept their appointments. Show rates did not differ based on age, sex, race, or language. Patients with commercial insurance were more likely to keep appointments than Medicare, Medicaid, and uninsured (OR, 51.3; 95% confidence interval [CI], 2.53-1041.64; P = .010). The 116 no-show patients averaged 0.39 return ED visits (95% CI, 0.15-0.63), and the 265 patients who kept their appointments averaged 0.28 (95% CI, 0.17-0.39). Two hundred twenty-nine patients who kept their appointment had no return ED visits, but 36 patients had 74 return ED visits. There was no difference in return ED visits between the 18 who had diagnostic cardiac testing (mean, 1.78; 95% CI, 1.60-3.06) and the 18 who did not (mean, 2.33; 95% CI, 1.20-2.36; P = .251).

Conclusions

This program did not reduce repeat ED visits. Patients with insurance were more likely to keep follow-up appointments.     

Short-term Unscheduled Return Visits of Adult Patients to the Emergency Department

Background

Emergency department (ED) crowding is a major international concern that affects patients and providers.

Study Objective

We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding.

Methods

Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding.

Results

Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding.

Conclusion

Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.     

Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Objective

Our objective was to investigate the risk factors and prognostic predictors of unexpected intensive care unit (ICU) admission within 3 days after emergency department (ED) discharge.

Methods

From January 1, 2001, through December 31, 2005, patients admitted to the ICU unexpectedly within 3 days after being discharged from the ED were enrolled. Medical records of these patients were retrospectively reviewed. We categorized each patient's characteristics into dichotomous groups and used the χ² test to identify risk factors for unexpected ICU admission within 3 days after ED discharge. A multiple logistic regression was applied to examine possible independent predictors of poor prognoses.

Results

During the study period, 365 321 patients visited our ED; 241(0.07%) were unexpectedly admitted to the ICU within 3 days after being discharged from the ED. Mean patient age was 74.2 ± 16.4 years. The rate of ICU admissions caused by medical error was 0.019% ± 0.004% of all visits and 29.0% ± 5.7% of all unexpected ICU admissions. The overall mortality rate was 19.9% (48/241). Risk factors for unexpected ICU admission within 3 days after discharge from the ED were age of 65 years or older (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.0-7.4), ambulance transport (OR, 5.1; 95% CI, 3.9-6.5), no accompanying family (OR, 3.5; 95% CI, 2.7-4.5), nonambulatory status (OR, 4.2; 95% CI, 2.9-5.0), not living at home (OR, 2.5; 95% CI, 1.9-3.3), Medicaid insurance (OR, 3.6; 95% CI, 2.8-4.7), and emergency stay of more than 24 hours (OR, 4.4; 95% CI, 3.4-5.7). The independent predictors of mortality were age of 65 years or older (OR, 2.4; 95% CI, 1.7-3.6), multiple comorbidities (OR, 4.0; 95% CI, 1.8-8.5), medical error leading to ICU admission (OR, 3.9; 95% CI, 1.8-8.3), and Acute Physiology and Chronic Health Evaluation II score of 20 or higher (OR, 2.9; 95% CI, 1.1-7.8).

Conclusions

In our study, the risk factors and prognostic predictors of unexpected ICU admission within 3 days after ED discharge were identified. Based on these risk and prognostic prediction factors, further strategies for decreasing the incidence of serious adverse events of ED-discharged patients can be implemented.     

Factors associated with delayed evaluation of patients with potential stroke in US EDs

Background

The American Heart Association/American Stroke Association guidelines recommend all patients presenting to emergency departments (EDs) with a potential stroke be seen within 10 minutes of arrival, although this may not be achieved in all patients. We sought to identify factors associated with delayed evaluation of ED patients with potential stroke.

Methods

Using the National Hospital Ambulatory Medical Care Survey, we identified all patient ED visits from 2003 to 2010 and further identified those patients with strokes or stroke-like symptoms using International Classification of Disease, Ninth Revision codes. Visits were classified as those evaluated within 10 minutes of ED arrival or those where evaluation by the treating provider was 10 minutes or greater (delayed evaluation). We stratified visits, compared proportions, and calculated the unadjusted and adjusted odds ratios (ORs) in a multivariable model.

Results

We identified 743 cases in the database representing an estimated 2.3 million ED visits for patients with strokes. Of these, 600 000 were seen within 10 minutes and 1.7 million visits with delayed evaluation. Visits at nonmetropolitan statistical area hospitals were associated with decreased odds of delayed evaluation (OR, 0.41 [95% confidence interval, 0.26-0.64]; P < .001). Being triaged to a less urgent emergency severity index category was associated with increased odds of delayed evaluation (OR 3.08 (95% CI 1.94-4.89) p < 0.001). Other factors were not associated with delayed evaluation.

Conclusion

In this national sample of patients presenting with strokes to US EDs, patient visits to metropolitan statistical area hospitals and those triaged to less urgent categories were associated with delayed evaluation.     

Cancer diagnosis and outcomes in Michigan EDs vs other settings

Objective

This study determined the proportion of incident colorectal and lung cancers with a diagnosis associated with an emergency department (ED) visit. The characteristics of these patients and the correlation between diagnosis near an ED visit and stage at diagnosis were also examined.

Methods

A population-based sample of all Michigan cancer cases diagnosed in all EDs and other health care settings was used to extract a sample of patients >65 years old, diagnosed with colorectal and lung cancers between January 1, 1996, and June 30, 2000 (n = 20 311). Logistic regressions were used for the statistical analysis.

Results

Patients with a colorectal cancer diagnosis associated with an ED visit were more likely insured by Medicaid before diagnosis (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.17-1.60), had an inpatient admission before diagnosis (OR, 1.29; 95% CI, 1.06-1.56), had 3 or more comorbidities (OR, 4.11; 95% CI, 3.53-4.79), were more likely to be female (OR, 1.18; 95% CI, 1.07-1.31), and were more likely to be aged 85 years and older (OR, 1.89; 95% CI, 1.57-2.27). Patients who had at least one primary care physician (PCP) visit before diagnosis were less likely to have a diagnosis associated with an ED visit (OR, 0.68; 95% CI, 0.61-0.76). Patients diagnosed with lung cancer in association with an ED visit were also more likely to have an inpatient admission before diagnosis (OR, 1.21; 95% CI, 1.02-1.43), a higher comorbidity burden (OR, 12.44; 95% CI, 10.18-15.20), be female (OR, 1.13; 95% CI, 1.02-1.25), African-American (OR, 1.42; 95% CI, 1.21-1.66), and older (80 years and older) (ages 80-84 years: OR, 1.33; 95% CI, 1.13-1.57; age 85 years and older: OR, 1.52; 95% CI, 1.25-1.85). Patients with an ED visit near a colorectal cancer (OR, 1.28; 95% CI, 1.15-1.42) or lung cancer diagnosis (OR, 1.65; 95% CI, 1.44-1.88) were more likely to be diagnosed at a later stage compared with patients diagnosed in other settings.

Conclusions

An examination of patients' patterns of care leading to a cancer diagnosis in association with an ED visit lends insight to conditions precipitating a more immediate diagnosis and their associated outcomes.     

Predictors and outcomes of frequent chest pain unit users

Aim

To determine predictors of frequent chest pain unit (CPU) users and to identify characteristics and outcomes of their CPU visits.

Patients and Methods

Observational prospective case-control study. Frequent CPU user was defined by 3 or more CPU visits within the study year. A control patient and a control visit were randomly selected for each case patient and case visit. Demographic, clinical, and outcome variables were collected from medical record and phone interview performed in a 30-day interval. A multivariate logistic regression analysis was used to identify frequent CPU users′ predictors.

Results

Of 1934 patients presenting during the year, 80 (4.1%) met the definition for case patient. They accounted for 352 (13%) of 2709 CPU visits. Sixty-seven (83.7%) case patients and 71 (88.7%) control patients were contacted. The final predictors were the following: Karnofsky Performance Scale of 70 or lesser (odds ratio [OR], 5.24 [95% confidence interval {CI}, 1.71-16.06]), previous hospitalization (OR, 3.76 [95% CI, 1.49-9.49]), previously known coronary artery disease (OR, 3.72 [95% CI, 1.32-10.52]), and symptoms of depression (OR, 2.98 [95% CI, 1.14-7.78]). Case visits were more likely at night (OR, 2.41 [95% CI, 1.64- 3.52]), generated more diagnostic uncertainty (OR, 2.39 [95% CI, 1.71-3.35]), but did not increase the need of hospital admission.

Conclusions

Frequent CPU user is associated with previously known coronary artery disease, previous hospitalization, impaired performance status, and presence of symptoms of depression. They are more likely to arrive on CPU at night and generate more diagnostic uncertainty.     

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

Objective

The objective was to test the hypothesis that in‐hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

Methods

This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as “ED return admissions” (discharged at ED index visit and admitted at return visit) or “readmissions” (admission at both ED index and return visits). In‐hospital outcomes for ED return admissions and readmissions were compared to “index admissions without return admission” (admitted at ED index visit without 7‐day return visit admission).

Results

Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = –$193; 95% CI = –$479 to $93) compared to index admissions without return admission.

Conclusions

Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

     

National Study of Patient, Visit, and Hospital Characteristics Associated With Leaving an Emergency Department Without Being Seen: Predicting LWBS

Objectives: The objective was to estimate the national left‐without‐being‐seen (LWBS) rate and to identify patient, visit, and institutional characteristics that predict LWBS. Methods: This was a retrospective cross‐sectional analysis using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1998 to 2006. Bivariate and multivariate analyses were performed to identify predictors of LWBS. Results: The national LWBS rate was 1.7 (95% confidence interval [CI] = 1.6 to 1.9) patients per 100 emergency department (ED) visits each year. In multivariate analysis, patients at extremes of age (<18 years, odds ratio [OR] = 0.80, 95% CI = 0.66 to 0.96; and ≥65 years, OR = 0.46, 95% CI = 0.32 to 0.64) and nursing home residents (OR = 0.29, 95% CI = 0.08 to 1.00) were associated with lower LWBS rates. Nonwhites (black or African American (OR = 1.41, 95% CI = 1.22 to 1.63) and Hispanic (OR = 1.25, 95% CI = 1.04 to 1.49), Medicaid (OR = 1.47, 95% CI = 1.27 to 1.70), self‐pay (OR = 1.96, 95% CI = 1.65 to 2.32), or other insurance (OR = 2.09, 95% CI = 1.74 to 2.52) patients were more likely to LWBS. Visit characteristics associated with LWBS included visits for musculoskeletal (OR = 0.70, 95% CI = 0.57 to 0.85), injury/poisoning/adverse event (OR = 0.65, 95% CI = 0.53 to 0.80), and miscellaneous (OR = 1.56, 95% CI = 1.19 to 2.05) complaints. Visits with low triage acuity were more likely to LWBS (OR = 3.59, 95% CI = 2.81 to 4.58), whereas visits that were work‐related were less likely to LWBS (OR = 0.19, 95% CI = 0.12 to 0.29). Institutional characteristics associated with LWBS were visits in metropolitan areas (OR = 2.11, 95% CI = 1.66 to 2.70) and teaching institutions (OR = 1.33, 95% CI = 1.06 to 1.67). Conclusions: Several patient, visit, and hospital characteristics are independently associated with LWBS. Prediction and benchmarking of LWBS rates should adjust for these factors.     

Hospitalizations and return visits after chronic obstructive pulmonary disease ED visits

Purpose

The aim of this study was to describe population-based patterns of chronic obstructive pulmonary disease (COPD)–related emergency department (ED) visits.

Methods

We analyzed all COPD-related ED visits made by North Carolina residents 45 years or older in 2008 to 2009 using statewide surveillance system data. Return visits were identified when patients returned to the same ED within 3 or 14 days of a prior COPD-related visit. We quantify the prevalence of hospitalization and return visits by age, sex, and payment method and describe ED disposition patterns.

Results

Nearly half (46.3%) of the 97?511 COPD-related ED visits resulted in hospital admission. The percent of visits preceded by another COPD-related visit within 3 and 14 days was 1.6% and 6.2%, respectively. Emergency department–related hospitalizations increased with age; there were no differences by sex. Hospitalizations were less likely for uninsured, Medicare, and Medicaid visits than for privately insured visits. In contrast, 3- and 14-day return visits were more likely to be uninsured, Medicare, and Medicaid visits than privately insured visits. Fourteen-day returns were more likely to be made by men. Return visits initially increased with age compared with the 45- to 49-year age group, then decreased steadily after age 65 years. When return visits were made, discharge at both visits was the most common disposition pattern. However, 33.7% of 3-day returns and 22.7% of 14-day returns were discharged at the first visit and hospitalized upon returning to the ED.

Conclusions

Chronic obstructive pulmonary disease–related hospital admissions and short-term return ED visits were common and varied by age and insurance status. Chronic obstructive pulmonary disease management remains a critical area for intervention and quality improvement.     

Emergency Department Occupancy Ratio is Associated With Increased Early Mortality

Background

To measure emergency department (ED) crowding, the emergency department occupancy ratio (EDOR) was introduced.

Objective

Our aim was to determine whether the EDOR is associated with mortality in adult patients who visited the study hospital ED.

Methods

We reviewed data on all patients who visited the ED of an urban tertiary academic hospital in Korea for 2 consecutive years. The EDOR is defined by the total number of patients in the ED divided by the number of licensed ED beds. We tested the association between the EDOR (quartile) and each outcome using a multivariable logistic regression analysis adjusted for potential confounders: age, sex, emergency medical services transport, transferred case, weekend visit, shift, triage acuity, visit cause of injury, operation, vital signs, intensive care unit or ward admission, and ED length of stay (quartile). The main outcome measures were survival status at discharge and at 1–7 days.

Results

A total of 54,410 adult patients were enrolled. The EDOR ranged from 0.41 to 2.31 and the median was 1.24. On multivariable analyses, in comparison with the lowest (first) quartile, the highest (fourth) quartile of the EDOR was associated with 1-day mortality (adjusted odds ratio [OR] = 1.42; 95% confidence interval [CI] 1.08–1.88), 2-day mortality (adjusted OR = 1.31; 95% CI 1.04–1.67), and 3-day mortality (adjusted OR = 1.27; 95% CI 1.02–1.58). The EDOR was not significantly associated with 4- to 7-day mortalities and overall mortality at discharge.

Conclusions

The EDOR is associated with increased 1- to 3-day mortality even after controlling for potential confounders.     

ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease

Objective

The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

Methods

We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels.

Results

After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5).

Conclusions

Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.     

Effect of advanced age and vital signs on admission from an ED observation unit

Objectives

The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission.

Methods

We conducted a prospective, observational cohort study of ED patients placed in an ED-basedobservation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at acutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol.

Results

Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14?000/mm³ or greater (OR, 11.35; 95% CI, 3.42-37.72).

Conclusions

Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.     

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

Objective

The aim of the study was to evaluate use of physician assistants (PAs) and nurse practitioners (NPs) in US emergency departments (EDs).

Methods

We analyzed visits from the 1993 to 2005 National Hospital Ambulatory Medical Care Survey, seen by midlevel provider (MLP), and compared characteristics of MLP visits to those seen by physicians only.

Results

From 1993 to 2005, 5.2% (95% CI, 4.6%-5.8%) of US ED visits were seen by PAs and 1.7% (95% CI, 1.5%-2.0%) by NPs. During the study period, PA visits rose from 2.9% to 9.1%, whereas NP visits rose from 1.1% to 3.8% (both P_trend < .001). Compared to physician only visits, those seen only by MLPs arrived by ambulance less frequently (6.0% vs 15%), had lower urgent acuity (37% vs 59%), and were admitted less often (3.0% vs 13%).

Conclusions

Midlevel provider use has increased in US EDs. Their involvement in some urgent visits and those requiring admission suggests that the role of MLPs extends beyond minor presentations.     

Pediatric abscess characteristics associated with hospital admission from the ED

Objective

To determine the characteristics of pediatric soft tissue abscesses that result in hospital admission.

Methods

All visits for soft tissue abscesses to the study emergency department (ED) were examined during 2008.Detailed records were reviewed to determine ED disposition, abscess size, location, presence of fever, duration of symptoms, previous antibiotic therapy, prior ED visit(s), and wound and blood culture results. Data were analyzed to determine which of these characteristics were associated with hospital admission from the ED.

Results

Six hundred twenty-two patients met the inclusion criteria. One hundred thirteen (18%) patients were admitted to the hospital and 509 (82%) were discharged home. Compared to those sent home, abscesses resulting in admission were more likely to be located in the genital area (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.37-6.90), breast (OR, 4.8; 95% CI, 1.08-21.4), or face (OR, 4.39; 95% CI, 1.86-10.3), and were more likely to be larger than 3 cm (OR, 3.66, 95% CI, 2.10-6.36). Patients who were admitted to the hospital were also more likely to have fever (OR, 5.93; 95% CI, 3.4-10.3) and have had a prior ED visit with the same complaint (OR, 3.81; 95% CI, 1.77-8.2). Seventy-seven percent of abscesses that were cultured were positive for methicillin-resistant Staphylococcus aureus.

Conclusions

Size and location (especially those in the genital region, breast, and face), appear to be associated with admission for pediatric abscesses. History of fever and previous ED visit also appear to be associated with hospital admission. Obtaining blood cultures for pediatric abscesses is likely of little clinical benefit.     

Predictors of acute decompensation after admission in ED patients with sepsis

Purposes

The aim of the study was to identify predictors of acute decompensation within 48 hours of admission among infected emergency department (ED) patients admitted to a regular nursing floor.

Procedures

This used a case control study of infected ED patients admitted to a regular nursing floor and who received a discharge diagnosis of sepsis. A multivariate logistic regression model was constructed with the dependent variable as transfer to an intensive care unit (ICU) within 48 hours of admission.

Findings

Seventy-eight patients were enrolled—34 in the ICU group and 44 in the floor group. Only low bicarbonate (<20 mmol/L) (odds ratio [OR], 7.40; 95% confidence interval [CI], 2.35-23.30) and absence of fever (OR, 3.66; 95% CI, 1.11-12.60) were predictive of ICU transfer.

Conclusions

Among infected ED patients admitted to a regular floor, absence of fever and low bicarbonate were independently associated with ICU transfer within 48 hours. Particular attention should be paid to similar patients to ensure appropriate identification of severe infection and appropriate risk stratification.     

Does the Emergency Medical Treatment and Labor Act Affect Emergency Department Use?

Background

Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA).

Study objective

To determine whether modifying EMTALA might reduce ED use.

Methods

We surveyed ED patients to assess their knowledge of hospitals’ obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use.

Results

Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p = 0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24–1.67), adult patient (OR 1.94; 95% CI 1.69–2.22), and government insurance (OR 2.67; 95% CI 2.30–3.08) or uninsured (OR 1.72; 95% CI 1.42–2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p = 0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28–2.24), adult patient (OR 2.59; 95% CI 2.00–3.36), and government insurance (OR 3.73; 95% CI 2.76–5.06) or uninsured (OR 3.77; 95% CI 2.65–5.35).

Conclusion

Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.     

Identifying patients with cellulitis who are likely to require inpatient admission after a stay in an ED observation unit

Background

Emergency department observation units (EDOU) are often used for patients with cellulitis to provide intravenous antibiotics followed by a transition to an oral regimen for discharge. Because institutional regulations typically limit EDOU stays to 24 hours, patients lacking a clinical response within this period will often be subsequently admitted to the hospital for further treatment.

Objective

The aim of this study was to determine the rate of hospital admission and characteristics predictive of admission in patients with cellulitis who are initially placed in an ED observation unit.

Methods

A retrospective cohort study of patients placed into EDOU with a diagnosis of skin infection was conducted. Age, sex, history of diabetes mellitus, immunosuppression, intravenous drug use, location of cellulitis, presence of abscess, laboratory infectious markers, vital signs, and outpatient antibiotic treatment were recorded. The primary outcome was a hospital admission due to failure to respond to treatment within the 24-hour observation time window. Significant variables on univariate analysis were used to create a multivariate analysis, which identified predictive characteristics.

Results

Four hundred six patient charts were reviewed, with 377 meeting inclusion criteria; the inpatient admission rate from EDOU was 29.2%. Using logistic regression techniques, we created a model of independent predictors for need of admission after 24 hours: cellulitis of the hand (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.9), measured temperature higher than 100.4°F (OR, 2.5; 95% CI, 1.1-5.5), and lactate greater than 2 (OR, 3.1; 95% CI, 1.3-7.3) were predictive of failure of ED observation.

Conclusions

Patients with cellulitis placed into ED observation status were more likely to fail an observation trial if they had an objective fever in the ED, an elevated lactate, or a cellulitis that involved the hand.