Improved care of acute exacerbation of chronic obstructive pulmonary disease in two academic emergency departments

Background

Although several chronic obstructive pulmonary disease (COPD) practice guidelines have been published, there is sparse data on the actual emergency department (ED) management of acute exacerbation of COPD (AECOPD).

Aims

Our objectives were to examine concordance of ED care of AECOPD in older patients with guideline recommendations and to evaluate whether concordance has improved over time in two academic EDs.

Methods

Data were obtained from two cohort studies on AECOPD performed in two academic EDs during two different time periods, 2000 and 2005–2006. Both studies included ED patients, aged 55 and older, who presented with AECOPD, and cases were confirmed by emergency physicians. Data on ED management and disposition were obtained from chart review for both cohorts.

Results

The analysis included 272 patients: 72 in the 2000 database and 200 in the 2005–2006 database. The mean age of the patients was 72 years; 50% were women and 80% white. In 2005–2006, overall concordance with guideline recommendations was high (for chest radiography, pulse oximetry, bronchodilators, all ≥?90%), except for arterial blood gas testing (7% among the admitted) and discharge medication with systemic corticosteroids (42%). Compared to the 2000 data, the use of systemic corticosteroids in the ED improved from 53 to 77% [absolute improvement: 24%, 95% confidence interval (CI): 11–37%], and the use of antibiotics among the patients with respiratory infection symptoms improved from 56 to 78% (absolute improvement: 22%, 95% CI: 6–38%).

Conclusions

Overall concordance with guideline-recommended care for AECOPD was high in two academic EDs, and some emergency treatments have improved over time.     

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.     

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross-sectional Analysis From a Nationally Representative Sample

Objectives: The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith‐repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders. Methods: This was a cross‐sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993–2005) was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD‐9], 386.11) or APV (ICD‐9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure. Results: A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV). Conclusions: Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.     

National Study on Emergency Department Visits for Transient Ischemic Attack, 1992–2001

Objectives: To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten‐year time period. Methods: The authors obtained data from the 1992–2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD‐9 code 435. Results: From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten‐year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). Conclusions: Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation.     

Racial and Ethnic Differences in Emergency Care for Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objectives:  The objective was to investigate racial and ethnic differences in emergency care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).
Methods:  The authors performed a prospective multicenter cohort study involving 24 emergency departments (EDs) in 15 U.S. states. Using a standard protocol, consecutive ED patients with AECOPD were interviewed, their charts reviewed, and 2-week telephone follow-ups were completed.
Results:  Among 330 patients, 218 (66%) were white, 84 (25%) were African American, and 28 (8%) were Hispanic. A quarter of the 24 EDs cared for 59% of all minority patients. Compared with white patients, African American and Hispanic patients were more likely to be uninsured or with Medicaid (19, 49, and 52%, respectively; p < 0.001), were less likely to have a primary care provider (93, 81, and 82%, respectively; p = 0.005), and had more frequent ED visits in the past year (medians = 1, 2, and 3, respectively; p = 0.002). In the unadjusted analyses, minority patients were less likely to receive diagnostic procedures, more likely to receive systemic corticosteroids in the ED, less likely to be admitted, and more likely to have a relapse. After adjustment for patient and ED characteristics, these many racial and ethnic differences in quality of care were nearly completely eliminated.
Conclusions:  Despite pronounced racial and ethnic differences in stable COPD, all racial and ethnic groups received comparable quality of emergency care for AECOPD and had similar short-term outcomes.     

Impact of quality circles for improvement of asthma care: results of a randomized controlled trial

Rationale and aims Quality circles (QCs) are well established as a means of aiding doctors. New quality improvement strategies include benchmarking activities. The aim of this paper was to evaluate the efficacy of QCs for asthma care working either with general feedback or with an open benchmark. Methods Twelve QCs, involving 96 general practitioners, were organized in a randomized controlled trial. Six worked with traditional anonymous feedback and six with an open benchmark; both had guided discussion from a trained moderator. Forty‐three primary care practices agreed to give out questionnaires to patients to evaluate the efficacy of QCs. Results A total of 256 patients participated in the survey, of whom 185 (72.3%) responded to the follow‐up 1 year later. Use of inhaled steroids at baseline was high (69%) and self‐management low (asthma education 27%, individual emergency plan 8%, and peak flow meter at home 21%). Guideline adherence in drug treatment increased (P = 0.19), and asthma steps improved (P = 0.02). Delivery of individual emergency plans increased (P = 0.008), and unscheduled emergency visits decreased (P = 0.064). There was no change in asthma education and peak flow meter usage. High medication guideline adherence was associated with reduced emergency visits (OR 0.24; 95% CI 0.07–0.89). Use of theophylline was associated with hospitalization (OR 7.1; 95% CI 1.5–34.3) and emergency visits (OR 4.9; 95% CI 1.6–14.7). There was no difference between traditional and benchmarking QCs. Conclusions Quality circles working with individualized feedback are effective at improving asthma care. The trial may have been underpowered to detect specific benchmarking effects. Further research is necessary to evaluate strategies for improving the self‐management of asthma patients.     

Factors influencing inappropriate use of ED visits among type 2 diabetics in an evidence‐based management programme

Object This study analyses inappropriate use of emergency department (ED) services among type 2 diabetics under an evidence‐based management programme. Methods Using 1999‐2006 databases of Louisiana Health Care Services Division (HCSD) eight public hospitals ED visits among the uninsured and other patients in Louisiana, we termed urgent ED visits appropriate and less‐urgent visits inappropriate. Eliminating weekend ED visits, 17 458 urgent and 22 395 less‐urgent visits by 8596 patients were analysed, using generalized estimating equation methods. Results Caucasians were 0.82 times (95% CI: 0.751–0.889) less likely to use the ED inappropriately compared with African Americans. Patients with commercial insurance, Medicaid and Medicare used the ED more inappropriately than uninsured, with odds ratios of 1.28, 1.32 and 1.28, respectively. Patients hospitalized the prior year were 0.84 times (95% CI: 1.08–1.31) less likely for inappropriate. Patients in larger hospitals used the ED more inappropriately, with an odds ratio of 1.44 (95% CI: 1.32–1.56). Conclusions The study suggests that inappropriate use of the ED among diabetic patients in an evidence‐based management programme is more likely to occur among African American, patients with insurance coverage and those seeking care in larger hospitals. Reinforcing the regular use of clinic services for diabetes management, providing clinic access in off‐hours, and engaging the health plans in providing incentives for more appropriate use of the ED might reduce inappropriate ED visits. Notably, uninsured patients with diabetes from HCSD were more efficient users of the ED.     

Comparison of associations of adherence to a Dietary Approaches to Stop Hypertension (DASH)‐style diet with risks of cardiovascular disease and venous thromboembolism

Summary. Background: Venous thromboembolism (VTE) and cardiovascular disease (CVD) share some risk factors, including obesity, but it is unclear how dietary patterns associated with reduced risk of CVD relate to risk of VTE. Objective: To compare the relationships of adherence to a Dietary Approaches to Stop Hypertension (DASH)‐style diet with the risks of CVD and VTE. Patients/Methods: We confirmed by medical record review 1094 incident cases of CVD and 675 incident VTEs during a mean follow‐up of 14.6 years in 34 827 initially healthy participants in the Women’s Health Study who completed at baseline a 133‐item food frequency questionnaire scored for adherence to a DASH diet. We compared estimated associations of dietary patterns with CVD and VTE from proportional hazards models in a competing risk framework. Results: Initial analyses adjusted for age, energy intake and randomized treatments showed 36–41% reduced hazards of CVD among women in the top two quintiles of DASH score relative to those in the bottom quintile (P_trend < 0.001). In multivariate analysis, women in the top two quintiles had 12–23% reduced hazards of CVD relative to women in the bottom quintile (P_trend = 0.04). Analyses restricted to coronary events showed more variable 10–33% reduced hazards in the top two quintiles (P_trend = 0.09). In contrast, higher DASH scores were unrelated to risk of VTE, with a 1% reduced hazard for the top vs. bottom quintile (P_trend = 0.95). Conclusion: An apparently strong association of adherence to the DASH diet with incidence of CVD was attenuated upon control for confounding variables. Adherence to the DASH diet was not associated with risk of VTE in women.     

Frequent emergency department visitors are frequent primary care visitors and report unmet primary care needs

A small percentage of emergency department (ED) visitors account for a disproportionate portion of ED visits. Little is known about their relationships with their primary care providers (PCPs). This study compares frequent and infrequent ED visitors' primary care utilization and perceptions of primary care access, continuity, and connectedness and examines primary care utilization and perceptions as predictors of ED use. Data were obtained from 2 cross‐sectional studies of psychosocial predictors of high levels of utilization at 2 urban hospitals. Data included age, sex, race/ethnicity, number and type of chronic conditions, self‐rated health, and number of primary care and ED visits in the previous 12 months. Participants also answered 8 primary care access, continuity, and connectedness items. Participants with frequent ED visits (N = 70) were younger (43.24 vs 48.34, P = .020), more likely to be African American (61.4% vs 41.8%, P < .001), had a significant chronic illness burden (5.83 vs 2.83 chronic conditions, P < .001), and were more likely to report fair or poor health (65.7% vs 50.4%, P = .009). Frequent ED users were as likely as infrequent users to have a usual source of care, and reported similar primary care access, relationship length, and likelihood of provider knowing them well. Although making twice as many primary care visits, these participants were less likely to report that they could get what they need from their PCP (76.12% vs 92.53%, P < .001). Despite similar primary care access and continuity, frequent ED visitors are less likely to report that they get what they need from their PCPs. Further research should investigate their needs and how primary care can best provide high‐value care to this complex population.     

Quality of care for joint dislocation in 47 US EDs

Background

Little is known about emergency department (ED) quality of care for joint dislocation. We sought to determine concordance of ED management of dislocation with guideline recommendations and to assess whether higher concordance was associated with better patient outcomes.

Methods

We conducted a retrospective chart review study of joint dislocation as part of the National ED Safety Study (www.emnet-usa.org). We identified all charts with a primary ED or hospital discharge diagnosis of joint dislocation in 47 EDs across 19 US states between 2003 and 2005. Concordance with guideline recommendations was evaluated using 5 individual quality measures and composite guideline concordance scores. Concordance scores were calculated as the percentage of eligible patients receiving guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.

Results

The cohort consisted of 1980 ED patients; the patients' median age was 38 years, and 63% were men. Care for dislocation was excellent, with a concordance score of more than 85 across all quality measures. The median ED composite guideline concordance score was 93 (interquartile range, 90-95). In multivariable analyses, receiving treatment in EDs with the highest (fourth quartile) composite guideline concordance scores was independently associated with a significantly higher likelihood of successful joint reduction (adjusted odds ratio, 3.28; 95% confidence interval, 1.38-7.81), as compared with treatment in EDs with the lowest (first quartile) scores.

Conclusions

Concordance of ED management of joint dislocation with guideline recommendations was high. Greater concordance with guideline-recommended care may increase the likelihood of successful joint reduction.     

Emergency physicians can reliably assess emergency department patient cardiac output using the USCOM continuous wave Doppler cardiac output monitor

Objectives: 1 To develop a training package for ultrasonic cardiac output monitor (USCOM) cardiac output assessments and determine the number of proctored studies necessary for skill acquisition. 2 To develop criteria for acceptance of cardiac output results obtained with the USCOM. 3 To evaluate the reliability of USCOM cardiac output assessments in the ED. Methods: The authors developed an audiovisual training package. Four emergency physicians and one geriatrician subsequently underwent hands‐on training, and skill acquisition was assessed at the fifth, 10th, 15th and 20th examinations. Six image‐scoring criteria were developed to assess acoustic image quality. Upon completion of training a protocol was developed to optimize interassessor reliability. Two trained emergency physicians then performed blinded examinations on ED patients using the protocol and interassessor reliability was evaluated. Results: During training average image score improved between the fifth and 20th assessed patient from 4.6 (95% CI 4.0–5.3) to 5.5 (95% CI 5.0–6.0, P_t‐test = 0.02) out of 6 and average intra‐assessor cardiac output difference improved from 17% (95% CI 4–25) to 5% (95% CI 0–11, P_t‐test = 0.02). Analysis of 52 cardiac output assessments in 21 ED patients demonstrated excellent interassessor correlation (r = 0.96, 95% CI 0.90–0.98, P < 0.001). The average interassessor difference in cardiac output and index was 0.2 L/min (4%, 95% CI 3–6) and 0.1 L/min/m² (4%, 95% CI 2–6), respectively. Conclusion: Emergency physicians with no prior ultrasonographic experience can be trained to obtain reliable cardiac output estimations upon conscious ED patients with the USCOM over the course of 20 patient assessments.     

Emergency Department Visits for Injury in School-aged Children in the United States: A Comparison of Nonfatal Injuries Occurring Within and outside of the School Environment

Objectives: To compare the demographic and injury characteristics of children visiting the emergency department (ED) for nonfatal injuries occurring at school with those of same‐aged children who were injured outside of school. Methods: Data from a stratified probability sample of U.S. hospitals providing emergency services in the National Electronic Injury Surveillance System (NEISS) were analyzed for 2001 and 2002. School and nonschool injury‐related ED visits were analyzed for patients who were 5 through 19 years of age. Results: There were an estimated 58,147,518 injury visits in all ages to the ED in 2001 and 2002. Injuries to school‐aged children (ages 5–19) accounted for an estimated 15,405,392 (26%) visits overall, of which 1,859,215 occurred at school (16.5% of visits by school‐aged children when location of injury was known). Males accounted for 63% of injuries at school; middle‐school children (ages 10–14 yr) accounted for a significantly greater proportion of injuries (46%) than did primary‐ (5–9 yr, 24%) or secondary‐school (15–19 yr, 30%) children (p < 0.001). In contrast, for injuries outside of school, secondary‐school children were injured most (40%), followed by middle‐ (32%) and primary‐aged children (27%). Nearly 11% of school injuries were classified as violent, whereas only 6.4% of the nonschool injuries in school‐aged children were violent (p < 0.001). Similarly, sports injuries were significantly more common at school (53% of injuries) than outside of school (32.9%; p < 0.001). Conclusions: A significant proportion of injuries to school‐aged children occur at school. Notable differences exist between the epidemiology of in‐ and out‐of‐school injuries. The nature of these injuries differs by age group. Efforts to reduce school injuries will require that these differences be examined further and incorporated into prevention initiatives.     

Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma

Objective

The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians.

Methods

We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay).

Results

Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled β-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (−6 points; 95% CI, −9 to −3 points). Supervised MLPs provided similar quality of care to that of physicians.

Conclusions

The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.     

Timed Up and Go test is not useful as a discharge risk screening tool

Objective: To determine whether the ‘Timed Up and Go’ (TUG) test is a useful test for predicting re‐attendance at an ED, emergency hospital admission or death within 90 days in elderly patients discharged from the ED. Methods: This was a prospective blinded cohort study at a tertiary referral ED. Patients completed a TUG test during their Allied Health assessment prior to discharge from the department. After 90 days, patient ED attendances, emergency admissions to hospital or deaths were recorded and confirmed by phone. Data were analysed using logistic regression and reported as odds ratios (OR) or log‐transformation and Pearson analysis. Results: One hundred patients were enrolled: 78 (78%, 95% confidence interval [CI] 70–86%) patients remained event free, 22 (22%, 95% CI 14–30%) patients re‐attended an ED and 15 (15%, 95% CI 8–22%) were admitted to hospital as an emergency admission. There was no significant difference between TUG test times and whether patients re‐attended an ED (OR 1.0 [0.93–1.06]P = 0.9) or were admitted to hospital (OR 0.99 [0.91–1.07]P = 0.74). There was no significant correlation between a patient's TUG test time and the number of days to ED re‐attendance (Pearson correlation coefficient 0.38 [?0.04 to 0.69]P = 0.08) or admission (Pearson correlation coefficient 0.32 [?0.23 to 0.71]P = 0.25). Conclusion: This study did not detect any predictive value of the TUG test for ED re‐attendance or hospital admission within 90 days of discharge among aged ED patients.     

Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome

Objective: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED. Methods: A prospective observational multicentre study was undertaken of patients undergoing evaluation in the ED for possible ACS. We compared the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline and the Thrombolysis in Myocardial Infarction (TIMI) risk score for differentiating high‐ and low‐risk patients. Composite outcome was all cause death, myocardial infarction or coronary revascularisation within 30 days. Results: Of 1758 enrolments, 223 (13%) reached the study outcome. Area under the receiver operator characteristic (ROC) curve was 0.79 (95% CI 0.76–0.81) for the NHF/CSANZ group and 0.71 (0.68–0.75) for TIMI score based on initial troponin result (P < 0.001), and 0.82 (95% CI 0.80–0.84) and 0.76 (0.73–0.79) respectively when the 8–12 h troponin result is included (P = 0.001). Thirty day event rates were 33% for NHF/CSANZ high‐risk vs 1.5% for combined low/intermediate risk (P < 0.001). For TIMI score, 30 day event rates were 23% for a score ≥2 and 4.8% for TIMI < 2 (P < 0.001). The NHF/CSANZ guideline identified more patients as low risk compared with the TIMI risk score (61% vs 48%, P < 0.001). Conclusions: The NHF/CSANZ guideline is superior to the TIMI risk score for risk stratification of suspected ACS in the ED.     

Exploring Patterns of Health Service Use in Older Emergency Department Patients

Objectives: Study objectives were to identify groups of older patients with similar patterns of health care use in the 12 months preceding an index outpatient emergency department (ED) visit and to identify patient‐level predictors of group membership. Methods: Subjects were adults ≥ 65 years of age treated and released from an academic medical center ED. Latent cluster analysis (LCA) models were estimated to identify groups with similar numbers of primary care (PC), specialist, and outpatient ED visits and hospital days within 12 months preceding the index ED visit. Results: In this sample (n = 308), five groups with distinct patterns of health service use emerged. Low Users (35%) had fewer visits of all types and fewer hospital days compared to sample means. Low Users were more likely to be female and had fewer chronic health conditions relative to the overall sample (p < 0.05). The ED to Supplement Primary Care Provider (PCP) (23%) group had more PCP visits, but also significantly more ED visits. Specialist Heavy (22%) group members had twice as many specialist visits, but no difference in PCP visits. Members of this class were more likely to be white and male (p < 0.05). High Users (15%) received more care in all categories and had more chronic baseline health conditions (p < 0.05) but no differences in demographic characteristics relative to the whole sample. The ED and Hospital as Substitution Care (6%) group had fewer PC and specialist visits, but more ED visits and hospital days. Conclusions: In this sample of older ED patients, five groups with distinct patterns of health service use were identified. Further study is needed to determine whether identification of these patient groups can add important information to existing risk‐assessment methods. ACADEMIC EMERGENCY MEDICINE 2010; 17:1086–1092 © 2010 by the Society for Academic Emergency Medicine     

Educational and long-term therapeutic intervention in the ED: Effect on outcomes in adult indigent minority asthmatics

Minorities have increased morbidity and mortality rates resulting from asthma. The segment of minorities that is socioeconomically depressed often uses the emergency department (ED) as their primary site of medical care. For these reasons, we provided major long-term therapeutic intervention as well as intensive education in the ED for indigent adult African American asthmatics. We intervened in the cases of 30 patients who were frequent visitors to the ED over the previous 2 years. The intervention consisted of 1 hour of education in the ED before discharge regarding the prevention of asthma, the importance of decreasing inflammation as a means of improving asthma control, self-monitoring with a peak flow meter, and a demonstration of correct inhalation technique with metered-dose inhalers and a spacer device. Further, the intervention included management consistent with recent NIH Guidelines, stressing inhaled corticosteroids. After the intervention in the ED, patients were scheduled for follow-up asthma clinic visits. Outcome measures were ED visits and hospitalizations for 1 year after the ED intervention. Using the same inclusion/exclusion criteria, a retrospective control group of 22 patients for the same time period was compared with the intervention group. Before our intervention, the mean number of ED visits per patient for the previous 2 years was 4.4 ± 2.7, and after the intervention, 2.6 ± 2.6 (P < .01). The control group did not show a difference in the number of ED visits (3.4 ± 2.6 before and 3.5 ± 2.7 after, P = .96). After the intervention, the mean number of hospitalizations decreased significantly in the study group (P < .01). A nonsignificant reduction in hospitalizations was seen in the control group (P = .07). The amount of decrease was not significantly different between groups (P = .37). Only 6 of 30 patients routinely kept subsequent clinic appointments. Innovative approaches are needed to improve clinical outcomes in indigent adult minority asthmatics. These data suggest that long-term intervention and education in the ED reduces subsequent ED visits for asthma. Further studies in larger patient populations are recommended.     

Categorizing Urgency of Infant Emergency Department Visits: Agreement between Criteria

Background The lack of valid classification methods for emergency department (ED) visit urgency has resulted in large variation in reported rates of nonurgent ED utilization. Objectives To compare four methods of defining ED visit urgency with the criterion standard, implicit criteria, for infant ED visits. Methods This was a secondary data analysis of a prospective birth cohort of Medicaid‐enrolled infants who made at least one ED visit in the first six months of life. Complete ED visit data were reviewed to assess urgency via implicit criteria. The explicit criteria (adherence to prespecified criteria via complete ED charts), ED triage, diagnosis, and resources methods were also used to categorize visit urgency. Concordance and agreement (κ) between the implicit criteria and alternative methods were measured. Results A total of 1,213 ED visits were assessed. Mean age was 2.8 (SD ± 1.78) months, and the most common diagnosis was upper respiratory infection (21.0%). Using implicit criteria, 52.3% of ED visits were deemed urgent. Urgent visits using other methods were as follows: explicit criteria, 51.8%; ED triage, 60.6%; diagnosis, 70.3%; and resources, 52.7%. Explicit criteria had the highest concordance (78.3%) and agreement (κ= 0.57) with implicit criteria. Of limited data methods, resources demonstrated the best concordance (78.1%) and agreement (κ= 0.56), while ED triage (67.9%) and diagnosis (71.6%) exhibited lower concordance and agreement (κ= 0.35 and κ= 0.42, respectively). Explicit criteria and resources equally misclassified urgency for 11.1% of visits; ED triage and diagnosis tended to overclassify visits as urgent. Conclusions The explicit criteria and resources methods best approximate implicit criteria in classifying ED visit urgency in infants younger than six months of age. If confirmed in further studies, resources utilized has the potential to be an inexpensive, easily applicable method for urgency classification of infant ED visits when limited data are available.     

Examining the utility of in-clinic "rescue" therapy for acute migraine

Background.— Management options currently are limited for patients with acute migraine whose symptoms prove refractory to self‐administered therapy. Objective.— To evaluate the clinical utility and cost‐effectiveness of a management program offering in‐clinic “rescue” treatment for patients with acute migraine. Methods.— Two hundred consecutive migraine patients presenting to a university‐based headache clinic were randomized to receive either optimal self‐administered medical therapy for acute migraine (“standard therapy”) or similar therapy plus the option of in‐clinic parenteral drug administration should self‐administered therapy prove ineffective (“rescue therapy”). Patients randomized to the latter group were restricted to a maximum of 2 “rescue visits” per month, and all patients were followed for one year. Patients “rescued” in clinic were contacted by telephone 24 hours following treatment to evaluate their treatment response. The primary analysis involved a comparison of the number of emergency department (ED) visits for headache recorded within each group over the one‐year period of study. For all ED visits in the rescue group and for a randomly selected and equal number of ED visits within the standard group, the direct costs associated with those visits were assessed, and the direct costs of all in‐clinic rescue visits also were recorded and analyzed. Results.— The 2 groups studied were similar in terms of age, gender ratio, migraine subtype, migraine‐related disability status at baseline and type/extent of medical insurance coverage. Over the one‐year study period, the rescue group recorded 423 in‐clinic rescue visits and reported 27 ED visits for headache treatment. The standard therapy group reported 73 ED visits (27 vs 73 visits; P < .01). The total direct costs associated with ED visits were $45,330 for the rescue group (mean $1690 per ED visit) and (by extrapolation from the sample selected) $147,971 for the standard therapy group (mean $2027 per ED visit). The total direct cost of the 423 “rescue visits” was $33,647 (mean $80 per visit). In 79% of the 423 rescue encounters, the patients involved reported no residual functional disability 24 hours following treatment. Of those in the rescue group who sought in‐clinic rescue, 89% reported themselves “very satisfied” with such management. Conclusion.— Providing the alternative of in‐clinic “rescue” for acute migraine refractory to self‐administered therapy offers an attractive alternative for patients and appears to substantially lower use of an ED for headache treatment and the cost associated with that use.