Availability and Quality of Computed Tomography and Magnetic Resonance Imaging Equipment in U.S. Emergency Departments

Objectives:  The objective was to determine the availability and quality of computed tomography (CT) and magnetic resonance imaging (MRI) equipment in U.S. emergency departments (EDs). The authors hypothesized that smaller, rural EDs have less availability and lower-quality equipment.
Methods:  This was a random selection of 262 (5%) U.S. EDs from the 2005 National Emergency Department Inventories (NEDI)-USA ( http://www.emnet-usa.org/ ). The authors telephoned radiology technicians about the presence of CT and MRI equipment, availability for ED imaging, and number of slices for the available CT scanners. The analysis was stratified by site characteristics.
Results:  The authors collected data from 260 institutions (99% response). In this random sample of EDs, the median annual patient visit volume was 19,872 (interquartile range = 6,788 to 35,757), 28% (95% confidence interval [CI] = 22% to 33%) were rural, and 27% (95% CI = 21% to 32%) participated in the Critical Access Hospital program. CT scanners were present in 249 (96%) institutions, and of these, 235 (94%) had 24/7 access for ED patients. CT scanner resolution varied: 28% had 1–4 slice, 33% had 5–16 slice, and 39% had a more than 16 slice. On-site MRI was available for 171 (66%) institutions, and mobile MRI for 53 (20%). Smaller, rural, and critical access hospitals had lower CT and MRI availability and less access to higher-resolution CT scanners.
Conclusions:  Although access to CT imaging was high (>90%), CT resolution and access to MRI were variable. Based on observed differences, the availability and quality of imaging equipment may vary by ED size and location.     

Responding to sexual assault victims' medical and emotional needs: a national study of the services provided by SANE programs

We measured the consistency with which a national random sample of 110 Sexual Assault Nurse Examiner (SANE) programs provided 17 services to sexual assault victims. SANE programs consistently offered forensic evidence collection, sexually transmitted infection (STI) prophylaxis, information on HIV, information on pregnancy risk, and referrals to community resources. Reasons programs did not routinely offer particular services (e.g., STI cultures, HIV testing/prophylaxis, emergency contraception (EC)) included financial constraints, difficulties balancing medical care with legal prosecution, and affiliations with Catholic hospitals.     

Emergency Department Utilization in the United States and Ontario, Canada

Objectives: The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics.
Methods: This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year.
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada.
Conclusions: ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.     

Emergency department management of the sexual assault victim

The optimal management of the sexual assault victim involves a multidisciplinary effort on the part of all legal, police, medical, and support personnel who interface in the emergency department. History, general physical examination, and pelvic examination are performed methodically, keeping in mind that the primary goal is to tend to the patient's medical needs. The gathering of evidence proceeds simultaneously with the physical examination. Evidence to be obtained and techniques are reviewed. Treatment entails attention to physical injuries, potential venereal disease and pregnancy, and psychiatric intervention. Management of the male rape victim or child victim of sexual abuse requires special attention to the peculiarities of those problems.     

Reasons for Using the Emergency Department: Results of the EMPATH Study

Objectives: Emergency Medicine Patients' Access To Healthcare (EMPATH) was a cross-sectional, observational study conducted to identify the principal reasons why patients seek care in hospital emergency departments (EDs) in the United States. Methods: Twenty-eight U.S. hospitals, stratified by geographic region and hospital characteristics, participated in this study. Demographic, clinical, and insurance data were collected for a 24-hour period at each site, using chart reviews and a structured interview administered to all consenting adult patients seeking treatment during that period. Patients' reasons for presenting to the ED were assessed by their level of agreement (on a three-point Likert scale) with 21 carefully worded statements designed to capture a range of possible reasons for seeking care in the ED. Factor analysis was used to consolidate highly correlated responses and to identify the principal factors explaining patients' reasons for coming to the ED. Results: A total of 1,579 patient interviews and 2,004 chart reviews were obtained from a diverse sample that was 55.4% female, 58.3% white, 28.3% African American, 7.0% Hispanic, and 6.0% other ethnic groups. This exploratory analysis yielded five factors characterizing patients' principal reasons for seeking ED care, with medical necessity the most frequent, followed by ED preference, convenience, affordability, and limitations of insurance. Conclusions: Use of the ED is, for most people, an affirmative choice over other providers rather than a last resort; it is often a choice driven by lack of access to or dissatisfaction with other sources of care.     

Access to Care A Review of the Emergency Medicine Literature

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.     

Factors Influencing the Timeliness of Emergency Medical Service Response to Time Critical Emergencies

Objective: While emergency medical service (EMS) response times (ERT) remain a leading measure of system performance in many developed countries, relatively few studies have explored the factors associated with meeting benchmark performance for potentially time critical incidents. The purpose of this study was to identify system-level and patient-level factors associated with ERT, which are readily available at the time of ambulance dispatch. Methods: Between July 2009 and June 2014, we included data from 1,000,458 EMS responses to time critical “lights and sirens” incidents in Melbourne, Australia. The primary outcome measure was ERT, defined as the time from emergency call to the arrival of the first EMS team on scene. Quantile regression models were used to identify system-level and patient-level factors associated with 10-percentile intervals of ERT. Results: The median ERT was 10.6 minutes (IQR: 8.1–14.0), increasing from 9.6 minutes (IQR: 7.6–12.5) in 2009/10 to 11.0 minutes (IQR: 8.4–14.7) in 2013/14 (p < 0.001). System-level factors independently associated with the 90th percentile ERT were distance to scene, activation time, turnout time, case upgrade, hour of day, day of week, workload in the previous hour, ambulance skill set, priority zero case (e.g., suspected cardiac or respiratory arrest), and average hospital delay time in the previous hour. Patient-level factors such as age, gender, chief medical complaint, and severity of complaint were also significantly associated with ERT. Conclusions: System-level and patient-level factors available at the time of ambulance dispatch are useful predictors of ERT performance, which could be used to improve the timeliness of EMS response.     

Information Technology in Emergency Medicine Residency–Affiliated Emergency Departments

OBJECTIVES: To describe acquisition and implementation of information technology (IT) in U.S. emergency medicine (EM) residency-affiliated emergency departments (EDs), including automatic medication error checking. METHODS: This was a survey of all U.S. EM residencies active in September 2000. Respondents specified whether specific IT tools had been "acquired" and "implemented fully." EDs were categorized according to primary versus affiliated training site, trauma level, and census. Numbers of "yes" responses were compared according to ED type (Kruskal-Wallis test, p < or = 0.05 significant). RESULTS: Of 121 residency programs, data were obtained from 93 (77%) for a total of 149 EDs. The percentages of EDs that reported full implementation for each technology are as follows: medication error checking, 7%; medication order entry, 18%; nonmedication orders, 7%; clinical documentation, 21%; old electrocardiograms, 62%; laboratory results, 84%; radiography order entry, 62%; image retrieval, 29%; radiologists' interpretations, 67%; cardiology reports, 62%; pathology reports, 70%; surgical reports/dictations, 60%; triage, 34%; tracking, 46%; electronic reference materials, 56%; registration, 84%; accounts, 72%; patient management software package, 20%; voice recognition, 7%. Trauma centers reported more IT tools than nontrauma centers (p = 0.01), and primary training sites reported fewer IT tools than affiliated EDs (p = 0.027). CONCLUSIONS: Incorporation of IT is not uniform in EDs where EM residents train. Acquisition of effective IT tools varies, and implementation lags behind acquisition. Fully implemented IT for medication error checking was reported in 7% of EDs; an additional 12% had acquired IT without implementing it fully.     

Academic Departments of Emergency Medicine: The Effects of Managed Care

Abstract. Objective: To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice. Methods: A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994–1995 and 1995–1996. Results: Forty-seven ADEMs (90.3%) responded. When comparing the 1995–1996 and 1994–1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs. Conclusion: ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.     

A Profile of Freestanding Emergency Departments in the United States, 2007

Background

Freestanding Emergency Departments (FSEDs) have emerged as an alternative to traditional hospital-based emergency care.

Study Objective

We sought to determine the number, basic types, distribution, and characteristics of United States (US) FSEDs in 2007.

Methods

Combining data from the 2007 National Emergency Department Inventory-USA database, the 2007 American Hospital Association Annual Survey of Hospitals, Internet searches, and telephone calls, we established an inventory of FSEDs. We define FSEDs as emergency care facilities physically distinct from a hospital. FSEDs include “satellite” Emergency Departments (EDs), which are owned by a parent hospital, and “autonomous” EDs, which lack such an affiliation.

Results

We identified 80 FSEDs operating in 2007, representing 1.6% of all US EDs; 73 (91%) in 20 states were satellite EDs, and seven (9%) in three states were autonomous EDs. Most FSEDs (92%; 95% confidence interval 83–97%) were located in urban areas, which is considerably higher than the proportion for hospital-based EDs (58%). The median distance from a satellite ED to a parent hospital ED was 10.6 miles. In 2007, FSED annual visit volumes ranged from 700 to 56,545 visits. The 2007 median visit volume was 18,769 (interquartile range 11,106–23,504; n = 52). This value did not vary by geographic region and is almost identical to the 2007 median visit volume for hospital-based EDs (18,776 visits).

Conclusions

FSEDs represent <2% of US EDs, with satellite EDs comprising a majority of all FSEDs. Most (92%) FSEDs are located in urban areas.     

Computers and Connectivity in Illinois Emergency Departments

Although the Internet has been described as "ubiquitous," little is known about the extent to which physicians have access to the Internet while providing clinical care. OBJECTIVE: To assess the extent of Internet connectivity within the clinical area of every ED within the state of Illinois. METHODS: This was a prospective observational study. Each Illinois ED listed in a published directory was called by telephone, and a responsible party was identified to provide information regarding the type and size of the ED, patient demographics, the types of personal computers (PCs) available in the ED (if any), the types of operating systems used, the availability of access to the World Wide Web (Web), and the highest speed at which an Internet connection could be established. Responses regarding the presence and types of PCs and the types of operating systems used were assessed using one-factor chi-square. Univariate and multivariate predictors of the type of PC used, the presence or absence of Web access, and the highest speed of Internet access were evaluated using optimal discriminant analysis and nonlinear classification tree analysis, respectively. RESULTS: One hundred ninety-eight of the 199 EDs in the state of Illinois (99.5%) completed the survey. Of the responding EDs, 50.5% had PCs, but only 17.6% had Web access. When Web access was available, it was most often available through a high-speed Internet connection that was faster than a dial-up modem. Most departments (68.1%) with PCs used the Windows 95 or Windows 98 operating systems. A majority (62.5%) used the Netscape browser exclusively. Larger EDs (more than six ED beds) in rural or suburban areas were more likely to have a PC compared with smaller EDs (six or fewer beds). Large EDs (more than 12 ED beds) in private tertiary care or academic hospitals were most likely to have Web access. CONCLUSIONS: Although half of Illinois EDs have PCs, only one in six has access to the Internet; thus, most emergency physicians do not have ready access to the Web from the site where they deliver clinical care.     

Violence against Women: Provider Barriers to Intervention in Emergency Departments

Objective: To determine: 1) provider behavior in screening for domestic violence (DV) and sexual assault (SA); 2) provider training in DV and SA; 3) provider knowledge of available protocols for DV and SA; and 4) provider perception of barriers to intervention.
Methods: Anonymous, structured surveys were distributed to physicians, nurses, and social workers at an adult ED trauma center, an affiliated pediatric ED, and a women's urgent care center between July and September 1995.
Results: Of 207 staff members (59%) responding, 54% and 68% indicated that they never/rarely screen for DV or SA, respectively. Thirty-five percent had received no DV training and 27% had received no SA training. Thirty-one percent of the staff had knowledge of existing protocols for DV and 63% had knowledge of existing protocols for SA. Providers trained in DV were more likely to screen for DV (RR 1.5, 95% CI 1.27–1.92, p ≤ 0.001) and SA (RR 1.49, 95% CI 1.24–1.79, p ≤ 0.0018), and providers trained in SA were more likely to screen for SA (RR 1.32, 95% CI 1.13–1.54, p = 0.0019) and DV (RR 1.35, 95% CI 1.13–1.60, p = 0.0007). Barriers that the majority of staff experienced in the care of DV/SA victims included: frustration that the victim would return to an abusive partner, concerns about misdiagnosis, lack of time, personal discomfort, reluctance to intrude into familial privacy, and lack of 24-hour social service support.
Conclusion: Providers surveyed had received little training in and rarely screen for violence, and there are a range of personal and institutional barriers impeding intervention with victims of SA and DV. Institutional changes to enhance training and support providers working in the front line of this epidemic may improve services for victims of violence.     

Use of Emergency Departments by Elder Patients: A Five -year Follow-up Study

Abstract. Objective: Tb compare the use of emergency medical care by elders in the United States in 1995 with that previously described for 1990. Methods: A computerized billing database of 88 EDs in 21 states was retrospectively reviewed for 1995, comparing elder and nonelder patients, estimating national use of emergency medical services by elders, and comparing the 1995 data with previously published results for 1990. Results: From 1990 to 1995, the number of ED visits in the United States increased from 92 million to 100 million. The number of visits made by patients aged 65 years or older increased from 13,639,400 (15%) to 15,666,300 (15.7%), but this increase did not reach statistical significance (p = 0.17). The admission rate for elder ED patients increased from 32% to 46% over the five-year interval (p < 0.01). This represents more than 7 million hospital admissions for elder patients in 1995. The rate of intensive care unit (ICU) admission for elders decreased from 7% to 6% over the five-year interval (p = 0.56), compared with 1.3% for nonelder patients for both years. Thirty percent of elder ED patients arrived by ambulance in 1990, compared with 33% in 1995 (p = 0.02). Based on 1995 data, elders comprised 39% of patients arriving by ambulance [odds ratio (OR) 4.75, 95% confidence interval (CI) = 4.71 to 4.79], 43% of all admissions (OR 6.59, 95% CI = 6.54 to 6.64), and 47% of ICU admissions (OR 5.00, 95% CI = 4.91 to 5.09). The comparable ORs in 1990 were 4.4, 5.6, and 5.5, respectively. Conclusions: From 1990 to 1995, the overall number of ED visits increased. The rate of increase was somewhat greater for elder patients. The use of ambulance services also disproportionately grew among elder patients, as did the rate of hospital admission. The overall rate of ICU admission was stable, but actually fell modestly for elder patients. Of these changes, only the increase in the rate of hospital admission for elders reached statistical significance.     

Availability of Rapid Human Immunodeficiency Virus Testing in Academic Emergency Departments

Objectives:  The Centers for Disease Control and Prevention (CDC) recommends routine human immunodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. The study objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify factors that influence an ED's adoption of testing, and to describe current HIV testing practices.
Methods:  Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs ( n  = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent ( n  = 102) responded. Most e-mail recipients ( n  = 121) were Emergency Medicine Network (EMNet) investigators; remaining contacts were obtained from residency-related Web sites.
Results:  Most academic EDs ( n  = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIV testing. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32 EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than 10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offer HIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation could link an HIV-positive patient to subspecialty care. The facility characteristic most important to availability of rapid HIV testing was the presence of on-site HIV counselors.
Conclusions:  Most academic EDs now offer rapid HIV testing (57%), but few use it in situations other than occupational exposure. Less than half of academic EDs expect to implement CDC guidelines regarding routine screening within the next few years. The authors identified facility characteristics (e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.     

Predictors of injury associated with rape

The purpose of this study was to assess predictors of injury in a preliminary model with victim and forensic characteristics as variables. Assessment of predictors will fill gaps in the literature, help clinicians improve data-gathering methods, and identify characteristics associated with rape-related injury of women who may be at higher risk for subsequent poor health.     

Most Transfers from Urgent Care Centers to Emergency Departments Are Discharged and Many Are Unnecessary

Background

Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied.

Do California Counties With Lower Socioeconomic Levels Have Less Access to Emergency Department Care?

Objectives: The study objective was to examine the relationship between number of emergency departments (EDs) per capita in California counties and measures of socioeconomic status, to determine whether individuals living in areas with lower socioeconomic levels have decreased access to emergency care. Methods: The authors linked 2005 data from the American Hospital Association (AHA) Annual Survey of Hospitals with the Area Resource Files from the United States Department of Health and Human Services and performed Poisson regression analyses of the association between EDs per capita in individual California counties using the Federal Information Processing Standard (FIPS) county codes and three measures of socioeconomic status: median household income, percentage uninsured, and years of education for individuals over 25 years of age. Multivariate analyses using Poisson regression were also performed to determine if any of these measures of socioeconomic status were independently associated with access to EDs. Results: Median household income is inversely related to the number of EDs per capita (rate ratio = 0.83; 95% confidence interval [CI] = 0.71 to 0.96). Controlling for income in the multivariate analysis demonstrates that there are more EDs per 100,000 population in FIPS codes with more insured residents when compared with areas having less insured residents with the same levels of household income. Similarly, FIPS codes whose residents have more education have more EDs per 100,000 compared with areas with the same income level whose residents have less education. Conclusions: Counties whose residents are poorer have more EDs per 100,000 residents than those with higher median household incomes. However, for the same income level, counties with more insured and more highly educated residents have a greater number of EDs per capita than those with less insured and less educated residents. These findings warrant in‐depth studies on disparities in access to care as they relate to socioeconomic status. ACADEMIC EMERGENCY MEDICINE 2010; 17:508–513 © 2010 by the Society for Academic Emergency Medicine