Medication-related visits to the emergency department: a prospective study

OBJECTIVE: To assess the prevalence, preventability, category, and severity of drug-related problems; medications involved; common causes of preventable medication-related visits (MRVs); and cost of MRVs. METHODS: In this prospective, observational study of emergency department visits, patients were identified as having MRVs by use of a questionnaire. The patients or their representatives were interviewed to assess whether the emergency department visit was caused by a medication-related problem. Patient selection was consecutive. A blinded panel of pharmacists and one physician was used to assess study objectives. RESULtS: Of the 253 patients interviewed, 71 patients (28.1%) presenting to the emergency department had a medication-related reason for their visits. Of the 71 MRVs, 50 (70.4%) were judged to be preventable and 21 (29.6%) nonpreventable. The data showed that MRVs are most often caused by an adverse drug reaction, followed by overprescribing of the correct medication. The severity of MRVs was most often classified as moderate. The most common medications involved were cardiovascular agents. The preventable MRVs were mostly due to noncompliance issues, inappropriate prescribing, inappropriate monitoring, and lack of patient education. The average cost to the institution was approximately $1444 per preventable MRV. CONCLUSIONS: In our study, the prevalence of MRVs was higher than in previous studies due to the prospective nature of the study and the assistance of drug experts in identifying and classifying the incidents. Areas identified for improvement included compliance issues with patients, education of healthcare workers regarding prescribing and monitoring of medications, and patient education.     

The impact of resident physician coverage on emergency department visits in South Carolina

BACKGROUND: This study examines emergency department (ED) visits to assess the potential impact on rural and minority patients if the practice of resident moonlighting was limited. METHODS: Billing data from all South Carolina ED visits in 1998 were linked to the physician licensure file. Logistic regression analysis was performed to determine patient characteristics predictive of being seen by a resident physician. RESULTS: Resident physicians attended 3.4% of visits for patients residing in rural areas and 1.4% of those from urban areas. The odds of being treated by a resident were higher among persons living in health professional shortage-designated or rural areas, minorities, and persons with government insurance. CONCLUSION: Patients from vulnerable populations have greater odds of being seen by a resident physician for an ED visit. These populations may be placed at risk for reduced access to health care services if limitations on resident physician moonlighting impair the ability of rural hospitals to staff EDs.     

Nurse discharge planning in the emergency department: a Toowoomba, Australia, study

Aim. This study aimed to ascertain whether a model of risk screening carried out by an experienced community nurse was effective in decreasing re‐presentations and readmissions and the length of stay of older people presenting to an Australian emergency department. Objectives. The objectives of the study were to (i) identify all older people who presented to the emergency department of an Australian regional hospital; (ii) identify the proportion of re‐presentations and readmissions within this cohort of patients; and (iii) risk‐screen all older patients and provide referrals when necessary to community services. Design. The study involved the application of a risk screening tool to 2139 men and women over 70 years of age from October 2002 to June 2003. Of these, 1102 (51·5%) were admitted and 246 (11·5%) were re‐presentations with the same illness. Patients presenting from Monday to Friday from 08:00 to 16:00 hours were risk‐screened face to face in the emergency department. Outside of these hours, but within 72 hours of presentation, risk screening was carried out by telephone if the patient was discharged or within the ward if the patient had been admitted. Results. There was a 16% decrease in the re‐presentation rate of people over 70 years of age to the emergency department. Additionally during this time there was a 5·5% decrease in the readmission rate (this decrease did not reach significance). There was a decrease in the average length of stay in hospital from 6·17 days per patient in October 2002 to 5·37 days per patient in June 2003. An unexpected finding was the decrease in re‐presentations in people who represented to the emergency department three or more times per month (known as ‘frequent flyers’). Conclusions. Risk screening of older people in the emergency department by a specialist community nurse resulted in a decrease of re‐presentations to the emergency department. There was some evidence of a decreased length of stay. It is suggested that the decrease in re‐presentations was the result of increased referral and use of community services. It appears that the use of a specialist community nurse to undertake risk screening rather than the triage nurse may impact on service utilization. Relevance to clinical practice. It is apparent that older people presenting to the emergency department have complex care needs. Undertaking risk screening using an experienced community nurse to ascertain the correct level of community assistance required and ensuring speedy referral to appropriate community services has positive outcomes for both the hospital and the patient.     

The influence of coronavirus disease 2019 on emergency department visits in Nanjing,China: A multicentre cross-sectional study

IntroductionInfluenza has been linked to the crowding in emergency departments (ED) across the world. The impact of the Coronavirus Disease 2019 (COVID-19) pandemic on China EDs has been quite different from those during past influenza outbreaks. Our objective was to determine if COVID-19 changed ED visit disease severity during the pandemic.MethodsThis was a retrospective cross sectional study conducted in Nanjing, China. We captured ED visit data from 28 hospitals. We then compared visit numbers from October 2019 to February 2020 for a month-to-month analysis and every February from 2017 to 2020 for a year-to-year analysis. Inter-group chi-square test and time series trend tests were performed to compare visit numbers. The primary outcome was the proportion of severe disease visits in the EDs.ResultsThrough February 29 ^th 2020, there were 93 laboratory-confirmed COVID-19 patients in Nanjing, of which 40 cases (43.01%) were first seen in the ED. The total number of ED visits in Nanjing in February 2020, were dramatically decreased (n = 99,949) in compared to January 2020 (n = 313,125) and February 2019 (n = 262,503). Except for poisoning, the severe diseases in EDs all decreased in absolute number, but increased in proportion both in year-to-year and month-to-month analyses. This increase in proportional ED disease severity was greater in higher-level referral hospitals when compared year by year.ConclusionThe COVID-19 outbreak has been associated with decreases in ED visits in Nanjing, China, but increases in the proportion of severe ED visits.     

The increasing impact of asthma on a metropolitan emergency department

Statistics relating to asthma were collected at Ryde Hospital from 1983 and 1988. Particular attention was paid to the amount of time emergency department staff devoted to the assessment and treatment of patients with asthma. Asthma attendances increased by 52% over the five years with the proportion of patients admitted increasing from 24% to 32%. The peak times of presentation were the evenings; April, May and June were the busiest months. The time taken in the emergency department for assessment and treatment increased over the five years from 2.3 to 4,2 hours per day, an 83% increase. While the factors behind this rising incidence are debatable and require attention in their own right, it is clear that the work load from asthma is increasing for emergency departments. Important issues raised include emergency department staffing and outpatient asthma education.     

Effects of seasonality and daylight savings time on emergency department visits for mental health disorders

ObjectivesEmergency Department (ED) utilization accounts for a large portion of healthcare services in the US. Disturbance of circadian rhythms may affect mental and behavioral health (MBH) conditions, which could result in increased ED visits and subsequent hospitalizations, thus potentially inducing staffing shortages and increasing ED wait time. Predicting the burden of ED admissions helps to better plan care at the EDs and provides significant benefits. This study investigates if increased ED visits for MBH conditions are associated with seasonality and changes in daylight savings time.MethodsUsing ED encounter data from a large academic medical center, we have examined univariate and multivariate associations between ED visits for MBH conditions and the annual time periods during which MBH conditions are more elevated due to changes in the seasons. We hypothesize that ED visits for MBH conditions increase within the 2-week period following the daylight savings time changes.ResultsIncreased MBH ED visits were observed in certain seasons. This was especially true for non-bipolar depressive illness. We saw no significant changes in MBH visits as associated with changes in the daylight savings time.ConclusionsData do not provide conclusive evidence of a uniform seasonal increase in ED visits for MBH conditions. Variation in ED MBH visits may be due to secular trends, such as socioeconomic factors. Future research should explore contemporaneous associations between time-driven events and MBH ED visits. It will allow for greater understanding of challenges regarding psychiatric patients and opportunities for improvement.     

The impact of violence on emergency department staff

The impact of violence on the carers has yet to be clearly defined and explored. Research has shown that there is significant under-reporting of violence against emergency department personnel. There exist published reports of serious injury or death to staff due to violence occurring in the emergency department. Physical violence occurs in about 50% of violent incidents. The occurrence of threats, assault not resulting in injury, and the psychological impact of such violence need further examination. The part workplace violence has to play in occupational stress and ‘burnout’ are all issues yet to be comprehensively studied and reported. One study has shown a significant reduction in assault and injury in staff trained in aggression control techniques. Further evaluation of aggression control training and psychological debriefing are needed to determine the effect of such measures on the incidence of violence and its sequelae on care givers. Only when there is further research to determine the physical, emotional and financial impact on the carer can the cost of violent events be defined and give financial justification to employers for investing in measures aimed at reducing the impact of these events on the carer.     

Ferritin,fever, and frequent visits: Hyperferritinemic syndromes in the emergency department

Fever of unknown origin (FUO) is defined as persistent fevers without an identifiable cause despite extensive medical workup. Emergency physicians caring for patients reporting a persistent, nonspecific, febrile illness should carefully consider potentially serious non-infectious causes of FUO. We present a case of a 35-year-old man who presented to the emergency department (ED) three times over a 10-day period for persistent febrile illness and was ultimately diagnosed with Adult-Onset Still's Disease (AOSD) after a serum ferritin level was found to be over 42,000 μg/L. AOSD, along with macrophage activation syndrome, catastrophic antiphospholipid syndrome, and septic shock comprise the four hyperferritinemic syndromes. These are potentially life-threatening febrile illnesses that characteristically present with elevated ferritin levels. In this article, we highlight the value of a serum ferritin level in the workup of a patient with prolonged febrile illness and its utility in facilitating early diagnosis and prompt treatment of hyperferritinemic syndromes in the ED.     

Resident productivity as a function of emergency department volume,shift time of day,and cumulative time in the emergency department

Objectives

We sought to determine if resident productivity changed based on emergency department (ED) volume, shift time of day, or over time during a shift.

Methods

This is a retrospective review of patients evaluated in the ED by emergency medicine residents. Data were collected using the computerized tracker that provides time of physician assignment and daily volume. Regression analysis was used to determine relationship between productivity and volume as well as relationship between productivity and accumulated time in the ED. Analysis of variance was used to assess for productivity differences by shift time of day.

Results

One hundred sixty-one postgraduate year-1 (PGY-1), 264 PGY-2, and 193 PGY-3 shifts were included. PGY-1, PGY-2, and PGY-3 residents saw 0.85, 1.13, and 1.25 patients per hour, respectively. PGY-3 and PGY-2 productivity had a weak relationship to ED volume (R = 0.28, P = .03; and R = 0.36, P = .03), whereas PGY-1 productivity had a moderate relationship to ED volume (R = 0.44, P = .0001). There were no differences in productivity based on shift time of day. Accumulated time in the ED had a strongly negative relationship to productivity, with R values from −0.79 to −0.93 (P < .002 for all comparisons).

Conclusions

Resident productivity is not strongly linked to volume or time of day. If specific times have statistically higher volume, they should be staffed with larger numbers of residents. In addition, emergency medicine resident productivity declines reliably over shift time. Therefore, scheduling should be adjusted to create larger shift overlaps to aid in smoother patient flow.     

The impact of emergency department observation units on a health system

ImportanceProtocol driven ED observation units (EDOU) have been shown to improve outcomes for patients and payers, however their impact on an entire health system is unknown. Two thirds of US hospitals do not have such units.ObjectiveTo determine the impact of a protocol-driven EDOU on health system length of stay, cost, and resource utilization.MethodsA retrospective, observational, cross-sectional study of observation patients managed over 25 consecutive months in a four-hospital academic health system. Patients were identified using the “admit to observation” order and limited to adult, emergent / urgent, non-obstetric patients. Data was retrieved from a cost accounting database. The primary study exposure was the setting for observation care which was broken into three discrete groups: EDOUs (n = 3), hospital medicine observation units (HMSOU, n = 2), and a non-observation unit (NOU) bed located anywhere in the hospital. Outcomes included observation-to-inpatient admission rate, length of stay (LoS), total direct cost, and inpatient bed days saved. Unadjusted outcomes were compared, and outcomes were adjusted using multiple study variables. LoS and cost were compared using quantile regressions. Inpatient admit rate was compared using logistic regressions.ResultsThe sample consisted of 48,145 patients who were 57.4% female, 48% Black, 46% White, median age of 58, with some variation in most common diagnoses and payer groups. The median unadjusted outcomes favored EDOU over NOU settings for admission rate (13.1% vs 37.1%), LoS [17.9 vs 35.6 h), and cost ($1279 vs $2022). The adjusted outcomes favored EDOU over NOU settings for admission rates [12.3% (95% CI 9.7–15.3) vs 26.4% (CI 21.3–32.3)], LoS differences [11.1 h (CI 10.6–11.5 h)] and cost differences [$127.5 (CI $105.4 - $149.5)]. Adjusted differences were similar and favored EDOU over HMSOU settings. For the health system, the total adjusted annualized savings of the EDOUs was 10,399 bed days and $1,329,443 in total direct cost per year.ConclusionWithin an academic medical center, EDOUs were associated with improved resource utilization and reduced cost. This represents a significant opportunity for hospitals to improve efficiency and contain costs.     

“一条龙服务”带教法在急诊科的应用

急诊科是医院收治危急重症病人的重要窗口，面对的人群和病种复杂，又是医疗纠纷易发地，给临床带教工作带来了很大难度。护生实践机会明显少于病房．不利于实习目标的完成。针对这一问题，结合急诊科实际情况，改变以往“分点式”带教方法，采用“一条龙服务”教学方式进行带教，即从病人的接诊至转归整个过程，护生在带教老师的指导下完成对病人的各项护理工作，收到了良好的效果。现将具体方法介绍如下。     

"一条龙服务"带教法在急诊科的应用

急诊科是医院收治危急重症病人的重要窗口,面对的人群和病种复杂,又是医疗纠纷易发地,给临床带教工作带来了很大难度。护生实践机会明显少于病房,不利于实习目标的完成。针对这一问题,结合急诊科实际情况,改变以往“分点式”带教方法,采用“一条龙服务”教学方式进行带教,即从病人的接诊至转归整个过程,护生在带教老师的指导下完成对病人的各项护理工作,收到了良好的效果。现将具体方法介绍如下。1方法1.1参加人员由护理部支持,急诊科护士长主持,科室专职带教老师参加。1.2准备阶段护生进入急诊科时,护士长首先对他们进行入科宣教;其次给他…     

The impact of emergency department overcrowding on resident education

Background

Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.

Objectives

To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.

Materials and Methods

A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann–Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.

Results

During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7–10), compared to 8 (IQR 8–10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4–13.2), compared to 13.9 (95% CI 12.7–15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6–1.2), compared to 1.3 (95% CI 1–1.6) in group N (p = 0.047).

Conclusions

During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.     

The impact of an emergency care access point on pediatric attendances at the emergency department: An observational study

ObjectiveCrowding is a growing concern in general and pediatric Emergency Departments (EDs). The Emergency Care Access Point (ECAP) - a collaboration between general practitioners and the ED - has been established to reduce the number of self-referrals and non-urgent ED visits. The aim of this study was to determine the impact of an ECAP on pediatric attendances in the ED.MethodsRetrospective analysis of 3997 pediatric patients who visited the ED of a regional teaching hospital in the Netherlands, one year before and one year after the implementation of an ECAP. Patient characteristics, presented complaints and diagnoses, throughput times, and follow-up between the study groups were compared, both during office hours and after-hours.ResultsAfter ECAP implementation, a 16.3% reduction in pediatric ED visits was observed. ECAP implementation was associated with a decline in self-referrals by 97.2%. Presented complaints, ED diagnoses and acuity were similar pre- and post-ECAP. However, consultations and follow-up were required more frequently. The admission rate during nights increased (49.3% versus 64.0%). Overall admission rates were similar.ConclusionsThe implementation of an ECAP was associated with a reduction of pediatric ED use, including a considerable but expected decline in pediatric self-referrals. Patient acuity pre- and post-ECAP was similar. Our results suggest that this primary care intervention might help reduce the workload in a pediatric ED. Future studies are warranted to further investigate this hypothesis and to evaluate the impact of an ECAP in other healthcare settings. These future efforts need to include patient oriented outcomes.     

Epidemiological impact of universal varicella vaccination on consecutive emergency department visits for varicella and its economic impact among children in Kobe City,Japan

IntroductionPrevious studies reported a dramatic decline in the incidence of varicella and varicella-related deaths after implementing universal varicella vaccination (VarV). Although previous studies reported the effectiveness and economic impact of VarV, they were unknown in the emergency department (ED) setting.MethodsTo determine the effectiveness and economic impact of VarV in the ED, Kobe, Japan, we retrospectively reviewed the clinical database of consecutive patients younger than 16 years presenting to our primary ED from 2011 to 2019.ResultsOf the 265,191 children presenting to our ED, 3,092 patients were clinically diagnosed with varicella. The number of patients with varicella was approximately 500 annually, before introducing the universal two-dose VarV for children aged 1 to <3 years in October 2014, in the Japanese national immunization program, and decreased to approximately 200 in 2019. The number of patients with varicella younger than 1 year (ineligible for the vaccination) also decreased. Regarding the economic impact, the medical cost in our ED reduced after the introduction of VarV was JPY 4.1 million (US$ 40,049) annually. From the central data, approximately 95% of children were vaccinated after October 2014; however, a relatively large percentage of infected unvaccinated children (59.0%) presented to ED in this study. After the implementation of the universal VarV, infection was mainly observed in older children (i.e., the unvaccinated generation).ConclusionsOur data showed the effectiveness and economic impact of VarV in the ED setting. Additionally, our data suggested that the public vaccination program should include older unvaccinated children and other unvaccinated individuals.