Estimated Use of a Pediatric Emergency Department Observation Unit

Study objective: To estimate the use of a pediatric ED observation unit, including the number of anticipated admissions per 10,000 pediatric ED visits per year and the distribution of those admissions by age group, by month, and by time of day. Methods: Hospital and ED computer records on all ED patients younger than 18 years who were seen during a 2-year period were abstracted for diagnostic, demographic, and time-flow data. We retrospectively reviewed the charts of patients admitted to the hospital and discharged within 24 hours to determine whether discharge in less than 24 hours could have been anticipated and whether the patient could have been cared for in a pediatric ED observation unit. To refine the estimate, we also reviewed the ICD-9 discharge diagnoses of patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED. Results: Of 29,667 pediatric ED visits in a 2-year period, 2,940 (10%) resulted in admission. Of 626 patients discharged in less than 24 hours, only 410 met the anticipation and pediatric ED observation unit level of care criteria. Patients younger than 4 years represented 43% of potential observation unit patients; those aged 16 and 17 years represented 15%. Potential use of an observation unit varied throughout the year. Admission occurred between 3 and 11:59 pm in 60% of the patients. Only 20% of the 176 patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED were estimated to be candidates for a pediatric ED observation unit. Conclusion: On the basis of these data, approximately 150 patients per 10,000 each year who visit the University of Virginia pediatric ED would be likely to use an observation unit. Staffing and facility use would be seasonally uneven and would be required during the busiest part of the day. Furthermore, even in a pediatric ED large enough to admit 365 pediatric ED observation unit patients each year, random daily variation in demand means that a single bed would be inadequate 25% of the time and empty 37% of the time. Optimal use of even a single-bed pediatric ED observation unit would not occur until pediatric ED census exceeded 30,000 to 40,000 visits annually. Bond GR, Wiegand CB: Estimated use of a pediatric emergency department observation unit. Ann Emerg Med June 1997; 29:739-742.]     

Emergency Department Use by Nursing Home Residents

Study objective: To describe a community's experience with the use of emergency department services by nursing home residents. Methods: We performed a retrospective chart review of a population-based cohort of nursing home residents in an urban county in central Georgia with 10 nursing homes (1,300 beds) and 4 hospital-based EDs. All ED visits by nursing home residents during 1995 were analyzed. Demographic data, timing of the visit, chief complaint, tests and treatments, disposition, and financial charges were recorded. Further, we calculated the number of ED visits per 100 nursing home patient-years. Results: A total of 873 nursing home residents made 1,488 ED visits. Mean age was 76.0 years; 66.4% were female, and 55.2% were white. Of the transfers, 42.9% occurred during regular working hours. The most common chief complaints were respiratory symptoms (14.4%), altered mental status (10.1%), gastrointestinal symptoms (9.9%), and falls (8.2%); 101 patients (6.8%) were transferred for malfunction of a gastrostomy tube. The most common laboratory tests were complete blood cell count (69.5%), chest radiograph (52.0%), electrocardiogram (45.0%), urinalysis (42.7%), and determination of electrolytes (42.7%). A total of 42.4% of the ED visits led to admission to the hospital. From the 10 nursing homes, there were 110 ED visits per 100 patient-years. A 3.5-fold difference in ED use among these nursing homes could not be explained by age, gender, or other factors. The average charge per ED visit was $1,239. Conclusion: Elders living in nursing homes are frequently transferred to EDs for costly medical evaluations, and more than 40% of such visits lead to admission to the hospital. [Ackermann RJ, Kemle KA, Vogel RL, Griffin RC Jr: Emergency department use by nursing home residents. Ann Emerg Med June 1998;31:749-757.]     

Distribution of Emergency Department Costs

Study objective: To report the distribution of emergency department costs by category of expense and level of patient urgency. Methods: Cost-to-charge and relative-value methods were used to determine direct and indirect physician, facility, supply, pharmacy, laboratory, radiology, and miscellaneous costs for 24,010 ED patients. Explicit criteria were used to classify patient visits as nonurgent, semiurgent, or urgent. Results: For all patients, the average costs were physician, $64; facility, $84; laboratory, $21; radiology, $24, and total, $209. Laboratory and radiology costs accounted for 5% of the total costs for nonurgent visits and 23% of the total costs for urgent visits. Conclusion: The distribution of ED costs varies significantly according to the urgency of the medical condition. For nonurgent patient visits, most costs are represented by the hospital facility and ED physicians' costs. Ancillary services represent a much greater proportion of costs for patients with urgent conditions. Although reduced test-ordering might result in some savings among patients with urgent conditions, overall improved cost efficiency can be achieved only through reductions in the fixed costs of operation of hospital EDs. [Williams RM: Distribution of emergency department costs. Ann Emerg Med December 1996;28:671-676.]     

Outcomes of follow-up care after an emergency department visit among pediatric asthmatics in the military health system

Background and Objectives: Asthma exacerbations frequently trigger emergency department (ED) visits. Guidelines recommend timely follow-up after an ED visit for asthma, however, other studies have questioned the quality of follow-up care and their effect on subsequent ED utilization. We evaluated follow-up care on asthma outcomes in pediatric asthmatics enrolled in the Military Health System (MHS) after an ED visit for asthma. Methods: This retrospective study utilized MHS data to evaluate 2–17-year-old persistent asthmatics with an ED visit for asthma between 2010–2012. Demographics, medication dispensing, and subsequent asthma related ED and hospital utilization were compared between those with or without a 28-day follow-up appointment. Results: 10,460 of 88,837 persistent asthmatics met inclusion criteria for an asthma ED visit. 4,964 (47.5%) had ≥ 1 follow-up visit. In the 29–365 days after their ED visit, 21.1% of the follow-up cohort required an ED re-visit compared to 24.0% of the patients without follow-up. Follow-up care was associated with a reduction in ED re-visits (adjusted hazard ratio 0.86; 95% confidence interval 0.79, 0.93). Controller medications were dispensed to 76.0% of the follow-up cohort within 90 days of their ED visit compared to 49.7% in the group without follow-up. Conclusions: Despite universal access to healthcare, less than half of pediatric MHS asthma patients had follow-up within 28 days of an ED visit. Those with follow-up were more likely to fill a controller medication within 90 days post-ED visit, and less likely to have an asthma ED re-visit in the subsequent year.     

Septic Arthritis in Emergency Departments in the US: A National Study of Health Care Utilization and Time Trends

Objective

To assess the health care utilization and emergency department (ED) charges for septic arthritis.

Methods

We performed a retrospective cohort study of ED visits with septic arthritis as the primary diagnosis using the US Nationwide Emergency Department Sample data from 2009–2012. We examined ED charges, hospitalization, and associated time trends. Multivariable models were adjusted for demographics (age, sex, insurance status, residence, and household income), comorbidity, and hospital characteristics to assess factors associated with ED charges and hospitalization.

Results

Septic arthritis was responsible for 16,382 ED visits in 2012 in the US, which constituted 0.01% of all ED visits. The number of ED visits was stable from 2009–2012. Total ED charges were $34.6, $30.6, and $36.9 million in 2009, 2010, and 2012, respectively, and mean ED charges were $2,149, $1,866, and $2,257, respectively. The majority of the patients with an ED visit for septic arthritis were hospitalized: 82%, 83%, and 84% in 2009, 2010, and 2012, respectively. Metropolitan residence and western US location were associated with higher ED charges, and the highest income quartile, renal failure, or osteoarthritis were associated with lower ED charges. Female sex, metropolitan residence, metropolitan teaching hospital status, and medical comorbidity (diabetes mellitus, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, coronary heart disease, gout, osteoarthritis, renal failure, and heart failure) were associated with a higher risk of hospitalization.

Conclusion

Comorbidities were associated with a higher risk of hospitalization after an ED visit for septic arthritis, but not higher ED charges. No time trends in ED visit incidence, ED charges, or hospitalization rate for septic arthritis from 2009–2012 were noted.

     

Characteristics of asthmatic patients with and without repeat emergency department visits at an inner city hospital

Objective: The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma. Methods: During an ED visit for asthma in an inner city hospital (‘index visit’), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit. Results: One hundred and ninety-two patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multivariate model, more past ED visits (OR 1.7, 95% CI 1.4, 2.1; p?p?=?0.02) remained associated with having a repeat ED visit. Most patients had the first repeat ED visit within 30 days and 18 returned within only 7 days. Among all patients with a repeat visit, those who were not hospitalized for the index visit were more likely to have a repeat visit within 7 days (37%) compared to those who were hospitalized (17%) (p?=?0.05 in multivariate analysis). Conclusions: Repeat ED visits were prevalent among inner city asthma patients and most occurred shortly after the index visit. The strongest predictors of repeat visits were male gender and more ED visits in the 12 months before the index visit.     

The Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) improves physician assessment of asthma morbidity in pediatric emergency department patients

Objectives: To determine whether the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED), a 12-item questionnaire, can help ED attendings accurately assess a patient’s asthma control and morbidity. Methods: This was a randomized-controlled trial performed at an urban pediatric ED of children aged 1–17 years presenting with an asthma exacerbation. Parents answered PACCI-ED questions about their children’s asthma. Attendings were randomized to view responses to the PACCI-ED (intervention group) or to be blinded to the completed PACCI-ED (control group). The two groups were compared on their empirical clinical assessment of: (1) chronic asthma control categories, (2) asthma trajectory (stable, worsening or improving), (3) patient adherence to controller medications, and (4) burden of disease for the patient’s family. The validated PACCI algorithm was used as the criterion standard for these four outcomes. Accuracy of clinical assessment was compared between intervention and control groups using chi-squared tests and an intention-to-treat approach. Results: Seventeen ED attendings were enrolled in the study and 77 children visits were included in the analysis. There were no significant differences between the intervention and the control groups for child’s gender, age, race, and asthma characteristics. Intervention group attendings were more accurate than control group attendings in assessing the category of chronic asthma control (43% versus 19%; p?=?0.03), disease trajectory (72% versus 45%; p?=?0.02), and the disease burden for families (74% versus 35%; p?=?0.001) over the past 12 months. There was a trend towards more accuracy of intervention versus control attendings for estimating patient adherence to controller medications (72% versus 48%; p?=?0.06). Conclusions: The PACCI-ED improves the assessment of asthma control, trajectory, and burden by ED attendings, and may help assessment of asthma medication adherence and prior asthma exacerbations. The PACCI-ED can be used to improve provider assessment of asthma morbidity during pediatric ED visits for asthma exacerbations, and to identify children who may benefit from interventions to reduce asthma morbidity.     

Corticosteroid Timing and Length of Stay for Children with Asthma in the Emergency Department

Objective. The aim of this study was to evaluate the relationship between time of corticosteroid administration to children with asthma exacerbations in the Emergency Department (ED) and length of stay (LOS). We hypothesized administration within 60 minutes would be associated with a 10- minute or greater decrease in mean LOS. Methods. A retrospective chart review of 882 patients was conducted. Children between the ages of 2 and 18 years presented to the Connecticut Children’s Medical Center’s (CCMC’s) ED with an acute asthma exacerbation were included. Children were excluded if they did not receive oral corticosteroids in the ED, had significant co-morbidities, were currently taking corticosteroids, or had taken them within the past 7 days. Children receiving corticosteroids within 60 minutes of triage were compared with children receiving corticosteroids for 61 minutes or later. The primary outcome was mean LOS. Results. Children treated with corticosteroids within 60 and 61 minutes or later had similar age, gender, insurance, and disposition. Children treated with corticosteroids within 60 minutes had a 25-minute decrease in LOS compared with children treated for 61-minute or later (95% CI: 15–35), p < .0001. Conclusions. Administering corticosteroids to pediatric asthma patients in the ED within an hour of triage is associated with a 25-minute mean decrease in LOS. With large numbers of asthma visits, a 25-minute decrease in LOS for each child could have a significant impact on patient throughput in the ED.     

Patient Characteristics Associated with Nocturnal Emergency Department Visits for Asthma

Study objectives: To identify patient characteristics associated with nocturnal emergency department (ED) visits for asthma. Methods: Asthmatic patients 18 to 55 years of age who visited Ontario EDs between April 1, 2003 and March 31, 2004, were identified through an administrative clinical database. Patients' time of ED presentation was analyzed for circadian pattern using histogram and polynomial regression. Risk of nocturnal visit (presentation at the ED between midnight and 8 AM) was modeled through generalized estimating equations with patient age, gender, and asthma severity level as covariates. The effect of nocturnal visit on return rate to the ED within 14 days after the initial visit was determined through Cox regression. Results: During study period there were 31,490 ED visits for asthma made by 23,253 patients. Their time of ED visits displayed a distinct circadian pattern with peak between 7 and 8 PM, and trough at 5 AM. Approximately 22% of visits (6,868) occurred at night. Men had higher odds of presenting at night than women (OR 1.61; 1.49–1.73). Patients with mild asthma were significantly less likely to visit the ED at night than patients with moderate or severe asthma. Nocturnal presentation was not associated with higher odds of subsequent returns to the ED (HR 1.00; 0.89–1.14). Conclusion: Higher odds of nocturnal visits in men suggest the existence of gender-differences in health-seeking behavior in asthmatics. Although nocturnal visits are associated with more severe asthma, they do not lead to higher return rates.     

Effect of inhaled corticosteroid use on weight (BMI) in pediatric patients with moderate-severe asthma

Objectives: Assess the relationship between inhaled corticosteroid use (ICS) and weight (BMI) in pediatric patients with moderate-severe asthma. Assess if the number of emergency department (ED) visits correlates with overall BMI trajectory. Assess the trend of prescribing biologic therapy in pediatric patients with moderate-severe asthma and determine its relationship with weight (BMI). Methods: A retrospective chart review was performed on 93 pediatric patients with moderate-severe asthma to determine the relationship between ICS use and weight (BMI), biologic therapy and BMI, and number of ED visits and BMI trajectory. A mixed effects model was employed with the correlation between repeated measures accounted for through the random effects. Results: There is a statistically significant increase of 0.369 kg/m² in BMI trajectory per year in subjects on high-dose steroids compared to an increase of 0.195 kg/m² in the low dose group (p < 0.05). The BMI of subjects initiated on biologic therapy (omalizumab or mepolizumab) had a statistically significant decrease in BMI trajectory of 0.818 kg/m² per year (p < 0.05). Subjects with ≥5 ED visits due to asthma exacerbations had a significantly higher BMI trajectory (p < 0.05). Conclusions: The potency of ICS use in pediatric patients with moderate-severe asthma affects BMI trajectory; the higher the dose, the greater the projected BMI increase per year. Initiation of biologic therapy decreased BMI trajectory over time. Lastly, those with frequent ED visits had a higher BMI trend. Future prospective studies are warranted that further evaluate the potential metabolic impacts of ICS and assess the effects of biologic therapy on BMI.     

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

Objective: Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods: A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. Results: A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45?min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1?h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received?>?1 bronchodilator dose within 1?h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). Conclusion: A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.     

Frequency of health service use in the year prior to asthma death

Objective: High frequency health service use (HSU) is associated with poorly controlled asthma, and is a recognized risk factor for near-fatal or fatal asthma. The objective of this study was to describe the frequency of HSU in the year prior to asthma death. Methods: Individuals aged 0–99 years who died from asthma from April 1996 to December 2011 in Ontario, Canada were identified as cases. Cases were matched to 4–5 live asthma controls by age, sex, rural/urban residence, socioeconomic status, duration of asthma and a co-diagnosis of COPD. HSU records in the year prior to death [hospitalization, emergency department (ED) and outpatient visits] were assembled. The association of prior HSU and asthma death was measured by conditional logistic regression models. Results: From 1996 to 2011, 1503 individuals died from asthma. While the majority of cases did not have increased HSU as defined in the study, compared to matched live asthma controls, the cases were 8-fold more likely to have been hospitalized two or more times (OR?=?7.60; 95% CI: 4.90, 11.77), 13-fold more likely to have had three or more ED visits (OR?=?13.28; 95% CI: 7.55, 23.34) and 4-fold more likely to have had five or more physician visits for asthma (OR?=?4.41; 95% CI: 3.58, 5.42). Conclusions: Frequency of HSU in the year prior was substantially higher in those died from asthma. Specifically, more than one asthma hospital admission, three ED visits or five physician visits increased the asthma mortality risk substantially and exponentially.     

Gout‐Related Health Care Utilization in US Emergency Departments, 2006 Through 2008

Objective

To characterize gout‐related emergency department (ED) utilization using a nationally representative sample and to examine factors associated with the frequency and charges of gout‐related ED visits.

Methods

Using the National Emergency Department Sample data from 2006–2008, the weighted national frequency of gout visits was calculated along with the median ED charge and total national ED‐related charges. Associations of several patient‐ and facility‐level factors were examined with the occurrence of gout visits using multivariable logistic regression and with ED‐related charges using multivariable linear regression.

Results

Gout was the primary indication for 168,410 ED visits in 2006, 171,743 visits in 2007, and 174,823 visits in 2008, accounting for ～0.2% of all visits annually and generating ED charges of more than $128 million in 2006, $144 million in 2007, and $166 million in 2008. Age, male sex, household income <$39,000, private insurance, and hospital locations in nonmetropolitan areas and the southern US were associated with an increased propensity for ED utilization in gout. Higher ED‐related charges for gout were associated with female sex, age, a higher number of coded diagnoses, and a metropolitan residence.

Conclusion

Gout accounts for a substantial proportion of ED visits, leading to significant health care charges. Effective strategies to reduce gout burden in EDs could potentially benefit by targeting groups characterized by factors demonstrated to be related to a higher ED utilization in gout as identified by our study.     

Nebulizer and Spacer Device Maintenance in Children with Asthma

Objective. To evaluate inhalation device cleaning practices of children with asthma and its effect on their asthma morbidity. Methods. A survey of patients aged 4 to 18 years admitted to an urban pediatric emergency department (ED) with an acute asthma exacerbation. Questions included demographics, asthma history, preference of delivery devices, and frequency of device cleaning. Patients were followed until their disposition from the ED, or until the end of their hospitalization, if admitted. Results. 220 subjects completed the survey. Mean age was 9.2 (± 3.9) years-old. One hundred and four (47.3%) patients used both nebulizers and spacer devices, while 18 (8.1%) used spacers only and 98 (44.5%) used nebulizers alone. Seventy-seven (38.1%; 95%CI: 31.7%–45.0%) patients cleaned their nebulizers and 57 (46.7%; 95%CI: 38.1%–55.4%) cleaned their spacer devices after each use as recommended by the Centers for Disease Control. There were no detectable differences in visit admission rate, total number of previous admissions, number of asthma exacerbations per year, and number of ED visits in one year between users who cleaned their devices after every, or every other use, compared to those who cleaned their devices less frequently. Conclusion. Although the majority of patients did not follow accepted guidelines for inhalation device cleaning, further studies are necessary to correlate cleaning practices to patients' clinical outcome.     

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma

Objective: Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. Methods: Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2–18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. Results: None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ² = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ² = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children. Conclusions: The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.     

The relationship between Direct to Consumer Advertising (DTCA) and asthma-related emergency department use among Medicaid-enrolled children

Objective: Asthma is a leading cause of emergency department (ED) visits. There has been much debate on the impact of direct to consumer advertising (DTCA) on healthcare. This study seeks to examine the association between DTCA expenditure and asthma-related ED use. Study design: In this study, we combined Medicaid administrative data and a national advertising data on asthma medications. The sample size consisted of 180?584 Medicaid-enrolled children between the ages of 5 and 18 years who had an asthma diagnosis. Twenty percent of the Medicaid-enrolled children in the sample had asthma-related ED visits. Results: We found that DTCA expenditure is associated with a decrease in asthma-related ED visits (OR?=?0.75; CI: 0.64–0.89). However, at higher levels of DTCA expenditure, the likelihood of asthma-related ED visits increases (OR?=?1.25; CI: 1.05–1.49), indicating a decreased relationship between DTCA and asthma-related ED visits. Conclusions: Our findings suggest that DTCA may be associated with improved health outcomes for Medicaid-enrolled children with asthma.