Syndromic surveillance of vaccine-associated adverse events in U.S. emergency departments

The Centers for Disease Control and Prevention explored use of emergency department (ED) visit data, during 2018–2020, from the National Syndromic Surveillance Program to monitor vaccine-associated adverse events (VAE) among all age groups. A combination of chief complaint terms and administrative diagnosis codes were used to detect VAE-related ED visits. Postvaccination fever was among the top 10 most frequently noted diagnoses. VAE annual trends demonstrated seasonality; visits trended upward starting in September of each year, coinciding with the administration of seasonal influenza vaccines. The 2020 VAE-related visit trend declined below the 2018 and 2019 baselines during March 22–September 5, 2020, before returning to the seasonal pattern. VAE-related visits declined in children aged 3–18 years in 2020 compared with 2018–2019, especially in the back-to-school months. These findings demonstrate that syndromic surveillance can complement traditional VAE reporting systems without an additional demand on data collection resources.     

Vaccination practices in U.S. emergency departments, 1992-2000

To determine how frequently emergency department (ED) patients are vaccinated against influenza and pneumococcus, we analyzed all adult ED vaccinations in the combined databases of the annual National Hospital Ambulatory Medical Care Surveys, 1992-2000. During this period, EDs gave 27,738,000 vaccinations (95%CI: 25,878,000-29,598,000). Of these, 93% (87-100%) were against tetanus. The count of pneumococcal or influenza vaccinations was too small to permit estimation of a national total. Large-scale vaccination of ED patients appears feasible, given the tetanus experience, but ED patients are rarely vaccinated against influenza or pneumococcus. Reasons for this disconnect between burden of disease and preventive practices are discussed.     

Race/ethnicity-related and payer-related disparities in the timeliness of emergency care in U.S. emergency departments

Our study objectives were to examine race/ethnicity-related and insurance-related differences in the timeliness of emergency care for a nationally representative sample of adults and to explore the role of uncertainty and location of care in explaining overall differences. We estimated a logistic regression model with hospital fixed effects to derive estimates of within-hospital group differences in the likelihood of waiting for more than 60 minutes to see a physician for several presenting conditions. We further estimated a model without hospital fixed effects to derive overall group differences. We observed race/ethnicity-related and payer-related differences in the timeliness of a medical screening exam for abdominal pain and chest pain visits but not for extremity laceration visits. Overall (within- and between-hospitals) differences in waiting time were due to patients receiving different care from the same hospital and from patients receiving care from different hospitals.     

Medicaid/State Children's Health Insurance Program patients and infectious diseases treated in emergency departments: U.S., 2003

OBJECTIVE: Emergency departments (EDs) are a critical source of medical care in the U.S. Information is sparse concerning infectious disease visits among Medicaid entitlement enrollees nationwide. The objective of this study was to describe infectious diseases in terms of Medicaid/State Children's Health Insurance Program (SCHIP) as an expected source of payment. METHODS: Data for 2003 from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for infectious disease visits. NHAMCS is a national probability sample survey of visits to hospital EDs and outpatient departments of nonfederal, short-stay, and general hospitals in the U.S. Data are collected annually and are weighted to generate national estimates. RESULTS: Nationally in 2003, an estimated 21.6 million visits were made to hospital EDs for infectious diseases (rate = 76 visits/1,000 people). Medicaid/SCHIP was the expected source of payment for an estimated 6.7 million infectious disease-related visits (rate = 200 visits/1,000 people covered by Medicaid). Children aged < 15 years made 39% of visits nationwide (nationwide rate = 139 visits/1,000 people). Of Medicaid visits, 63% were made by children < 15 years of age (Medicaid enrollees rate = 255 visits/1,000 people). The rate of visits for Medicaid enrollees was comparable for females and males (198 visits vs. 201/1,000 people). The rate of visits for black Medicaid enrollees was 33% higher than for white Medicaid enrollees (255 vs. 192 visits/1,000 people). Upper respiratory tract infection (URTI) is the most frequent infectious condition recorded at ED visits. An estimated 47% of ED visits with an expected pay source of Medicaid relate to URTIs (93 visits/1,000 people), compared with 38% of ED visits in general (29 visits/1,000 people). CONCLUSION: Medicaid enrollee-specific ED visit rates for infectious diseases were higher by age group, gender, race, and region, compared with national rates. Because approximately half of visits relate to URTIs for a Medicaid payment group, URTIs should form the basis for development of appropriate control strategies.     

Management of alcohol abusing patients in accident and emergency departments.

A pilot study was undertaken in the Accident & Emergency (A & E) departments of two central London teaching hospitals to determine if patients who were abusing alcohol and had not received any prior medical treatment or counselling for their drinking problem were amenable to offers of help. During the 24-month study period 104 patients were identified as having a previously untreated alcohol problem, and of these 46% attended an appointment to discuss their drinking habits. The group identified was much smaller than would be expected from the number attending the A & E departments during the study period and the reasons for this are discussed. However, the important observation from the study is that almost half the patients identified as having an alcohol problem returned to the department the following day to seek advice. This suggests that A & E departments are an appropriate place to offer patients initial help about their drinking habits.     

Full-time employees of U.S. local health departments, 1992-1993.

This article describes a study to assess the most recent data on full-time U.S. local health department (LHD) staff positions. The authors used data from the National Association of County and City Health Officials' 1992-1993 national survey of LHDs. The study concludes that nurses, environmental specialists, sanitarians, and administrators constitute the core of the public health workforce in smaller and mid-sized LHDs. Numerous vacancies in these core occupations signal a weakness in the front lines of public health and vulnerability in its ability to respond to urgent health threats. To address these problems, a renewed commitment to recruiting, retraining, and retaining the local public health worker is urgently needed.     

Explaining the efficiency of local health departments in the U.S.: an exploratory analysis

No study to date has analyzed the efficiency at which local health departments (LHDs) produce public health services. As a result, this study employs data envelopment analysis (DEA) to explore the relative technical efficiency of LHDs operating in the United States using 2005 data. The DEA indicates that the typical LHD operates with about 28% inefficiency although inefficiency runs as high as 69% for some LHDs. Multiple regression analysis reveals that more centralized and urban LHDs are less efficient at producing local public health services. The findings also suggest that efficiency is higher for LHDs that produce a greater variety of services internally and rely more on internal funding. However, because this is the first study of LHD efficiency and some shortcomings exist with the available data, we are reluctant to draw strong policy conclusions from the analysis.     

Neurocysticercosis in children: clinical findings and response to albendazole therapy in a randomized, double-blind, placebo-controlled trial in newly diagnosed cases

The clinical findings of neurocysticercosis, diagnosed primarily on the basis of computed tomography (CT), and response to albendazole therapy in a randomized, double-blind, placebo-controlled trial were studied in 72 newly diagnosed children aged 1.5-12 years admitted to hospital in New Delhi, India, during March to July 2000. The lesions by initial CT were mostly single with perilesional oedema, and were located in the parietal lobes. The most common clinical finding was partial seizure (79.2%). The outcome of the albendazole trial was assessed through changes in CT lesions and status of seizure after 6 months of follow-up; about 55% of the lesions had disappeared and about 80% of the children were seizure-free. The frequency of healing of CT lesions in the albendazole-treated group and placebo group was 54.2% and 55.2%, respectively, and the frequency of a seizure-free state in the albendazole-treated group and placebo group was 87.5% and 77.5%, respectively; the differences were not statistically significant. Changes in lesions by CT and the recurrence of seizures after 6 months of follow-up were not related to the number of lesions by initial CT and albendazole was not beneficial in neurocysticercosis in children with ring-enhancing lesions in CT.     

Alcohol consumption of patients attending two accident and emergency departments in north-west England.

The impact of alcohol use on the workload of two accident & emergency departments in north-west England was assessed by blood alcohol concentration (BAC) measurement, inspection of clinical records and interview of all patients aged 16 and over attending throughout a two-week period. The frequency of intoxication was similar to the previous reported rate in Scotland: 13.2% of all patients had a positive BAC. Inebriated injured patients arrived at all times of the day--varying in frequency from 2.5% of midday attenders to 78% of those presenting after midnight. The incidence of alcohol-related industrial accidents was low, but 60% of all assaulted patients were inebriated, many having sustained head injuries. Of patients attending within 2 hours of an accident at home, 19% also had a positive BAC, but 92% of those with ankle sprains were sober. Patients in lower social classes reported higher rates of alcohol consumption. The popularity of beer in comparison to wines and spirits was inversely related to age and unrelated to social class. Alcohol abuse is commonly associated with injuries sustained at home and with assaults occurring in public places. Prevention campaigns directed at the reduction of these types of incidents should be as concerned with the inebriation of the patient as with the architectural, environmental and legal framework within which the 'accident' occurs.     

Nonemergency medicine-trained physician coverage in rural emergency departments.

CONTEXT: Rural areas have fewer physicians compared to urban areas, and rural emergency departments often rely on community or contracted providers for staffing. The emergency department workforce is composed of a variety of physician specialties and clinicians. PURPOSE: To determine the distribution of emergency department clinicians and the proportion of care they provide across the rural-urban continuum. METHODS: Cross-sectional analysis of secondary data. The distribution of clinicians who provide emergency department care by county was determined using the 2003 Area Resource File. The percentage of emergency department care provided by clinician type was determined using 2003 Medicare claims data. Logistic regression analyses assessed the odds of being seen by different clinicians with a patient's rurality when presenting to the emergency department. FINDINGS: Board-certified emergency physicians provide 75% of all emergency department care, but only 48% for Medicare beneficiaries of the most rural of counties. The bulk of the remainder of emergency department care is largely provided by family physicians and general internists, with the percentage increasing with rurality. The likelihood of being seen by an emergency physician in the emergency department decreases 5-fold as rurality increases, while being seen by a family physician increases 7-fold. CONCLUSION: Nonemergency physicians provide a significant portion of emergency department care, particularly in rural areas. Medical specialties must cooperate to ensure the availability of high-quality emergency department care to all Americans regardless of physician specialty.     

Characteristics of patients returning to emergency departments in Naples,Italy

Background  

Crowding in hospital Emergency Departments (EDs) is a problem in several countries. We evaluated the number and characteristics of patients who make repeated visits to the EDs in Naples, Italy.     

Redesigning the diagnostic pathway for chest pain patients in emergency departments

Patients presenting with chest pain at an emergency department in the United Kingdom receive troponin tests to assess the likelihood of an acute myocardial infarction (AMI). Until recently, serial testing with two blood samples separated by at least six hours was necessary in order to analyse the change in troponin levels over time. New high-sensitivity troponin tests, however, allow the inter-test time to be shortened from six to three hours. Recent evidence also suggests that the new generation of troponin tests can be used to rule out AMI on the basis of a single test if patients at low risk of AMI present with very low cardiac troponin levels more than three hours after onset of worst pain. This paper presents a discrete event simulation model to assess the likely impact on the number of hospital admissions if emergency departments adopt strategies for serial and single testing based on the use of high-sensitivity troponin. Data sets from acute trusts in the South West of England are used to quantify the resulting benefits.     

Rapid HIV testing in emergency departments--three U.S. sites, January 2005-March 2006

Approximately one fourth of the estimated 1 million persons living with human immunodeficiency virus (HIV) in the United States are unaware that they are infected with HIV and at risk for transmitting the virus to others. In April 2003, CDC announced a new initiative, Advancing HIV Prevention: New Strategies for a Changing Epidemic, aimed at reducing barriers to early diagnosis of HIV infection and increasing access of persons infected with HIV to medical care and prevention services. A priority strategy of this initiative is to make HIV testing a routine part of medical care. In April 2004, HIV testing was implemented in one emergency department (ED) in Los Angeles, California, and one in New York, New York, to determine the feasibility and acceptability of offering rapid HIV testing as a routine part of health care in EDs. In January 2005, an ED in Oakland, California, also began offering HIV testing routinely. This report summarizes the preliminary results of integrating rapid HIV testing into the health-care services routinely offered in the three EDs during January 2005-March 2006. Those results indicated that, of 9,365 persons tested, 97 (1.0%) ED patients had newly diagnosed HIV infection, and 85 (88%) of those 97 were linked after diagnosis to HIV care and treatment. EDs should consider integrating rapid HIV testing into their routine medical services to identify patients who are unaware that they are infected with HIV and link them to health and prevention services.