ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease

Objective

The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

Methods

We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels.

Results

After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5).

Conclusions

Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.     

Prospective Multicenter Bronchiolitis Study: Predicting Intensive Care Unit Admissions

Objectives: The authors sought to identify predictors of intensive care unit (ICU) admission among children hospitalized with bronchiolitis for ≥24 hours. Methods: The authors conducted a prospective cohort study during two consecutive bronchiolitis seasons, 2004 through 2006, in 30 U.S. emergency departments (EDs). All included patients were aged <2 years and had a final diagnosis of bronchiolitis. Regular floor versus ICU admissions were compared. Results: Of 1,456 enrolled patients, 533 (37%) were admitted to the regular floor and 50 (3%) to the ICU. Comparing floor and ICU admissions, multivariate ED predictors of ICU admission were age <2 months (26% vs. 53%; odds ratio [OR] = 4.1; 95% confidence interval [CI] = 2.1 to 8.3), an ED visit the past week (25% vs. 40%; OR = 2.2; 95% CI = 1.1 to 4.4), moderate/severe retractions (31% vs. 48%; OR = 2.6; 95% CI = 1.3 to 5.2), and inadequate oral intake (31% vs. 53%; OR = 3.3; 95% CI = 1.6 to 7.1). Unlike previous studies, no association with male gender, socioeconomic factors, insurance status, breast‐feeding, or parental asthma was found with ICU admission. Conclusions: In this prospective multicenter ED‐based study of children admitted for bronchiolitis, four independent predictors of ICU admission were identified. The authors did not confirm many putative risk factors, but cannot rule out modest associations.     

Effects of a Triage Process Conversion on the Triage of High‐risk Presentations

Objectives: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time‐sensitive therapy. Methods: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time‐sensitive care. Results: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. Conclusions: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time‐sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.     

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Objectives
To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.
Methods
The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression.
Results
Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines.
Conclusions
Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies.     

Predictive Validity of a Computerized Emergency Triage Tool

Background Emergency department (ED) triage prioritizes patients on the basis of the urgency of need for care. eTRIAGE is a Web‐based triage decision support tool that is based on the Canadian Triage and Acuity Scale (CTAS), a five level triage system (CTAS 1 = resuscitation, CTAS 5 = nonurgent). Objectives To examine the validity of eTRIAGE on the basis of resource utilization and cost as measures of acuity. Methods Scores on the CTAS, specialist consultations, computed‐tomography use, ED length of stay, ED disposition, and estimated ED and hospital costs (if the patient was subsequently admitted to hospital) were collected for each patient over a six month period. These data were queried from a database that captures all regional ED visits. Correlations between CTAS score and each outcome were measured by using logistic regression models (categorical variables), univariate analysis of variance (continuous variables), and the Kruskal‐Wallis analysis of variance (costs). A multivariate regression model that used cost as the outcome was used to identify interaction between the variables presented. Results Over the six month study, 29,524 patients were triaged by using eTRIAGE. When compared with CTAS level 3, the odds ratios for consultation, CT scan, and admission were significantly higher in CTAS 1 and 2 and were significantly lower in CTAS 4 and 5 (p < 0.001). When compared with CTAS levels 2–5 combined, the odds ratio for death in CTAS 1 was 664.18 (p < 0.001). The length of stay also demonstrated significant correlation with CTAS score (p < 0.001). Costs to the ED and hospital also correlated significantly with increasing acuity (median costs for CTAS levels in Canadian dollars: CTAS 1 =$2,690, CTAS 2 =$433, CTAS 3 =$288, CTAS 4 =$164, CTAS 5 =$139, and p < 0.001). Significant interactions between the data collected were found in a multivariate regression model, although CTAS score remained highly associated with costs. Conclusions Acuity measured by eTRIAGE demonstrates excellent predictive validity for resource utilization and ED and hospital costs. Future research should focus on specific presenting complaints and targeted resources to more accurately assess eTRIAGE validity.     

Effect of Mandated Nurse–Patient Ratios on Patient Wait Time and Care Time in the Emergency Department

Objectives: The objective was to evaluate the effect of mandated nurse–patient ratios (NPRs) on emergency department (ED) patient flow. Methods: Two institutions implemented an electronic tracking system embedded within the electronic medical record (EMR) of two EDs (an academic urban, teaching medical center—Hospital A; and a suburban community hospital—Hospital B), with a combined census of 60,000/year, to monitor real‐time NPRs and patient acuity, such that compliance with state‐mandated ratios could be prospectively monitored. Data were queried for a 1‐year period after implementation and included patient wait times (WTs), ED care time (EDCT), patient acuity, ED census, and NPR status for each nurse, patient, and the ED overall. Median WT and EDCT with interquartile ranges (IQRs) were analyzed to determine the effect of NPR status of each patient, nurse, and the ED overall. To control for factors that could affect the “within the mandated ratio” and the “outside of the mandated ratio” status, including patient volume and acuity, log‐linear regression models were used controlling for specified factors for each hospital facility and combined. Results: There were a total of 30,404 (50.9%) patients who waited in the waiting room prior to being placed in an ED bed (53.8% at Hospital A and 46.4% at Hospital B). Patients who waited at Hospital A waited a median duration of 55 minutes (IQR = 15–128 minutes), compared with 32 minutes (IQR = 12–67 minutes) at Hospital B with a combined median WT of 44 minutes (IQR = 13–101 minutes). In the log‐linear regression analysis, WTs were 17% (95% confidence interval [CI] = 10% to 25%, p < 0.001) longer at Hospital A and 13% (95% CI = 3% to 24%, p = 0.008) longer at Hospital B (combined 16% [95% CI = 10% to 22%, p < 0.001] longer at both sites) when the ED overall was out‐of‐ratio compared to in‐ratio. There were a total of 45,660 patients discharged from both EDs during the study period, from which EDCT data were collected (26,894 in Hospital A and 18,766 in Hospital B). Median EDCT was 184 minutes (IQR = 97–311 minutes) at Hospital A, compared to 120 minutes (IQR = 63–208 minutes) at Hospital B, for a combined median EDCT of 153 minutes (IQR = 81–269 minutes). In the log‐linear regression analysis, the EDCT for patients whose nurse was out‐of‐ratio were 34% (95% CI = 30% to 38%, p < 0.001) longer at Hospital A and 42% (95% CI = 37% to 48%, p < 0.001) longer at Hospital B (combined 37% [95% CI = 34% to 41%, p < 0.001] longer at both sites) when compared to patients whose nurse was in‐ratio. Conclusions: In these two EDs, throughput measures of WT and EDCT were shorter when the ED nurse staffing were within state‐mandated levels, after controlling for ED census and patient acuity. ACADEMIC EMERGENCY MEDICINE 2010; 17:545–552 © 2010 by the Society for Academic Emergency Medicine     

Cancer diagnosis and outcomes in Michigan EDs vs other settings

Objective

This study determined the proportion of incident colorectal and lung cancers with a diagnosis associated with an emergency department (ED) visit. The characteristics of these patients and the correlation between diagnosis near an ED visit and stage at diagnosis were also examined.

Methods

A population-based sample of all Michigan cancer cases diagnosed in all EDs and other health care settings was used to extract a sample of patients >65 years old, diagnosed with colorectal and lung cancers between January 1, 1996, and June 30, 2000 (n = 20 311). Logistic regressions were used for the statistical analysis.

Results

Patients with a colorectal cancer diagnosis associated with an ED visit were more likely insured by Medicaid before diagnosis (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.17-1.60), had an inpatient admission before diagnosis (OR, 1.29; 95% CI, 1.06-1.56), had 3 or more comorbidities (OR, 4.11; 95% CI, 3.53-4.79), were more likely to be female (OR, 1.18; 95% CI, 1.07-1.31), and were more likely to be aged 85 years and older (OR, 1.89; 95% CI, 1.57-2.27). Patients who had at least one primary care physician (PCP) visit before diagnosis were less likely to have a diagnosis associated with an ED visit (OR, 0.68; 95% CI, 0.61-0.76). Patients diagnosed with lung cancer in association with an ED visit were also more likely to have an inpatient admission before diagnosis (OR, 1.21; 95% CI, 1.02-1.43), a higher comorbidity burden (OR, 12.44; 95% CI, 10.18-15.20), be female (OR, 1.13; 95% CI, 1.02-1.25), African-American (OR, 1.42; 95% CI, 1.21-1.66), and older (80 years and older) (ages 80-84 years: OR, 1.33; 95% CI, 1.13-1.57; age 85 years and older: OR, 1.52; 95% CI, 1.25-1.85). Patients with an ED visit near a colorectal cancer (OR, 1.28; 95% CI, 1.15-1.42) or lung cancer diagnosis (OR, 1.65; 95% CI, 1.44-1.88) were more likely to be diagnosed at a later stage compared with patients diagnosed in other settings.

Conclusions

An examination of patients' patterns of care leading to a cancer diagnosis in association with an ED visit lends insight to conditions precipitating a more immediate diagnosis and their associated outcomes.     

Post-exposure prophylaxis for human immunodeficiency virus after sexual assault in a Midwestern U.S. emergency department

BackgroundEmergency departments (EDs) play an essential role in the timely initiation of HIV post-exposure prophylaxis (PEP) for sexual assault victims.MethodsRetrospective analysis of sexual assault victims evaluated and offered HIV PEP in an urban academic ED between January 1, 2005 and January 1, 2018. Data on demographics, comorbidities, nature of sexual assault, initial ED care, subsequent healthcare utilization within 28 days of initial ED visit, and evidence of seroconversion within 6 months of the initial ED visit were obtained. Predictors of subsequent ED visit and follow-up in the infectious diseases clinic were evaluated using logistic regression analysis.ResultsFour hundred twenty-three ED visits met criteria for inclusion in this study. Median age at ED presentation was 25 years (IQR 21–34 years), with the majority of victims being female (95.5%), Black (63.4%), unemployed (66.3%) and uninsured (53.9%); psychiatric comorbidities (38.8%) and substance abuse (23.6%) were common. About 87% of the patients accepted HIV PEP (368 of 423 ED visits). Age (OR 0.97, 95% CI 0.94–0.99, p = 0.025) and sexual assault involving >1 assailant (OR 0.48, 95% CI 0.26–0.88, p = 0.018) were associated with lower likelihood of HIV PEP acceptance. Ten patients (2.7%) followed up with the infectious disease clinic within 28 days of starting HIV PEP; 70 patients (19%) returned to the ED for care during the same time period. Psychiatric comorbidity (OR 2.48, 95% CI 1.43–4.30, p = 0.001) and anal penetration (OR 2.02, 95% CI 1.10–3.70, p = 0.024) were associated with greater likelihood of repeat ED visit; female gender (OR 0.30, 95% CI 0.11–0.85, p = 0.023) was associated with lower likelihood of repeat visit. Completion of HIV PEP was documented for 14 (3.3%) individuals.ConclusionsWhile ED patient acceptance of HIV PEP after sexual assault was high, infectious disease clinic follow-up and documented completion of PEP remained low. Innovative care models bridging EDs to outpatient clinics and community support services are needed to optimize transitions of care for sexual assault victims, including those receiving HIV PEP.     

Racial Disparities in Emergency Department Length of Stay for Admitted Patients in the United States

Objectives: Recent studies have demonstrated the adverse effects of prolonged emergency department (ED) boarding times on outcomes. The authors sought to examine racial disparities across U.S. hospitals in ED length of stay (LOS) for admitted patients, which may serve as a proxy for boarding time in data sets where the actual time of admission is unavailable. Specifically, the study estimated both the within‐ and among‐hospital effects of black versus non–black race on LOS for admitted patients. Methods: The authors studied 14,516 intensive care unit (ICU) and non‐ICU admissions in 408 EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS; 2003–2005). The main outcomes were ED LOS (triage to transfer to inpatient bed) and proportion of patients with prolonged LOS (>6 hours). The effects of black versus non–black race on LOS were decomposed to distinguish racial disparities between patients at the same hospital (within‐hospital component) and between hospitals that serve higher proportions of black patients (among‐hospital component). Results: In the unadjusted analyses, ED LOS was significantly longer for black patients admitted to ICU beds (367 minutes vs. 290 minutes) and non‐ICU beds (397 minutes vs. 345 minutes). For admissions to ICU beds, the within‐hospital estimates suggested that blacks were at higher risk for ED LOS of >6 hours (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.01 to 2.01), while the among‐hospital differences were not significant (OR = 1.08 for each 10% increase in the proportion of black patients, 95% CI = 0.96 to 1.23). By contrast, for non‐ICU admissions, the within‐hospital racial disparities were not significant (OR = 1.12, 95% CI = 0.94 to 1.23), but the among‐hospital differences were significant (OR = 1.13, 95% CI = 1.04 to 1.22) per 10% point increase in the percentage of blacks admitted to a hospital. Conclusions: Black patients who are admitted to the hospital through the ED have longer ED LOS compared to non–blacks, indicating that racial disparities may exist across U.S. hospitals. The disparity for non‐ICU patients might be accounted for by among‐hospital differences, where hospitals with a higher proportion of blacks have longer waits. The disparity for ICU patients is better explained by within‐hospital differences, where blacks have longer wait times than non–blacks in the same hospital. However, there may be additional unmeasured clinical or socioeconomic factors that explain these results.     

Clinical and Economic Factors Associated with Ambulance Use to the Emergency Department

Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross‐sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air‐medical transport, walk‐in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0–10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight–8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ≥65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means.     

Opioid free treatment algorithm for ED headache management: Effect on revisit rate

BackgroundThe opioid epidemic is a crisis leading to over utilization of resources within emergency departments (EDs). We assessed how implementation of an opioid-free headache and migraine treatment algorithm in the ED impacted patient centered outcomes.MethodsThis was a retrospective review of patients presenting to EDs across a health network with a primary diagnosis of headache or migraine. Two analyses were completed comparing patients presenting before and after implementation of an opioid-free treatment algorithm and patients treated with or without opioids in the ED. The primary outcome was incidence of an ED revisit within thirty days. Secondary outcomes included ED length of stay, admission rate, and incidence of revisit during the entire study period.ResultsIn total, 2953 patient encounters were included. Incidence of revisit within thirty days was lower in the post- (84/1339, 6.3%) versus pre-algorithm group (133/1614, 8.2%; odds ratio [OR] 0.75, 95% confidence interval [CI] 0.56–0.99; p = 0.049), as was the incidence of revisit within the entire study period (9.2% vs. 12.1%; OR 0.74, CI 0.58–0.93; p = 0.014). In the secondary analysis, patients treated with opioids had a higher incidence of revisit within thirty days (51/335, 15.2%) compared to those not treated with opioids (166/2618, 6.3%). The opioid group also had a higher incidence of admission rates and median ED length of stay.ConclusionsOpioid use in the ED to treat patients with headaches or migraines may have several negative ramifications including increased risk of revisit, hospital admission, and increased ED length of stay.     

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.     

A Brief Risk-stratification Tool to Predict Repeat Emergency Department Visits and Hospitalizationsin Older Patients Discharged from the Emergency Department

OBJECTIVES: To evaluate the predictive ability of a simple six-item triage risk screening tool (TRST) to identify elder emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within 30 and 120 days following ED discharge. METHODS: Prospective cohort study of 650 community-dwelling elders (age 65 years or older) presenting to two urban academic EDs. Subjects were prospectively evaluated with a simple six-item ED nursing TRST. Participants were interviewed 30 and 120 days post-ED index visit and the utilization of EDs, hospitals, or NHs was recorded. Main outcome measurement was the ability of the TRST to predict the composite endpoint of subsequent ED use, hospital admission, or NH admission at 30 and 120 days. Individual outcomes of ED use, hospitalization, and NH admissions were also examined. RESULTS: Increasing cumulative TRST scores were associated with significant trends for ED use, hospital admission, and composite outcome at both 30 and 120 days (p < 0.0001 for all, except 30-day ED use, p = 0.002). A simple, unweighted five-item TRST ("lives alone" item removed after logistic regression modeling) with a cut-off score of 2 was the most parsimonious model for predicting composite outcome (AUC = 0.64) and hospitalization at 30 days (AUC = 0.72). Patients defined as high-risk by the TRST (score > or = 2) were significantly more likely to require subsequent ED use (RR = 1.7; 95% CI = 1.2 to 2.3), hospital admission (RR = 3.3; 95% CI = 2.2 to 5.1), or the composite outcome (RR = 1.9; 95% CI 1.7 to 2.9) at both 30 days and 120 days than the low-risk cohort. CONCLUSIONS: Older ED patients with two or more risk factors on a simple triage screening tool were found to be at significantly increased risk for subsequent ED use, hospitalization, and nursing home admission.     

Mortality-related factors after hospitalization for acute exacerbation of chronic obstructive pulmonary disease: the burden of clinical features

Background

There is limited information about factors associated with mortality of patients with chronic obstructive pulmonary disease (COPD) admitted to hospital because of an acute exacerbation.

Methods

A retrospective cohort study including all patients admitted to hospital through our emergency department (ED) was conducted. A total of 972 electronic discharge reports were reviewed. Patient baseline features, aspects concerning acute exacerbation, as well as demographic, cardiac ultrasound, and microbiological data were collected.

Results

In-hospital mortality rate was 6.4%. Of 315 patients with mild exacerbation according to Anthonisen criteria, only 1 died. In the univariate analysis, moderate to severe acute exacerbation of COPD, age older than 75 years, severe COPD, abnormal blood gas values, onset of complications during hospital stay, radiologic consolidation, a positive result in a microbiological respiratory sample, home oxygenotherapy, admission to the intensive care unit, left ventricular ejection fraction, and department of admission were statistically significant (P < .05). The multivariate analysis showed that moderate to severe COPD acute exacerbation (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.6-17.7), age older than 75 years (OR 4.9; 95% CI, 2.3-10.8), severe COPD (OR 4.6; 95% CI, 2.1-10), abnormal blood gas values (OR 4.7; 95% CI, 1.1-19.8), and complication during hospital stay (OR 2.8; 95% CI 1.4-5.4) were independently related to mortality.

Conclusion

We found that clinical aspect appears the most relevant of all potential determinants of in-hospital mortality for patients admitted for acute exacerbation of COPD. Thus, the clinical assessment and therapeutic decision taken in this first moment at the ED are the key that predict the prognosis of this patients. These data suggest that the risk of mortality after the admission to hospital of patients with COPD because of an acute exacerbation can be successfully predicted by making a clinical assessment at the ED.     

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

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

Risk Factors for Mortality of Bacteremic Patients in the Emergency Department

Objectives: Patients with bacteremia have a high mortality and generally require urgent treatment. The authors conducted a study to describe bacteremic patients in emergency departments (EDs) and to identify risk factors for mortality. Methods: Bacteremic patients in EDs were identified retrospectively at a university hospital from January 2007 to December 2007. Demographic characteristics, underlying illness, clinical conditions, microbiology, and the source of bacteremia were collected and analyzed for their association with 28-day mortality. Results: During the study period, 621 cases (50.2% male) were included, with a mean (±SD) age of 62.8 (±17.4) years. The most common underlying disease was diabetes mellitus (39.3%). Escherichia coli (39.2%) was the most frequently isolated pathogen. The most common source of bacteremia was urinary tract infection (41.2%), followed by primary bacteremia (13.2%). The overall 28-day mortality rate was 12.6%. Multivariate stepwise logistic regression analysis showed age > 60 years (odds ratio [OR] = 2.52, 95% confidence interval [CI] = 1.29 to 4.92, p = 0.007), malignancy (OR = 2.66, 95% CI = 1.44 to 4.91, p = 0.002), liver cirrhosis (OR = 2.08, 95% CI = 1.02 to 4.26, p = 0.044), alcohol use (OR = 5.73, 95% CI = 2.10 to 15.63, p = 0.001), polymicrobial bacteremia (OR = 3.99, 95% CI = 1.75 to 9.10, p = 0.001), anemia (OR = 2.33, 95% CI = 1.34 to 4.03, p = 0.003), and sepsis (OR = 1.94, 95% CI = 1.16 to 3.37, p = 0.019) were independent risk factors for 28-day mortality. Conclusions: Bacteremic patients in the ED have a high mortality, particularly with these risk factors. It is important for physicians to recognize the factors that potentially contribute to mortality of bacteremic patients in the ED.     

Effect of advanced age and vital signs on admission from an ED observation unit

Objectives

The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission.

Methods

We conducted a prospective, observational cohort study of ED patients placed in an ED-basedobservation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at acutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol.

Results

Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14?000/mm³ or greater (OR, 11.35; 95% CI, 3.42-37.72).

Conclusions

Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.     

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective

ObjectivesEmergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.MethodsWe conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005–2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.ResultsFrom 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20–109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056–0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31–0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12–0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091–0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31–0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23–0.93).ConclusionsACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.     

Characteristics and Admission Patterns of Patients Presenting with Syncope to U.S. Emergency Departments, 1992–2000

OBJECTIVES: To describe the characteristics and admission patterns of patients with syncope presenting to U.S. emergency departments (EDs). METHODS: The ED portion of the National Hospital Ambulatory Medical Care Survey, 1992-2000, was analyzed. Nationally representative weighted estimates for incidence and admission rates were estimated and stratified by demographic variables. Presence of cardiovascular diagnoses on ED discharge was noted. RESULTS: Of the 865 million ED visits during the nine-year study period, an estimated 6.7 million (0.77%; 95% confidence interval [95% CI] = 0.69% to 0.85%) were related to syncope. Higher incidences of ED visits for syncope were found in elder, female, and non-Hispanic patients compared with their reference groups. The overall admission rate was 32% (95% CI = 28% to 36%). Older, male, and white patients were admitted more frequently than their counterparts. Of patients older than 80 years of age, 58% (95% CI = 49% to 67%) were admitted. Associated cardiovascular International Classification of Diseases, Ninth Revision (ICD-9), codes for ischemic, structural, and arrhythmic heart disease were noted in 10% (95% CI = 8% to 13%) of patients, and 66% (95% CI = 56% to 76%) of these patients were admitted. CONCLUSIONS: Syncope is a frequent reason for ED visits and admissions. Elders and patients with associated cardiovascular diagnoses are frequently discharged, and admission practices appear to deviate from consensus panel guidelines.