Epidemiologic Analysis of an Urban, Public Emergency Department''s Frequent Users

OBJECTIVES: To determine how the demographic, clinical, and utilization characteristics of emergency department (ED) frequent users differ from those of other ED patients. METHODS: A cross-sectional and retrospective cohort study was performed using a database of all 348,858 visits to the San Francisco General Hospital ED during a five-year period (July 1, 1993, to June 30, 1998). A "frequent user" visited the ED five or more times in a 12-month period. RESULTS: Frequent users constituted 3.9% of ED patients but accounted for 20.5% of ED visits. The relative risk (RR) of frequent use was high among patients who were homeless (RR = 4.5), African American (RR = 1.8), and Medi-Cal sponsored (RR = 2.1). Frequent users were more likely to be seen for alcohol withdrawal (RR = 4.4), alcohol dependence (RR = 3.4), and alcohol intoxication (RR = 2.4). Frequent users were also more likely to visit for exacerbations of chronic conditions, including sickle cell anemia (RR = 8.0), renal failure (RR = 3.6), and chronic obstructive pulmonary disease (RR = 3.3). They were less likely to visit for all forms of trauma (RR = 0.43). Survival analysis showed that only 38% of frequent users for one year remained frequent users the next year. However, 56% of frequent users for two consecutive years remained frequent users in the third year. CONCLUSIONS: Frequent use of the ED reflects the urban social problems of homelessness, poverty, alcohol abuse, and chronic illness. Frequent use of the ED shows a high rate of decline from one year to the next. This rate of decline slows after the first year and suggests the existence of a smaller group of chronic frequent users.     

Identifying Frequent Users of Emergency Department Resources

Background

There is growing focus on frequent users of acute care resources. If these patients can be identified, interventions can be established to offer more consistent management plans to decrease inappropriate utilization.

Objective

To compare a hospital-specific approach with a region-wide approach to identify frequent Emergency Department (ED) users.

Methods

A retrospective multi-center cohort study of hospital ED visits from all 18 nonmilitary, acute care hospitals serving the San Diego region (population 3.2 million) between 2008 and 2010 using data submitted to the California Office of Statewide Health Planning and Development. Frequent users and super users were defined as having 6 to 20 and 21 or more visits, respectively, during any consecutive 12 months in the study period. Comparisons between community-wide and hospital-specific methods were made.

Results

There were 925,719 individual patients seen in an ED, resulting in 2,016,537 total visits. There were 28,569 patients identified as frequent users and 1661 identified as super users, using a community-wide approach. Individual hospitals could identify 15.6% to 62.4% of all frequent users, and from 0.3% to 15.2% of all the super users who visited their facility. Overall, the hospital-specific approach identified 20,314 frequent users and 571 super users, failing to identify 28.9% of frequent users and 65.6% of super users visiting San Diego County EDs that would otherwise have been identified using a community-wide approach.

Conclusions

A community-wide identification method resulted in greater numbers of individuals being identified as frequent and super ED users than when utilizing individual hospital data.     

Analysis of Costs, Length of Stay, and Utilization of Emergency Department Services by Frequent Users: Implications for Health Policy

In efforts to decrease emergency department (ED) crowding and health care costs, frequent users of ED services have been targeted for interventions to decrease their utilization. Previous studies have had different definitions for "frequent users" and have considered all frequent users as a homogeneous group. To the authors' knowledge, no study has examined visit characteristics and resource utilization of different levels of frequent use. OBJECTIVES: 1) to determine the rates of ED utilization by five user groups defined by number of annual visits, 2) to examine variations in visit characteristics by frequency of ED use, and 3) to compare levels of resource utilization among frequent user groups. METHODS: This was a retrospective, cross-sectional study of clinical and financial records for all ED visits to an urban, academic hospital in 2001. Multinomial logistic and linear regression models were used for analyses. Estimates were corrected for multiple comparisons (with Bonferroni corrections), where applicable, and adjusted for clustering within individuals (with Huber-White estimators). Outcome measures were triage acuity, diagnosis-related group (DRG) severity, disposition status, primary complaint, medical diagnosis, hospital inpatient length of stay, payment method, costs, and demographics. RESULTS: Patients with three to 20 visits were more likely to be admitted to the hospital than patients visiting once or twice. Patients visiting more than 20 times were less likely to require hospital admission and more likely to present with "nonurgent" conditions, have lower severity scores, and elope or leave the ED without medical attention than patients visiting the ED once. The group had fewer inpatient days and lower average costs than patients visiting once. Patients with six to 20 visits had traditional Medicaid coverage more often than those with one or two visits. Virtually no patients visiting more than 20 times had Medicare or Medicaid managed care, a health maintenance organization, or a preferred provider organization. CONCLUSIONS: Frequent ED users are a heterogeneous group. Many patients previously thought to overutilize the ED for socioeconomic or insignificant medical problems are as sick as less-frequent ED users. There is a small subgroup with more than 20 visits who are less ill or injured but also incurred lower-than-average costs per visit.     

Imaging of Frequent Emergency Department Users with Alcohol Use Disorders

Background

Patients with altered level of consciousness secondary to alcohol use disorders (AUDs) often undergo imaging in the emergency department (ED), although the frequency and yield of this practice over time are unknown.

Study Objectives

We describe the use of imaging, the associated ionizing radiation exposure, cumulative costs, and identified acute and chronic injuries and abnormalities among frequent users of the ED with AUDs.

Methods

This is a retrospective case series of individuals identified through an administrative database having 10 or more annual ED visits in 2 consecutive years who were prospectively followed for a third year. International Classification of Diseases, 9^th Revision, Clinical Modification and Current Procedural Terminology codes were used to select individuals with alcohol-related diagnoses, track imaging procedures, and calculate cost. Diagnoses, imaging results, and radiation exposure per computed tomography (CT) study were abstracted from the medical record.

Results

Fifty-one individuals met inclusion criteria and had a total of 1648 imaging studies over the 3-year period. Subjects had a median of 5 (interquartile range [IQR] 2–10) CT scans, 20 (IQR 10–33) radiographs, 28.3 mSv (IQR 8.97–61.71) ionizing radiation, 0.2% (IQR 0.07–0.4) attributable risk of cancer, and $2979 (IQR 1560–5440) in charges using a national rate. The incidence of acute fracture or intracranial head injury was 55%, and 39% of the cohort had a history of moderate or severe traumatic brain injury.

Conclusion

The remarkable use of imaging and occurrence of injury among these highly vulnerable and frequently encountered individuals compels further study to refine clinical practices through the development of evidence-based, effective interventions.     

Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured,Frequent ED Users: A Randomized Controlled Trial

BackgroundSome Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings.ObjectivesTo determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs.MethodsWe conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4–18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization.ResultsOf 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (−$10,201, p = 0.10); Medicaid costs were unchanged (−$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02).ConclusionAn ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.     

High-Frequency Users of Emergency Department Care

Background

The heterogeneous group of patients who frequently use the Emergency Department (ED) have been of interest in public health care reform debate, but little is known about the subgroup of the highest frequency users.

Study Objectives

We sought to describe the demographic and utilization characteristics of patients who visit the ED 20 or more times per year.

Methods

We retrospectively studied patients who visited a large, urban ED over a 1-year period, identifying all patients using the department 20 or more times. Age, gender, insurance, psychosocial factors, chief complaint, and visit disposition were described for all visits. Inferential tests assessed associations between demographic variables, insurance status, and admission rates.

Results

Of the 59,172 unique patients to visit the ED between December 1, 2009 and November 30, 2010, 31 patients were identified as high-frequency ED users, contributing 1.1% of all visits. Patients were more likely to be 30–59 years of age (52%), stably insured (81%), and have at least one significant psychosocial cofactor (65%). Their admission rate was 15%, as compared to 21% for all other patients.

Conclusions

High-frequency users are patients with significant psychiatric and social comorbidities. Given their small proportion of visits, lower admission rates, and favorable insurance status, the impact of high-frequency users of the ED may be out of proportion to common perceptions.     

Frequent Users of the Emergency Department: Can We Intervene?

Objective: To determine whether the use of individualized patient care plans and multidisciplinary case management would decrease ED utilization by frequent ED users.
Methods: The authors performed a prospective, randomized clinical trial of the impact of a care plan on ED use by adults with frequent ED visits. Patients with >10 ED visits to a university hospital in 1993 were identified. Patients were matched for age, sex, and number of visits and then randomized into 2 groups. The control group received standard emergency care. The treatment group was managed by a multidisciplinary team and treated in the ED according to individualized care plans. ED use was tracked at the university hospital and at the other 5 community hospitals in the city.
Results: Of the 70 enrolled patients, 25 of 37 control patients and 27 of 33 treatment patients made visits to the university hospital during the 1-year study period. Only those patients with follow-up visits were included in the data analysis. Patients remaining in the control group made 247 total visits (range 1–65) to the university hospital and 179 total visits (range 0–38) to the community hospitals during the study period. Patients in the treatment group made 320 total visits (range 1–72) to the university hospital and 254 total visits (range 0–135) to the community hospitals during the study period. There was no significant difference in the median number of visits made to either the university hospital or the community hospitals by the patients in the control group and those in the treatment group.
Conclusions: The use of individualized care plans and case management did not significantly decrease ED utilization by frequent ED users. However, the impact of individualized care plans and case management on other quality-of-care measures (e.g., patient satisfaction, ED length of stay, hospitalizations, primary care visits, and health care costs) remains to be determined.     

Cost-Effective: Emergency Department Care Coordination with A Regional Hospital Information System

Background

Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs.

Study Objective

We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients’ individualized care plans with cooperating EDs.

Methods

ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3–11 ED visits in the 365 days preceding enrollment) or extreme (≥ 12 ED visits) users. Regression to the mean was tested using an adjusted measure of change.

Results

Both frequent and extreme users experienced significant decreases in ED visits (5 and 15, respectively; 95% confidence intervals [CI] 2–5 and 13–17, respectively) and direct-treatment costs ($1285; 95% CI $492–$2364 and $6091; 95% CI $4298–$8998, respectively), leading to significant hospital cost savings and increased net income ($431; 95% CI $112–$878 and $1925; 95% CI $1093–$3159, respectively). The results further indicate that fewer resources were utilized per visit. Regression to the mean did not seem to be an issue.

Conclusions

When examined as a whole, research on the program suggests that expanding it would be an efficient allocation of hospital, and possibly societal, resources.     

Predictors of Emergency Department Observation Unit Outcomes

Background: Acute decompensated heart failure (adHF) is the cause of approximately 1 million annual hospital admissions. In some of these, the use of a short‐stay emergency department observation unit (EDOU) decreases 90‐day ED revisits and 90‐day rehospitalizations and, if subsequent hospitalization is required, results in shorter stays. Objectives: To determine whether laboratory and clinical parameters, available at ED arrival, predict successful EDOU discharge. Methods: This was a 19‐month retrospective analysis of adHF EDOU admissions. Details of medical history, clinical course, patient management, laboratory data, and disposition destination were gathered through review of electronic medical records. Recorded laboratory data included measurements of sodium, creatinine, blood urea nitrogen (BUN), hemoglobin, b‐type natriuretic peptide, and initial ED systolic blood pressure. Data were analyzed for ability to predict the requirement of hospital admission after EDOU management. Results: There were 385 patients were enrolled. The mean (± standard deviation) age was 69.7 (± 13.6) years, and 50.1% were female. On ED admission chest radiograph, 69.0% had evidence of pulmonary edema. Elevations in creatinine and BUN levels had statistically significant associations with admission; however, on multivariable analysis, only a BUN value >30 mg/dL significantly predicted EDOU management failure, and subsequent inpatient admission. Conclusions: These results demonstrate that a BUN level >30 mg/dL is associated with an increased likelihood of admission in patients with adHF. This provides the emergency physician with a practical prognostic tool for disposition planning in congestive heart failure patients.     

Effectiveness of Case Management Strategies in Reducing Emergency Department Visits in Frequent User Patient Populations: A Systematic Review

Background

Case management (CM) is a commonly cited intervention aimed at reducing Emergency Department (ED) utilization by “frequent users,” a group of patients that utilize the ED at disproportionately high rates. Studies have investigated the impact of CM on a variety of outcomes in this patient population.

Objectives

We sought to examine the evidence of the effectiveness of the CM model in the frequent ED user patient population. We reviewed the available literature focusing on the impact of CM interventions on ED utilization, cost, disposition, and psychosocial variables in frequent ED users.

Discussion

Although there was heterogeneity across the 12 studies investigating the impact of CM interventions on frequent users of the ED, the majority of available evidence shows a benefit to CM interventions. Reductions in ED visitation and ED costs are supported with the strongest evidence.

Conclusion

CM interventions can improve both clinical and social outcomes among frequent ED users.     

Predictors of Repeat Emergency Department Visits by Elders

Objective: To determine which characteristics of older patients who use a hospital ED are associated with repeat visits during the 90 days following the index visit.
Methods: The study was conducted in the ED of a 400-bed university-affiliated acute care community hospital in Montreal. Patients aged ≥75 years who visited the ED between 08:00 and and 16:00 on a convenience sample of days over an 8-week period (July and August 1994) were assessed using a questionnaire, physical and cognitive status instruments, and a functional problem checklist. The hospital's administrative database was used to identify repeat visits during the 90 days following the ED visit. The representativeness of the sample was assessed by analyses of ED visits made by 4,466 persons aged ≥65 years during a 12-month period (September 1993 to August 1994) using the hospital's administrative database.
Results: 256 patients aged ≥75 years visited the ED during the study period and 167 were assessed. Of these, 54 (32%) were admitted to the hospital. Among the 113 patients released from the ED, 27 (24%) made repeat visits during the next 90 days. In univariate analyses, repeat visits were significantly associated with the number of functional problems, cognitive impairment, and previous ED visits. In multiple logistic regression, male gender, living alone, and number of functional problems were independent predictors of repeat visits. In the administrative data analyses, nighttime arrival to the ED for the index visit was significantly associated with repeat visits.
Conclusions: Self-reported risk factors can help to identify a group of elders likely to make repeated ED visits; the development of a screening instrument incorporating questions on these problems and implementation of appropriate interventions might improve these patients' quality of life and reduce the demand for further ED care in this age group.     

Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic precipitated fear of contagion and influenced many people to avoid the emergency department (ED). It is unknown if this avoidance effected overall health or disease mortality.ObjectiveWe aimed to quantify the decreased ED volume in the United States, determine whether it occurred simultaneously across the country, find which types of patients decreased, and measure resultant changes in patient outcomes.MethodsWe retrospectively accessed a multihospital, multistate electronic health records database managed by HCA Healthcare to obtain a case series of all patients presenting to an ED during the early COVID-19 pandemic (March 1–May 31, 2020) and the same dates in 2019 for comparison. We determined ED volume using weekly totals and grouped them by state. We also recorded final diagnoses codes and mortality data to describe patient types and outcomes.ResultsThe weekly ED volume from 160 facilities dropped 44% from 141,408 patients (week 1, March 1–7, 2020) to a nadir of 79,618 patients (week 7, April 12–18, 2020), before rising back to 105,667 (week 13, May 24–30, 2020). Compared with 2019, this overall decline was statistically significant (p < 0.001). The decline was universal across disease categories except for infectious disease and respiratory illnesses, which increased. All-cause mortality increased during the pandemic, especially for those with infectious disease, circulatory, and respiratory illnesses.ConclusionsThe COVID-19 pandemic and an apparent fear of contagion caused a decrease in ED presentations across our hospital system. The decline in ED volume was associated with increased ED mortality, perhaps from delayed ED presentations.     

The Effect of Emergency Department Crowding on Clinically Oriented Outcomes

Background:  An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.
Objectives:  The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).
Methods:  We reviewed the English-language literature for the years 1989–2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included ED crowding,ED overcrowding,mortality,time to treatment,patient satisfaction,quality of care, and others.
Results:  A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints.
Conclusions:  A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.     

Predictors of Emergency Department Patient Satisfaction: Stability over 17 Months

OBJECTIVES: The contradictory findings reported in the emergency department (ED) patient satisfaction literature may be due to methodologic differences between studies, as well as actual differences in predictors. The authors examined the stability of predictors of ED patient satisfaction across multiple assessments over 17 months. METHODS: All patients who presented for emergency care to the authors' hospital during four designated time periods spanning 17 months were eligible. The participants were contacted by telephone and the following were assessed: demographics, visit characteristics, perceived waiting times, subjective quality of care indicators, and overall satisfaction. The authors computed logistic regressions to predict overall satisfaction for each of the four periods. They compared the results across the assessments, both visually and using an aggregated logistic regression, to determine the consistency of the final equations. Interpretations based on traditional p-value cut-offs and odds ratios (ORs) were compared. RESULTS: When using a p-value cut-off strategy of p < 0.05, notable discrepancies in the predictors of overall satisfaction were common. Six indicators, including age, perceived wait before bed placement, perceived wait before physician evaluation, physician care, discharge instructions, and waiting time satisfaction, were statistically associated with satisfaction for only one of the four assessments. In contrast, examining the size of the ORs associated with each predictor showed far fewer discrepancies. Only physician care appeared to have large differences in the strength of its relation to overall satisfaction. This trend was confirmed by the aggregated logistic regression analysis. CONCLUSIONS: Using p-value cut-offs as the sole criterion for interpreting which variables are most important in determining ED patient satisfaction is ill-advised, and may lead to spurious conclusions of discrepant findings. Nevertheless, some determinants of ED satisfaction likely differ meaningfully based on the cohort that is being examined. Overgeneralizing conclusions derived from a single ED patient satisfaction study should be avoided, especially those studies that are cross-sectional and use a single site.     

Characteristics of Frequent Users of Emergency Medical Services in Singapore

Objectives: This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. Methods: All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n?=?243), with admission the primary outcome. Results: The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p?=?0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p?=?0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p?<?0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p?<?0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p?<?0.001). Many were picked up from public areas (45.5% vs. 19.6%, p?<?0.001), and had lower acuity triage scores at both EMS (p?<?0.001) and ED (p?=?0.001). They had lower admission rates (40.5% vs. 78.7%, p?<?0.001) and shorter length of stay (4.3 vs. 5.9 days, p?<?0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. Conclusion: Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission     

Emergency Department Patient Volume and Troponin Laboratory Turnaround Time

Objectives: Increases in emergency department (ED) visits may place a substantial burden on both the ED and hospital‐based laboratories. Studies have identified laboratory turnaround time (TAT) as a barrier to patient process times and lengths of stay. Prolonged laboratory study results may also result in delayed recognition of critically ill patients and initiation of appropriate therapies. The objective of this study was to determine how ED patient volume itself is associated with laboratory TAT. Methods: This was a retrospective cohort review of patients at five academic, tertiary care EDs in the United States. Data were collected on all adult patients seen in each ED with troponin laboratory testing during the months of January, April, July, and October 2007. Primary predictor variables were two ED patient volume measures at the time the troponin test was ordered: 1) number of all patients in the ED/number of beds (occupancy) and 2) number of admitted patients waiting for beds/beds (boarder occupancy). The outcome variable was troponin turnaround time (TTAT). Adjusted covariates included patient characteristics, triage severity, season (month of the laboratory test), and site. Multivariable adjusted quantile regression was carried out to assess the association of ED volume measures with TTAT. Results: At total of 9,492 troponin tests were reviewed. Median TTAT for this cohort was 107 minutes (interquartile range [IQR] = 73–148 minutes). Median occupancy for this cohort was 1.05 patients (IQR = 0.78–1.38 patients) and median boarder occupancy was 0.21 (IQR = 0.11–0.32). Adjusted quantile regression demonstrated a significant association between increased ED patient volume and longer times to TTAT. For every 100% increase in census, or number of boarders over the number of ED beds, respectively, there was a 12 (95% confidence interval [CI] = 9 to 14) or 33 (95% CI = 24 to 42)‐minute increase in TTAT. Conclusions: Increased ED patient volume is associated with longer hospital laboratory processing times. Prolonged laboratory TAT may delay recognition of conditions in the acutely ill, potentially affecting clinician decision‐making and the initiation of timely treatment. Use of laboratory TAT as a patient throughput measure and the study of factors associated with its prolonging should be further investigated. ACADEMIC EMERGENCY MEDICINE 2010; 17:501–507 © 2010 by the Society for Academic Emergency Medicine     

Emergency Department Management of Shoulder Dystocia

Background

Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome.

Objective

To review multiple techniques for managing a shoulder dystocia in the ED.

Discussion

We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort.

Conclusions

Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.     

General Characteristics and Activity of Emergency Department Short-Stay Units in Spanish Hospitals

Background

Emergency Department (ED) overcrowding mainly due to the lack of access to inpatient beds negatively affects safety and quality of care. Implementation of ED short-stay units (EDSSUs) may help to mitigate this situation.

Lyme Disease: Emergency Department Considerations

Background

Lyme disease (LD) is the most common vector-borne illness in North America. Reported cases of LD have increased from approximately 10,000 cases annually in 1991 to >25,000 cases in 2014. Greater recognition, enhanced surveillance, and public education have contributed to the increased prevalence, as have geographic expansion and the number of infected ticks. Cases are reported primarily in the Northeastern United States, Wisconsin, and Minnesota, with children having the highest incidence of LD among all age groups. The increased incidence and prevalence of LD in the United States makes it increasingly more common for patients to present to the emergency department (ED) for tick bites and LD-related chief complaints, such as the characteristic erythema migrans skin manifestation.