Emergency Department Return Visits Within a Large Geographic Area

Background

Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.

Incidence and Characteristics of Fall-related Emergency Department Visits

Abstract. Objective: Unintentional falls are the leading cause of injury and the second most common cause of unintentional injury deaths in the United States, and place a great burden on EDs. In this study, the objective was to describe the incidence and characteristics of ED visits associated with unintentional falls in the United States.
Methods: The authors performed a secondary analysis on data from the National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey for 1992–1994. An ED visit was defined as fall-related if an ICD-9-CM cause of injury code was reported as E880.0–886.9 or E888.
Results: There were an estimated 7,946,000 fall-related ED visits per year, corresponding to an annual rate of 3.1 per 100 persons (95% CI = 2.8 to 3.4). Children under 5 years of age comprised the largest proportion of visits (14%). Among those visits coded with respect to place of occurrence, the rate of visits associated with falls occurring at home (1.7/100; 95% CI = 1.6 to 1.9) was significantly higher than that associated with falls occurring in all other locations combined (1.1/100; 95% CI = 1.0 to 1.2). The mean injury severity score increased significantly with the age of the patient. Fall-related ED visits resulted in an estimated 860,000 hospitalizations, 62% of which involved individuals aged 65 years and older. An estimated $2.45 billion per year was paid for fall-related ED visits. Government sources paid all or part of 41% of visits.
Conclusions: This study reports nationally representative data describing the incidence and characteristics of fall-related ED visits. These data expand what is known about the epidemiology of falls and help to define the burden that fall injuries place on EDs in the United States. The results of this study could serve as a benchmark to evaluate the effectiveness of future fall prevention efforts.     

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.     

Does Functional Decline Prompt Emergency Department Visits and Admission in Older Patients?

Background: Older patients may visit the emergency department (ED) when their illness affects their function. Objectives: To quantify the function of older ED patients, to assess whether functional decline (FD) had occurred, and to determine whether function contributes to the ED visit and hospital admission. Methods: The authors performed an institutional review board–approved, prospective, cross‐sectional study in a community teaching hospital ED. Eligible patients were older than 74 years of age, with an illness at least 48 hours old. Patients from a nursing facility and those without a proxy who were unable or unwilling to complete the questions were excluded. The Older Americans Resources and Services Questionnaire, which tests seven instrumental activities of daily living (IADL) and seven physical ADLs (PADL), was used. Data are presented as means or proportions with 95% confidence intervals (95% CI), and comparisons as 95% CI for the difference between proportions. Results: The authors enrolled 90 patients (mean age, 81.6 yr [SD ± 4.9], 40% male). Dependence in at least one IADL was reported by 68% (95% CI = 57% to 77%), and in at least one PADL by 61% (95% CI = 50% to 71%). Functional decline was reported by 74% (95% CI = 64% to 83%). Two thirds of those with IADL decline and three quarters of those with PADL decline said that this contributed to their ED visit. Seventy‐seven percent with, and 63% without, IADL decline were admitted (14% difference, 95% CI =?6.1% to 33%). Seventy‐nine percent with and 61% without PADL decline were admitted (18% difference, 95% CI =?1.4% to 38%). Conclusions: Functional decline is common in older ED patients and contributes to ED visits in older patients; its role in admission is unclear.     

Uncompleted Emergency Department Care: Patients Who Leave against Medical Advice

Objectives: To compare the patient characteristics, clinical conditions, and short-term recidivism rates of emergency department (ED) patients who leave against medical advice (AMA) with those who leave without being seen (LWBS) or complete their ED care.
Methods: All eligible patients who visited the ED between July 1, 2004, and June 30, 2005 ( N = 31,252) were classified into one of four groups: 1) AMA ( n = 857), 2) LWBS ( n = 2,767), 3) admitted ( n = 8,894), or 4) discharged ( n = 18,734). The patient characteristics, primary diagnosis, and 30-day rates of emergent hospitalizations, nonemergent hospitalizations, and ED discharge visits were compared between patients who left AMA and each of the other study groups. A Cox proportional hazards model was used to examine the influence of study group status on the risk of emergent hospitalization, adjusted for patient characteristics.
Results: Patients who left AMA were significantly more likely to be uninsured or covered by Medicaid compared with those admitted or discharged (p < 0.001). The AMA visit rates were highest for nausea and vomiting (9.7%), abdominal pain (7.9%), and nonspecific chest pain (7.6%). During the 30-day follow-up period, patients who left AMA had significantly higher emergent hospitalization and ED discharge visit rates compared with each of the other study groups (p < 0.001). Insurance status, male gender, and higher acuity level were also associated with a significantly higher emergent hospitalization rate.
Conclusions: Patients who leave AMA may do so prematurely, as evidenced by higher emergent hospitalization rates compared with those who LWBS or complete their care.     

Determinants of Emergency Department Visits by Older Adults: A Systematic Review

OBJECTIVES: To conduct a systematic review of the literature on the determinants of hospital emergency department (ED) visits by elders, using a modification of the Andersen behavioral model of health services, adapted to explain ED utilization. METHODS: Relevant articles were identified through MEDLINE and a search of reference lists and personal files. Studies of populations aged 65 or older in which ED visits were a study outcome were included if they were: original, not restricted to a particular medical condition, written in English or French, and investigated one or more determinants. Data were abstracted and checked by two authors using a standard protocol. RESULTS: Fourteen studies (reported in 15 articles) were reviewed, 10 community-based and four using clinical samples. Among ten studies that measured multiple determinants, determinants reported from multivariate analyses included measures of need (perceived and evaluated health status, prior utilization), predisposing factors (health beliefs and sociodemographic variables), and enabling factors (physician availability, regular source of care, family resources, geographical access to services). CONCLUSIONS: Need is usually the primary determinant of ED visits in older people. Controlling for need, predisposing and enabling factors that promote access to primary medical care are associated with reduced ED utilization.     

Emergency Department Crowding and Decreased Quality of Pain Care

Objectives: The objective of this study was to evaluate the association of emergency department (ED) crowding factors with the quality of pain care. Methods: This was a retrospective observational study of all adult patients (≥18 years) with conditions warranting pain care seen at an academic, urban, tertiary care ED from July 1 to July 31, 2005, and December 1 to December 31, 2005. Patients were included if they presented with a chief complaint of pain and a final ED diagnosis of a painful condition. Predictor ED crowding variables studied were 1) census, 2) number of admitted patients waiting for inpatient beds (boarders), and 3) number of boarders divided by ED census (boarding burden). The outcomes of interest were process of pain care measures: documentation of clinician pain assessment, medications ordered, and times of activities (e.g., arrival, assessment, ordering of medications). Results: A total of 1,068 patient visits were reviewed. Fewer patients received analgesic medication during periods of high census (>50th percentile; parameter estimate = –0.47; 95% confidence interval [CI] = –0.80 to –0.07). There was a direct correlation with total ED census and increased time to pain assessment (Spearman r = 0.33, p < 0.0001), time to analgesic medication ordering (r = 0.22, p < 0.0001), and time to analgesic medication administration (r = 0.25, p < 0.0001). There were significant delays (>1 hour) for pain assessment and the ordering and administration of analgesic medication during periods of high ED census and number of boarders, but not with boarding burden. Conclusions: ED crowding as measured by patient volume negatively impacts patient care. Greater numbers of patients in the ED, whether as total census or number of boarders, were associated with worse pain care.     

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.     

Short-term Unscheduled Return Visits of Adult Patients to the Emergency Department

Background

Emergency department (ED) crowding is a major international concern that affects patients and providers.

Study Objective

We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding.

Methods

Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding.

Results

Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding.

Conclusion

Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.     

National Study of Patient, Visit, and Hospital Characteristics Associated With Leaving an Emergency Department Without Being Seen: Predicting LWBS

Objectives: The objective was to estimate the national left‐without‐being‐seen (LWBS) rate and to identify patient, visit, and institutional characteristics that predict LWBS. Methods: This was a retrospective cross‐sectional analysis using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1998 to 2006. Bivariate and multivariate analyses were performed to identify predictors of LWBS. Results: The national LWBS rate was 1.7 (95% confidence interval [CI] = 1.6 to 1.9) patients per 100 emergency department (ED) visits each year. In multivariate analysis, patients at extremes of age (<18 years, odds ratio [OR] = 0.80, 95% CI = 0.66 to 0.96; and ≥65 years, OR = 0.46, 95% CI = 0.32 to 0.64) and nursing home residents (OR = 0.29, 95% CI = 0.08 to 1.00) were associated with lower LWBS rates. Nonwhites (black or African American (OR = 1.41, 95% CI = 1.22 to 1.63) and Hispanic (OR = 1.25, 95% CI = 1.04 to 1.49), Medicaid (OR = 1.47, 95% CI = 1.27 to 1.70), self‐pay (OR = 1.96, 95% CI = 1.65 to 2.32), or other insurance (OR = 2.09, 95% CI = 1.74 to 2.52) patients were more likely to LWBS. Visit characteristics associated with LWBS included visits for musculoskeletal (OR = 0.70, 95% CI = 0.57 to 0.85), injury/poisoning/adverse event (OR = 0.65, 95% CI = 0.53 to 0.80), and miscellaneous (OR = 1.56, 95% CI = 1.19 to 2.05) complaints. Visits with low triage acuity were more likely to LWBS (OR = 3.59, 95% CI = 2.81 to 4.58), whereas visits that were work‐related were less likely to LWBS (OR = 0.19, 95% CI = 0.12 to 0.29). Institutional characteristics associated with LWBS were visits in metropolitan areas (OR = 2.11, 95% CI = 1.66 to 2.70) and teaching institutions (OR = 1.33, 95% CI = 1.06 to 1.67). Conclusions: Several patient, visit, and hospital characteristics are independently associated with LWBS. Prediction and benchmarking of LWBS rates should adjust for these factors.     

Predicting Hospital Admission and Returns to the Emergency Department for Elderly Patients

Objectives: Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED. Methods: All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008. Results: Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients. Conclusions: A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns. ACADEMIC EMERGENCY MEDICINE 2010; 17:252–259 © 2010 by the Society for Academic Emergency Medicine     

End-of-life Models and Emergency Department Care

Many people die in emergency departments (EDs) across the United States from sudden illnesses or injuries, an exacerbation of a chronic disease, or a terminal illness. Frequently, patients and families come to the ED seeking lifesaving or life-prolonging treatment. In addition, the ED is a place of transition-patients usually are transferred to an inpatient unit, transferred to another hospital, or discharged home. Rarely are patients supposed to remain in the ED. Currently, there is an increasing amount of literature related to end-of-life care. However, these end-of-life care models are based on chronic disease trajectories and have difficulty accommodating sudden-death trajectories common in the ED. There is very little information about end-of-life care in the ED. This article explores ED culture and characteristics, and examines the applicability of current end-of-life care models.     

严重创伤患者107例的院前急救护理

目的探讨和完善严重创伤患者的院前急救护理措施。方法回顾性分析解放军第202医院急诊科2008年1月至2011年12月间107例严重创伤患者的院前急救状况和护理措施。结果经过及时有效的包扎、止血、固定、维持呼吸等院前急救处理,本组患者院前抢救成功率达到98.13%。结论强化的急救护理专业队伍建设、采取正确的急救护理措施、合理配置院前急救资源,能有效提高严重创伤患者院前急救的成功率。     

Multicenter Study of Case Finding in Elderly Emergency Department Patients

Objectives: To assess the feasibility of a brief comprehensive case-finding program for detecting functional, cognitive, and social impairments among elderly ED patients and to estimate the prevalence of unknown, undetected, or untreated impairments elderly patients may have. Methods: A multicenter prospective study conducted at five private and public hospital EDs in five different communities across the country. Patients aged 60 years and older released to their homes during 52 randomly selected evening and weekend shifts between February 1 and April 30, 1993, were eligible for the case-finding program. They were evaluated by medical students who received special training (instructional videotape, supervised examinations, and conference calls) in the administration of a standardized 17-item protocol that included an interview and simple tests of function. The patients' physicians were notified of the screening results and were asked to return a one-month follow-up questionnaire. The physicians answered whether the presumed problem had been confirmed and whether a treatment plan for a new problem had been developed. Results: Patient acceptance of the case-finding program was good; 252 of 338 eligible patients (75%) agreed to participate, and 281 conditions were detected for 242 screened patients (96%). The most frequently reported problems were with: performing the activities of daily living (79%); vision (55%); lack of influenza vaccination (54%); home environment (49%); mental status (46%); general health (41%); falls (40%); and depression (36%). The physicians returned questionnaires for 153 patients (63%); 76 patients (50%) were evaluated at follow-up visits, during which 47 newly identified problems (62%) were confirmed and treatment plans were developed for 25 problems (53%) among 21 patients. A mean time of 17.7 ± 10.2 minutes was required to complete the screen. Conclusions: A brief comprehensive case-finding program for functional, cognitive, and social impairment among elderly ED patients is feasible. The screening uncovered a significant amount of morbidity among older patients visiting EDs.     

Epidemiology of Alcohol-related Emergency Department Visits

Abstract. Objective : To examine the population and geographic patterns, patient characteristics, and clinical presentations and outcomes of alcohol-related ED visits at a national level. Methods : Cross-sectional data on a probability sample of 21,886 ED visits from the 1995 National Hospital Ambulatory Medical Care Survey were analyzed with consideration of the individual patient visit weight. The annual number and rates of alcohol-related ED visits were computed based on weighted analysis in relation to demographic characteristics and geographic region. Specific variables of alcohol-related ED visits examined included demographic and medical characteristics, patient-reported reasons for visit, and physicians' principal diagnoses. Results : Of the 96.5 million ED visits in 1995, an estimated 2.6 million (2.7%) were related to alcohol abuse. The overall annual rate of alcohol-related ED visits was 10.0 visits per 1,000 population [95% confidence interval (CI) 8.7–11.3]. Higher rates were found for men (14.7 per 1,000, 95% CI 12.5–16.9), adults aged 25 to 44 years (17.8 per 1,000, 95% CI 15.0–20.6), blacks (18.1 per 1,000, 95% CI 14.0–22.1), and residents living in the northeast region (15.2 per 1,000, 95% CI 12.1–18.2). Patients whose visits were alcohol-related were more likely than other patients to be uninsured, smokers, or depressive. Alcohol-related ED visits were 1.6 times as likely as other visits to be injury-related, and 1.8 times as likely to be rated as "urgent" or "emergent." The leading principal reasons for alcohol-related ED visits were complaints of pain, injury, and drinking problems. Alcohol abuse/dependence was the principal diagnosis for 20% of the alcohol-related visits. Conclusion : Alcohol abuse poses a major burden on the emergency medical care system. The age, gender, and geographic characteristics of alcohol-related ED visits are consistent with drinking patterns in the general population.     

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.     

Referral of Medically Uninsured Emergency Department Patients to Primary Care

OBJECTIVE: To examine the impact primary care referral has on subsequent emergency department (ED) utilization. METHODS: Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital-based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral. RESULTS: Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self-pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p < 0.001). There was no significant difference in pre- or post-ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001). CONCLUSIONS: For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.     

Emergency Department Use by Adult Medicaid Patients after Implementation of Managed Care

OBJECTIVE: To determine whether the advent of a mandatory Medicaid managed care (MMC) plan had any effect on emergency department (ED) utilization by adult Medicaid patients at an urban teaching hospital. METHODS: This was a retrospective cohort study using four years of ED records encompassing the year prior to initiation of MMC (1994-95), the enrollment year (1995-96), and two years after the program had matured (1996-98). RESULTS: Total ED census declined slightly, then returned to 1995 levels. Emergency department use by MMC patients declined steadily, with the 1998 figure of 5,888 representing a 40% decline over the pre-MMC volume of 9,849. Visits by MMC patients with acute illness or injury declined by 29%; MMC low-acuity visits decreased by 43%. Medicaid managed care low-acuity after-hours/weekend visits declined by 19%, then leveled off. The MMC enrollment was stable throughout the study period. CONCLUSIONS: Mandatory managed care can be associated with considerable diminution in ED use by Medicaid patients. This decline is most pronounced in low-acuity triage categories, and least evident after hours and on weekends.