OpenAccessWith the overwhelming poll response on helping Annals of Emergency Medicine choose their two open-access articles for April 2014, this will now be an ongoing monthly event! Take a look at the article abstracts accepted for publication in May’s issue. Vote on your top two choices over the next 2 days, and they’ll be made open after the May issue of Annals of Emergency Medicine goes online.

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Access to Care for Patients With Time-Sensitive Conditions in Pennsylvania (Original Research)

Rama A. Salhi, J. Matthew Edwards, David F. Gaieski, Roger A. Band, et al.

Study objective

Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals.

Methods

All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles.

Results

The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes.

Conclusion

Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions.

Admit or Transfer? The Role of Insurance in High-Transfer-Rate Medical Conditions in the Emergency Department (Original Research)

Dana R. Kindermann, Ryan L. Mutter, Lara Cartright-Smith, Sara Rosenbaum,et al.

Study objective

We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers.

Methods

This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs).

Results

Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28).

Conclusion

Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

 

Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay

Daniel C. Keyes, Bonita Singal, Charles W. Kropf, Andrea Fisk

Study objective

Senior (geriatric) emergency departments (EDs) are an emerging phenomenon across the United States, designed to provide greater comfort for elders, screening for common morbidities, and selective contact with social workers. We hypothesize that the senior ED will reduce recidivism, rate of admission, and hospital length of stay.

Methods

This was a pre/postintervention observational study of seniors (≥65 years) before and after opening of a new senior ED in a large community hospital. Older nonseniors treated during the same periods were included to detect temporal trend bias. Outcomes included admission to the hospital, hospital length of stay, and ED return visits. Cox proportional hazards models, controlling for patient age, sex, triage level, insurance type, admission on the index visit, and hospital length of stay, were used to test association with time to return within 30 and 180 days. Multivariable regression modeling was used to determine whether the intervention was associated with admission on the index visit, and hospital length of stay.

Results

There was no significant difference in time to return within 30 days (HR=1.09; 95% confidence interval [CI] 0.95 to 1.23), 180 days (HR=0.99; 95% CI 0.91 to 1.08), or average hospital length of stay. Risk of being admitted on the index visit was lower for seniors treated in the senior ED compared with the regular ED (Relative Risk=0.93; 95% CI 0.89 to 0.98).

Conclusion

A new senior ED was not associated with reduced ED recidivism or hospital length of stay, but was associated with decreased rate of admission.

 

The Impact of Out-of-Hospital Non-Invasive Postive-Pressure Support Ventilation in Adult Patients With Severe Respiratory Distress: A Systematic Review

Sameer Mal, MD, FRCPC; Shelley McLeod, MSc; Alla Iansavichene, BSc, MLIS; Adam Dukelow, MD, FRCPC; Michael Lewell, MD, FRCPC

Study objective

Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to
determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with “standard” therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications.

Methods

Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched.
Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged 16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT).

Results

Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in
both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT¼18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT¼8). There was no difference in ICU or hospital length of stay.

Conclusion

Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress. [Ann Emerg Med. 2013;-:1-9.]

 

Interrupting My Shift: Disaster Preparedness and Response

Traci Pole, David Marcozzi, Richard C. Hunt

 

Investing in Emergency Medicine to Improve Health Care for All Americans: The Role of the Agency for Healthcare Research and Quality

Ryan Mutter, Carolyn Clancy

 

Measuring the Value of a Senior Emergency Department: Making Sense of Health Outcomes and Health Costs

Timothy F. Platts-Mills, Seth W. Glickman

 

 “No Diversion”: A Qualitative Study of Emergency Medicine Leaders in Boston, MA, and the Effects of a Statewide Diversion Ban Policy 

Shannon D. O’Keefe, Salma Bibi, Julia E. Rubin-Smith, James Feldman

Study objective

We examine the attitudes of emergency department (ED) key informants about the perceived effects of a statewide ban on ambulance diversion on patients, providers, and working relationships in a large urban emergency medical system.

Methods

We performed a qualitative study to examine the effects of a diversion ban on Boston area hospitals. Key informants at each site completed semistructured interviews that explored relevant domains pre- and postban. Interviews were deidentified, transcribed, coded, and analyzed with grounded theory for emerging themes. We identified important themes focused on patient safety, quality of care, and relationships before and after implementation of the diversion ban.

Results

Nine of 9 eligible sites participated. Eighteen interviews were completed: 7 MD ED directors, 2 MD designees, and 9 registered nurse leaders. Although most participants had negative opinions about diversion, some had considered diversion a useful procedure. Key themes associated with diversion were adverse effects on patient care quality, patient satisfaction, and a source of conflict among ED staff and with emergency medical services (EMS). All key informants described some positive effect of the ban, including those who reported that the ban had no direct effect on their individual hospital. Although the period preceding the ban was reported to be a source of apprehension about its effects, most key informants believed the ban had improved quality of care and relationships between hospital staff and EMS.

Conclusion

Key informants considered the diversion ban to have had a favorable effect on emergency medical care in Boston. These results may inform the discussion in other states considering a diversion ban.

 

Screening for Delirium in the Emergency Department: A Systematic Review

Michael A. LaMantia, Frank C. Messina, Cherri D. Hobgood, Douglas K. Miller

Older adults who visit emergency departments (EDs) often experience delirium, but it is infrequently recognized. A systematic review was therefore conducted to identify what delirium screening tools have been used in ED-based epidemiologic studies of delirium, whether there is a validated set of screening instruments to identify delirium among older adults in the ED or prehospital environments, and an ideal schedule during an older adult’s visit to perform a delirium evaluation. MEDLINE/EMBASE, Cochrane, PsycINFO, and CINAHL databases were searched from inception through February 2013 for original, English-language research articles reporting on the assessment of older adults’ mental status for delirium. Twenty-two articles met all study inclusion criteria. Overall, 7 screening instruments were identified, though only 1 has undergone initial validation for use in the ED environment and a second instrument is currently undergoing such validation. Minimal information was identified to suggest the ideal scheduling of a delirium assessment process to maximize the recognition of this condition in the ED. Study results indicate that several delirium screening tools have been used in investigations in the ED, though validation of these instruments for this particular environment has been minimal to date. The ideal interval(s) during which a delirium screening process should take place has yet to be determined. Research will be needed both to validate delirium screening instruments to be used for investigation and clinical care in the ED and to define the ideal timing and form of the delirium assessment process for older adults.

Severity-Adjusted Mortality in Trauma Patients Transported by Police

Roger A. Band, Rama A. Salhi, Daniel N. Holena, Elizabeth Powell,et al.

Study objective

Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia.

Methods

This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index.

Results

Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police.

Conclusion

We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.

Should Payment Policy Be Changed to Allow a Wider Range of EMS Transport Options?

Kristy G. Morganti, Abby Alpert, Gregg Margolis, Jeffrey Wasserman, et al.

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

 

Toward Patient-Centered Care: A Systematic Review of Older Adults’ Views of Quality Emergency Care

Kalpana N. Shankar, Bhavnit K. Bhatia, Jeremiah D. Schuur

Study objective

Observers have cited a quality gap between the current emergency care and the needs of elderly adults in the emergency setting. The Institute of Medicine identified patient-centeredness as a vital aim of quality health care. To develop a patient-centered approach in the emergency setting, we must first understand the elderly patients’ views of their emergency care. Thus, we performed a systematic review to synthesize the current knowledge about the elderly patient’s preferences and views of their emergency care.

Methods

Systematic review of qualitative studies and surveys addressing the elderly patients’ views of their emergency care using PUBMED and CINAHL. Using meta-ethnography, we identified 6 broad themes about the elderly’s perspectives of hospital-based emergency care.

Results

Of the 81 articles initially identified, our final review included 28 articles. We developed 6 themes of quality emergency care: (1) role of health care providers; (2) content of communication and patient education; (3) barriers to communication; (4) wait times; (5) physical needs in the emergency care setting; and (6) general elder care needs. Key findings were that emergency staff should (1) assume a leadership role with both the medical and social needs; (2) initiate communication frequently; (3) minimize potential barriers to communication; (4) check on patients during prolonged periods of waiting; (5) attend to distress caused by physical discomforts in the emergency care setting; and (6) address general elder care needs, including the care transition and involvement of caregivers when necessary.

Conclusion

Current qualitative research on the views of the elderly patient to hospital-based emergency care reveals common themes that should be considered in efforts to improve delivery of care to the elderly patient.

 

Two Cheers for Regulation

Robert L. Wears

 

Natalie Desouza, MD

Natalie Desouza, MD

ALiEM Resident Editor
Emergency Medicine PGY-4 Resident
University of California San Francisco
San Francisco General Hospital