Disparities in emergency department prioritization and rooming of patients with similar triage acuity score.

BACKGROUND: We identify patient demographic and emergency department (ED) characteristics associated with rooming prioritization decisions among ED patients who are assigned the same triage acuity score. METHODS: We performed a retrospective analysis of adult ED patients with similar triage acuity, as defined as an Emergency Severity Index (ESI) of 3, at a large academic medical center, during 2019. Violations of a first-come-first-served (FCFS) policy for rooming are identified and used to create weighted multiple logistic regression models and 1:M matched case-control conditional logistic regression models to determine how rooming prioritization is affected by individual patient age, sex, race, and ethnicity after adjusting for patient clinical and time-varying ED operational characteristics. RESULTS: A total of 15,781 ED encounters were analyzed, with 1612 (10.2%) ED encounters having a rooming prioritization in violation of a FCFS policy. Patient age and race were found to be significantly associated with being prioritized in violation of FCFS in both logistic regression models. The 1:M matched model showed a statistically significant relationship between violation of rooming prioritization with increasing age in years (adjusted odds ratio [aOR] 1.009, 95% confidence interval [CI] 1.005-1.013) and among African American patients compared to Caucasians (aOR 0.636, 95% CI 0.545-0.743). CONCLUSIONS: Among ED patients with a similar triage acuity (ESI 3), we identified patient age and patient race as characteristics that were associated with deviation from a FCFS prioritization in ED rooming decisions. These findings suggest that there may be patient demographic disparities in ED rooming decisions after adjusting for clinical and ED operational characteristics.

Emergency clinician participation and performance in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System.

BACKGROUND: The Merit-based Incentive Payment System (MIPS) is the largest national pay-for-performance program and the first to afford emergency clinicians unique financial incentives for quality measurement and improvement. With little known regarding its impact on emergency clinicians, we sought to describe participation in the MIPS and examine differences in performance scores and payment adjustments based on reporting affiliation and reporting strategy. METHODS: We performed a cross-sectional analysis using the Centers for Medicare & Medicaid Services 2018 Quality Payment Program (QPP) Experience Report data set. We categorized emergency clinicians by their reporting affiliation (individual, group, MIPS alternative payment model [APM]), MIPS performance scores, and Medicare Part B payment adjustments. We calculated performance scores for common quality measures contributing to the quality category score if reported through qualified clinical data registries (QCDRs) or claims-based reporting strategies. RESULTS: In 2018, a total of 59,828 emergency clinicians participated in the MIPS-1,246 (2.1%) reported as individuals, 43,404 (72.5%) reported as groups, and 15,178 (25.4%) reported within MIPS APMs. Clinicians reporting as individuals earned lower overall MIPS scores (median [interquartile range {IQR}] = 30.8 [15.0-48.2] points) than those reporting within groups (median [IQR] = 88.4 [49.3-100.0]) and MIPS APMs (median [IQR] = 100.0 [100.0-100.0]; p < 0.001) and more frequently incurred penalties with a negative payment adjustment. Emergency clinicians had higher measure scores if reporting QCDR or QPP non-emergency medicine specialty set measures. CONCLUSIONS: Emergency clinician participation in national value-based programs is common, with one in four participating through MIPS APMs. Those employing specific strategies such as QCDR and group reporting received the highest MIPS scores and payment adjustments, emphasizing the role that reporting strategy and affiliation play in the quality of care.

Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma.

This clinical policy from the American College of Emergency Physicians is an update of the 2004 clinical policy on the critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. A writing subcommittee reviewed the literature as part of the process to develop evidence-based recommendations to address 4 key critical questions: (1) In a hemodynamically unstable patient with blunt abdominal trauma, is ultrasound the diagnostic modality of choice? (2) Does oral contrast improve the diagnostic performance of computed tomography (CT) in blunt abdominal trauma? (3) In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal CT scan result? (4) In patients with isolated blunt abdominal trauma, are there clinical predictors that allow the clinician to identify patients at low risk for adverse events who do not need an abdominal CT? Evidence was graded and recommendations were based on the available data in the medical literature related to the specific clinical question.

Important historical efforts at emergency department categorization in the United States and implications for regionalization.

This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes.

Categorization, designation, and regionalization of emergency care: definitions, a conceptual framework, and future challenges.

This article reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.

Injuries from the 2002 North Carolina ice storm, and strategies for prevention.

CONTEXT: In 2002, an ice storm interrupted power to 1.3 million households in North Carolina, USA. Previous reports described storm injuries in regions with frequent winter weather. [Blindauer KM, Rubin C, Morse DL, McGeehin M. The 1996 New York blizzard: impact on noninjury visits. Am J Emerg Med 1999;17(1):23-7; Centers for Disease Control and Prevention. Community needs assessment and morbidity surveillance following an ice storm--Maine, January 1998. MMRW 1998;47(17):351-5; Daley WR, Smith A, Paz-Argandona E, Malilay J, McGeehin M. An outbreak of carbon monoxide poisoning after a major ice storm in Maine. J Emerg Med 2000;18(1):87-93; Hamilton J. Quebec's ice storm'98: "all cards wild, all rules broken" in Quebec's shell-shocked hospitals. Can Med Assoc J 1998;158(4):520-4; Hartling L, Brison RJ, Pickett W. Cluster of unintentional carbon monoxide poisonings presenting to the emergency departments in Kingston, Ontario during 'Ice Storm 98'. Can J Public Health 1998;89(6):388-90; Hartling L, Pickett W, Brison RJ. The injury experience observed in two emergency departments in Kingston, Ontario during 'ice storm 98'. Can J Public Health 1999;90(2):95-8; Houck, PM, Hampson NB. Epidemic carbon monoxide poisoning following a winter storm. J Emerg Med 1997;15(4):469-73; Lewis LM, Lasater LC. Frequency, distribution, and management of injuries due to an ice storm in a large metropolitan area. South Med J 1994;87(2):174-8; Smith RW, Nelson DR. Fractures and other injuries from falls after an ice storm. Am J Emerg Med 1998;16(1):52-5]. We postulated that injuries might differ in a region where ice storms are less common. OBJECTIVE: Identify storm-related injuries. DESIGN: Emergency department (ED) charts from the storm period (defined as onset of precipitation until 99% power restoration) were retrospectively reviewed. Included injuries were: falls on ice; injuries due to darkness; cold exposure; injuries from storm-related damage; burns; or carbon monoxide/smoke exposure. SETTING: Tertiary care ED, central North Carolina. PATIENTS: All ED patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Mechanism of injury. RESULTS: One hundred thirty incidents occurred, most resulting from storm damage and carbon monoxide. Seven were life threatening: four spinal fractures and two intracranial hemorrhages from falling tree limbs and one hypothermia. Carbon monoxide poisoning affected one pregnant woman and all children in our series. Twenty three percent of patients were Hispanic, although Hispanics comprise only 11% of the study ED population. CONCLUSIONS: Injuries from storm-related damage and carbon monoxide exposure predominated. Available hyperbaric chambers were quickly filled to capacity. Hispanics experienced a disproportionate number of injuries.