Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis.

BACKGROUND: Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS: We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS: Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION: Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.

How usability of a web-based clinical decision support system has the potential to contribute to adverse medical events.

INTRODUCTION: Clinical decision support systems (CDSS) have the potential to reduce adverse medical events, but improper design can introduce new forms of error. CDSS pertaining to community acquired pneumonia and neutropenic fever were studied to determine whether usability of the graphical user interface might contribute to potential adverse medical events. METHODS: Automated screen capture of 4 CDSS being used by volunteer emergency physicians was analyzed using structured methods. RESULTS: 422 events were recorded over 56 sessions. In total, 169 negative comments, 55 positive comments, 130 neutral comments, 21 application events, 34 problems, 6 slips, and 5 mistakes were identified. Three mistakes could have had life-threatening consequences. CONCLUSION: Evaluation of CDSS will be of utmost importance in the future with increasing use of electronic health records. Usability engineering principles can identify interface problems that may lead to potential medical adverse events, and should be incorporated early in the software design phase.

Frequency, determinants and impact of overcrowding in emergency departments in Canada: a national survey.

Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.

Characteristics of patients who leave emergency departments without being seen.

OBJECTIVES: Patients leaving the emergency department (ED) without being seen (LWBS) by a physician have become a growing concern in overcrowded EDs. The purpose of this study was to determine the acuity level, reasons, and outcomes of LWBS cases. METHODS: LWBS patients (or their guardians) from two linked Canadian EDs (one adult, one pediatric), identified during 11 sampling periods of seven days' duration each, were contacted by telephone. Descriptive statistics are provided. RESULTS: A total of 711 (4.5%) of 15,660 registered emergency patients left without being seen (50% male; median age, 33 years). Triage-matched controls waited a median of 87 minutes before seeing a physician. Of the 711 LWBS cases, 512 (72%) were contacted and 498 agreed to participate. The most common major reason for leaving was "fed up with waiting" (44.8%). Overall, 60% of LWBS cases sought medical attention within one week; 14 patients were hospitalized, and one required urgent surgery. Triage level was not associated with the probability of subsequently seeking medical attention (61%, 61%, and 60% in triage levels 3, 4, and 5, respectively). Of the 198 (39%) who did not subsequently seek medical attention, 50 patients (26%) had been triaged as urgent and one patient died six days after ED registration. CONCLUSIONS: The most common reason for LWBS is impatience during peak ED periods. Many of these patients seek medical care within one week. Complications occurred rarely; however, "high-risk" patients who leave without being seen do experience adverse health outcomes. Further research is required to examine ways to reduce LWBS cases.