Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California.

Importance: Insurance status has been associated with whether patients with ST-segment elevation myocardial infarction (STEMI) presenting to emergency departments are transferred to other facilities, but whether the facility's percutaneous coronary intervention capabilities mediate this association is unknown. Objective: To examine whether uninsured patients with STEMI were more likely than patients with insurance to experience interfacility transfer. Design, Setting, and Participants: This observational cohort study compared patients with STEMI with and without insurance who presented to California emergency departments between January 1, 2010, and December 31, 2019, using the Patient Discharge Database and Emergency Department Discharge Database from the California Department of Health Care Access and Information. Statistical analyses were completed in April 2023. Exposures: Primary exposures were lack of insurance and facility percutaneous coronary intervention capabilities. Main Outcomes and Measures: The primary outcome was transfer status from the presenting emergency department of a percutaneous coronary intervention-capable hospital, defined as a facility performing 36 percutaneous coronary interventions per year. Multivariable logistic regression models with multiple robustness checks were performed to determine the association of insurance status with the odds of transfer. Results: This study included 135 358 patients with STEMI, of whom 32 841 patients (24.2%) were transferred (mean [SD] age, 64 [14] years; 10 100 women [30.8%]; 2542 Asian individuals [7.7%]; 2053 Black individuals [6.3%]; 8285 Hispanic individuals [25.2%]; 18 650 White individuals [56.8%]). After adjusting for time trends, patient factors, and transferring hospital characteristics (including percutaneous coronary intervention capabilities), patients who were uninsured had lower odds of experiencing interfacility transfer than those with insurance (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98; P = .01). Conclusions and Relevance: After accounting for a facility's percutaneous coronary intervention capabilities, lack of insurance was associated with lower odds of emergency department transfer for patients with STEMI. These findings warrant further investigation to understand the characteristics of facilities and outcomes for uninsured patients with STEMI.

Burn related injuries: a nationwide analysis of adult inter-facility transfers over a six-year period in the United States.

BACKGROUND: US emergency department (ED) visits for burns and factors associated with inter-facility transfer are unknown and described in this manuscript. METHODS: We conducted a retrospective analysis of burn-related injuries from 2009-2014 using the Nationwide Emergency Department Sample (NEDS), the largest sample of all-payer datasets. We included all ED visits by adults with a burn related ICD-9 code and used a weighted multivariable logistic regression model to predict transfer adjusting for covariates. RESULTS: Between 2009-2014, 3,047,701 (0.4%) ED visits were for burn related injuries. A total of 108,583 (3.6%) burn visits resulted in inter-facility transfers occurred during the study period, representing approximately 18,097 inter-facility transfers per year. Burns with greater than 10% total body surface area (TBSA) resulted in a 10-fold increase in the probability of transfer, compared to burn visits with less than 10% TBSA burns. In the multivariable model, male sex (adjusted odds ratio [aOR] 2.4, 95% CI 2.3-2.6) was associated with increased odds of transfer. Older adults were more likely to be transferred compared to all other age groups. Odds of transfer were increased for Medicare and self-pay patients (vs. private pay) but there was a significant interaction of sex and payer and the effect of insurance varied by sex. CONCLUSIONS: In a national sample of ED visits, burn visits were more than twice as likely to have an inter-facility transfer compared to the general ED patient population. Substantial sex differences exist in U.S. EDs that impact the location of care for patients with burn injuries and warrants further investigation.

Charge Reductions Associated With Shorter Time to Recovery in Septic Shock.

BACKGROUND: Septic shock therapies that shorten the time to physiologic and clinical recovery may result in financial savings. However, the financial implications of improving these nonmortal outcomes are not well characterized. Therefore, we quantified hospital charges associated with four outcomes: ICU length of stay, duration of invasive mechanical ventilation, duration of vasopressor use, and new renal replacement therapy. METHODS: This was an observational study using administrative data from a large academic hospital in the United States. The analysis included adults treated with vasopressors for septic shock in a medical ICU. Linear regression modeling with ordinary least square was used to estimate the incremental hospital charges associated with 1 day of ICU length of stay, 1 day of mechanical ventilation, 1 day of vasopressor use, and new renal replacement therapy. RESULTS: The study population included 587 adults with septic shock, including 180 (30.7%) who died in the hospital. The median charge for a septic shock hospitalization was $98,583 (interquartile range [IQR], $61,177-$136,672). Decreases in ICU length of stay, mechanical ventilation duration, and vasopressor duration of 1 day were associated with charge reductions of $15,670 (IQR, $15,023-$16,317), $15,284 (IQR, $13,566-$17,002), and $17,947 (IQR, $16,344-$19,549), respectively. Avoidance of new renal replacement therapy was associated with a charge reduction of $36,051 (IQR, $22,353-$49,750). CONCLUSIONS: Septic shock therapies that reduce the duration of organ support and ICU care have the potential to lead to substantial financial savings.

Understanding Emergency Care Delivery Through Computer Simulation Modeling.

In 2017, Academic Emergency Medicine convened a consensus conference entitled, "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes." This article, a product of the breakout session on "understanding complex interactions through systems modeling," explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This article discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo simulation, system dynamics modeling, discrete-event simulation, and agent-based simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this article, our goal is to enhance adoption of computer simulation, a set of methods that hold great promise in addressing emergency care organization and design challenges.

Lessons Learned From the Development and Parameterization of a Computer Simulation Model to Evaluate Task Modification for Health Care Providers.

Computer simulation is a highly advantageous method for understanding and improving health care operations with a wide variety of possible applications. Most computer simulation studies in emergency medicine have sought to improve allocation of resources to meet demand or to assess the impact of hospital and other system policies on emergency department (ED) throughput. These models have enabled essential discoveries that can be used to improve the general structure and functioning of EDs. Theoretically, computer simulation could also be used to examine the impact of adding or modifying specific provider tasks. Doing so involves a number of unique considerations, particularly in the complex environment of acute care settings. In this paper, we describe conceptual advances and lessons learned during the design, parameterization, and validation of a computer simulation model constructed to evaluate changes in ED provider activity. We illustrate these concepts using examples from a study focused on the operational effects of HIV screening implementation in the ED. Presentation of our experience should emphasize the potential for application of computer simulation to study changes in health care provider activity and facilitate the progress of future investigators in this field.

Cost-effectiveness analysis of early point-of-care lactate testing in the emergency department.

PURPOSE: To determine the cost-effectiveness of implementing a point-of-care (POC) Lactate Program in the emergency department (ED) for patients with suspected sepsis to identify patients who can benefit from early resuscitation. MATERIALS AND METHODS: We constructed a cost-effectiveness model to examine an ED with 30 000 patients annually. We evaluated a POC lactate program screening patients with suspected sepsis for an elevated lactate ≥4 mmol/L. Those with elevated lactate levels are resuscitated and their lactate clearance is evaluated by serial POC lactate measurements. The POC Lactate Program was compared with a Usual Care Strategy in which all patients with sepsis and an elevated lactate are admitted to the intensive care unit. Costs were estimated from the 2014 Medicare Inpatient and National Physician Fee schedules, and hospital and industry estimates. RESULTS: In the base-case, the POC Lactate Program cost $39.53/patient whereas the Usual Care Strategy cost $33.20/patient. The screened patients in the POC arm resulted in 1.07 quality-adjusted life years for an incremental cost-effectiveness ratio of $31 590 per quality-adjusted life year gained, well below accepted willingness-to-pay-thresholds. CONCLUSIONS: Implementing a POC Lactate Program for screening ED patients with suspected sepsis is a cost-effective intervention to identify patients responsive to early resuscitation.

Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction.

Lack of health insurance is associated with interfacility transfer from emergency departments for several nonemergent conditions, but its association with transfers for ST-elevation myocardial infarction (STEMI), which requires timely definitive care for optimal outcomes, is unknown. Our objective was to determine whether insurance status is a predictor of interfacility transfer for emergency department visits with STEMI. We analyzed data from the 2006 to 2011 Nationwide Emergency Department Sample examining all emergency department visits for patients age 18 years and older with a diagnosis of STEMI and a disposition of interfacility transfer or hospitalization at the same institution. For emergency department visits with STEMI, our multivariate logistic regression model included emergency department disposition status (interfacility transfer vs hospitalization at the same institution) as the primary outcome, and insurance status (none vs any [including Medicare, Medicaid, and private insurance]) as the primary exposure. We found that among 1,377,827 emergency department STEMI visits, including 249,294 (18.1%) transfers, patients without health insurance (adjusted odds ratio 1.6, 95% CI 1.5 to 1.7) were more likely to be transferred than those with insurance. Lack of health insurance status was also an independent risk factor for transfer compared with each subcategory of health insurance, including Medicare, Medicaid, and private insurance. In conclusion, among patients presenting to United States emergency departments with STEMI, lack of insurance was an independent predictor of interfacility transfer. In conclusion, because interfacility transfer is associated with longer delays to definitive STEMI therapy than treatment at the same facility, lack of health insurance may lead to important health disparities among patients with STEMI.

Effects of Common Data Errors in Electronic Health Records on Emergency Department Operational Performance Metrics: A Monte Carlo Simulation.

OBJECTIVES: The objective was to estimate how data errors in electronic health records (EHRs) can affect the accuracy of common emergency department (ED) operational performance metrics. METHODS: Using a 3-month, 7,348-visit data set of electronic time stamps from a suburban academic ED as a baseline, Monte Carlo simulation was used to introduce four types of data errors (substitution, missing, random, and systematic bias) at three frequency levels (2, 4, and 7%). Three commonly used ED operational metrics (arrival to clinician evaluation, disposition decision to exit for admitted patients, and ED length of stay for admitted patients) were calculated and the proportion of ED visits that achieved each performance goal was determined. RESULTS: Even small data errors have measurable effects on a clinical organization's ability to accurately determine whether it is meeting its operational performance goals. Systematic substitution errors, increased frequency of errors, and the use of shorter-duration metrics resulted in a lower proportion of ED visits reported as meeting the associated performance objectives. However, the presence of other error types mitigated somewhat the effect of the systematic substitution error. Longer time-duration metrics were found to be less sensitive to data errors than shorter time-duration metrics. CONCLUSIONS: Infrequent and small-magnitude data errors in EHR time stamps can compromise a clinical organization's ability to determine accurately if it is meeting performance goals. By understanding the types and frequencies of data errors in an organization's EHR, organizational leaders can use data management best practices to better measure true performance and enhance operational decision-making.

The nature and necessity of operational flexibility in the emergency department.

Hospital-based emergency departments (EDs), given their high cost and major role in allocating care resources, are at the center of the debate about how to maximize value in delivering health care in the United States. To operate effectively and create value, EDs must be flexible, having the ability to rapidly adapt to the highly variable needs of patients. The concept of flexibility has not been well described in the ED literature. We introduce the concept, outline its potential benefits, and provide some illustrative examples to facilitate incorporating flexibility into ED management. We draw on operations research and organizational theory to identify and describe 5 forms of flexibility: physical, human resource, volume, behavioral, and conceptual. Each form of flexibility may be useful individually or in combination with other forms in improving ED performance and enhancing value. We also offer suggestions for measuring operational flexibility in the ED. A better understanding of operational flexibility and its application to the ED may help us move away from reactive approaches of managing variable demand to a more systematic approach. We also address the tension between cost and flexibility and outline how "partial flexibility" may help resolve some challenges. Applying concepts of flexibility from other disciplines may help clinicians and administrators think differently about their workflow and provide new insights into managing issues of cost, flow, and quality in the ED.

Cost analysis of strategies to reduce blood culture contamination in the emergency department: sterile collection kits and phlebotomy teams.

OBJECTIVE: Blood culture collection practices that reduce contamination, such as sterile blood culture collection kits and phlebotomy teams, increase up-front costs for collecting cultures but may lead to net savings by eliminating downstream costs associated with contamination. The study objective was to compare overall hospital costs associated with 3 collection strategies: usual care, sterile kits, and phlebotomy teams. DESIGN: Cost analysis. SETTING: This analysis was conducted from the perspective of a hospital leadership team selecting a blood culture collection strategy for an adult emergency department (ED) with 8,000 cultures drawn annually. METHODS: Total hospital costs associated with 3 strategies were compared: (1) usual care, with nurses collecting cultures without a standardized protocol; (2) sterile kits, with nurses using a dedicated sterile collection kit; and (3) phlebotomy teams, with cultures collected by laboratory-based phlebotomists. In the base case, contamination rates associated with usual care, sterile kits, and phlebotomy teams were assumed to be 4.34%, 1.68%, and 1.10%, respectively. Total hospital costs included costs of collecting cultures and hospitalization costs according to culture results (negative, true positive, and contaminated). RESULTS: Compared with usual care, annual net savings using the sterile kit and phlebotomy team strategies were $483,219 and $288,980, respectively. Both strategies remained less costly than usual care across a broad range of sensitivity analyses. CONCLUSIONS: EDs with high blood culture contamination rates should strongly consider evidence-based strategies to reduce contamination. In addition to improving quality, implementing a sterile collection kit or phlebotomy team strategy is likely to result in net cost savings.

The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the ED.

STUDY OBJECTIVE: Acute upper gastrointestinal (GI) hemorrhage is a common presentation in hospital-based emergency departments (EDs). A novel diagnostic approach is to use video capsule endoscopy to directly visualize the upper GI tract and identify bleeding. Our objective was to evaluate and compare the relative costs and benefits of video capsule endoscopy compared to other strategies in low- to moderate-risk ED patients with acute upper GI hemorrhage. METHODS: We constructed a model using standard decision analysis software to examine the cost-effectiveness of 4 available strategies for a base-case patient who presents to the ED with either mild- or moderate-risk scenarios (by Glasgow-Blatchford Score) for requiring invasive hemostatic intervention (ie, endoscopic, surgical, etc) The 4 available diagnostic strategies were (1) direct imaging with video capsule endoscopy performed in the ED; (2) risk stratification using the Glasgow-Blatchford score; (3) nasogastric tube placement; and, finally, (4) an admit-all strategy. RESULTS: In the low-risk scenario, video capsule endoscopy was the preferred strategy (cost $5691, 14.69 quality-adjusted life years [QALYs]) and was more cost-effective than the remaining strategies including nasogastric tube strategy (cost $8159, 14.69 QALYs), risk stratification strategy (cost $10,695, 14.69 QALYs), and admit-all strategy (cost $22,766, 14.68 QALYs). In the moderate-risk scenario, video capsule endoscopy continued to be the preferred strategy (cost $9190, 14.56 QALYs) compared to nasogastric tube (cost $9487, 14.58 QALYs, incremental cost-effectiveness ratio $15,891) and more cost effective than admit-all strategy (cost, $22,584, 14.54 QALYs.) CONCLUSION: Video capsule endoscopy may be cost-effective for low- and moderate-risk patients presenting to the ED with acute upper GI hemorrhage.

Cost-effectiveness of diagnostic strategies for evaluation of suspected subarachnoid hemorrhage in the emergency department.

OBJECTIVES: Diagnosing subarachnoid hemorrhage (SAH) in emergency department (ED) patients is challenging. Potential diagnostic strategies include computed tomography (CT) only, CT followed by lumbar puncture (CT/LP), CT followed by magnetic resonance imaging and angiography (CT/MRA), and CT followed by CT angiography (CT/CTA). The objective was to determine the relative cost-effectiveness of diagnostic strategies for SAH. METHODS: The authors created a decision model to evaluate the cost-effectiveness of SAH diagnostic strategies in ED patients with suspected SAH. Clinical probabilities were obtained from published data; sensitivity analyses were conducted across plausible ranges. RESULTS: In the base-case scenario, CT-only had a cost of $10,339 and effectiveness of 20.25 quality-adjusted life-years (QALYs), and CT/LP had a cost of $15,120 and effectiveness of 20.366 QALYs. Among the alternative strategies, CT/CTA had a cost of $12,840 and effectiveness of 20.24 QALYs, and CT/MRA had a cost of $16,207 and effectiveness of 20.27 QALYs. In sensitivity analyses, probability of severe disability from SAH, sensitivity of noncontrast CT, and specificity of LP and MRA were key drivers of the model, and CT-only and CT/LP were preferable. CONCLUSIONS: In the base-case scenario, CT-only was preferable to the CT/CTA and CT/MRA strategies. When considering sensitivity analyses and the current medicolegal environment, there are no overwhelming differences between the cost-effectiveness of CT/LP and the alternative strategies to suggest that clinicians should abandon the standard CT/LP approach.

Measuring value for low-acuity care across settings.

Increasing healthcare costs have created an emphasis on improving value, defined as how invested time, money, and resources improve health. The role of emergency departments (EDs) within value-driven health systems is still undetermined. Often questioned is the value of an ED visit for conditions that could be reasonably treated elsewhere such as office-based, urgent, and retail clinics. This paper presents a conceptual approach to assess the value of these low-acuity visits. It adapts an existing analytic model to highlight specific factors that impact key stakeholders' (patients, insurers, and society) assessments of the value of ED-based care compared with care in alternative settings. These factors are presented in 3 equations, 1 for each stakeholder, emphasizing how tangible and intangible benefits of care weigh against direct and indirect costs and how each perspective influences value. Aligning value among groups could allow stakeholders to influence each other and could guide rational change in the delivery of acute medical care for low-acuity conditions.

The mortality benefit threshold for patients with suspected pulmonary embolism.

OBJECTIVES: The mortality benefit for pulmonary embolism (PE) is the difference in mortality between treated and untreated patients. The mortality benefit threshold is the mortality benefit above which testing for a condition should be initiated and below which it should not. To illustrate this concept, the authors developed a decision model to estimate the mortality benefit threshold at several pretest probabilities for low-risk emergency department (ED) patients with possible PE and compare those thresholds with contemporary management of PE in the United States and what is known and not known about treatment benefits with anticoagulation. METHODS: The authors built a decision model of a 25-year-old female with suspected PE. Model inputs were obtained from the literature or clinical judgment when data were unavailable. One-way sensitivity analysis was used to derive the mortality benefit threshold at several fixed pretest probabilities, and two-way sensitivity analysis was used to determine drivers of the mortality benefit threshold. RESULTS: At a 15% pretest probability, the mortality benefit threshold was 3.7%; at 10% it was 5.2%; at 5% it was 9.8%; at 2% it was 23.5%; at 1% it was 46.3%; and at 0.5% it was 92.1%. In two-way sensitivity analyses, D-dimer specificity, CT angiography (CTA)/CT venography (CTV) sensitivity, annual cancer risk, probability of death from renal failure, and probability of major bleeding were major model drivers. CONCLUSIONS: The mortality benefit threshold for initiating PE testing is very high at low pretest probabilities of PE, which should be considered by clinicians in their diagnostic approach to PE in the ED. The mortality benefit threshold is a novel way of exploring the benefits and risks of ED-based testing, particularly in situations like PE where testing (i.e., CT use) carries real risks and the benefits of treatment are uncertain.

Geographic access to US Neurocritical Care Units registered with the Neurocritical Care Society.

BACKGROUND: Neurocritical care provides multidisciplinary, specialized care to critically ill neurological patients, yet an understanding of the proportion of the population able to rapidly access specialized Neurocritical Care Units (NCUs) in the United States is currently unknown. We sought to quantify geographic access to NCUs by state, division, region, and for the US as a whole. In addition, we examined how mode of transportation (ground or air ambulance), and prehospital transport times affected population access to NCUs. METHODS: Data were obtained from the Neurocritical Care Society (NCS), US Census Bureau and the Atlas and Database of Air Medical Services. Empirically derived prehospital time intervals and validated models estimating prehospital ground and air travel times were used to calculate total prehospital times. A discrete total prehospital time interval was calculated for each small unit of geographic analysis (block group) and block group populations were summed to determine the proportion of Americans able to reach a NCU within discrete time intervals (45, 60, 75, and 90 min). Results are presented for different geographies and for different modes of prehospital transport (ground or air ambulance). RESULTS: There are 73 NCUs in the US using ground transportation alone, 12.8, 20.5, 27.4, and 32.6% of the US population are within 45, 60, 75, and 90 min of an NCU, respectively. Use of air ambulances increases access to 36.8, 50.4, 60, and 67.3 within 45, 60, 75, and 90 min, respectively. The Northeast has the highest access rates in the US using ground ambulances and for 45, 60, and 75 min transport times with the addition of air ambulances. At 90 min, the West has the highest access rate. The Southern region has the lowest ground and air access to NCUs access rates for all transport times. CONCLUSIONS: Using NCUs registered with the NCS, current geographic access to NCUs is limited in the US, and geographic disparities in access to care exist. While additional NCUs may exist beyond those identified by the NCS database, we identify geographies with limited access to NCUs and offer a population-based planning perspective on the further development of the US neurocritical care system.

Cost-effectiveness of lower extremity compression ultrasound in emergency department patients with a high risk of hemodynamically stable pulmonary embolism.

BACKGROUND: Computed tomography angiograms (CTAs) for patients with suspected pulmonary embolism (PE) are being ordered with increasing frequency from the emergency department (ED). Strategies are needed to safely decrease the utilization of CTs to control rising health care costs and minimize the associated risks of anaphylaxis, contrast-induced nephropathy, and radiation-induced carcinogenesis. The use of compression ultrasonography (US) to identify deep vein thromboses (DVTs) in hemodynamically stable patients with signs and symptoms suggestive of PE is highly specific for the diagnosis of PE and may represent a cost-effective alternative to CT imaging. OBJECTIVES: The objective was to analyze the cost-effectiveness of a selective CT strategy incorporating the use of compression US to diagnose and treat DVT in patients with a high pretest probability of PE. METHODS: The authors constructed a decision analytic model to evaluate the scenario of an otherwise healthy 59-year-old female in whom PE was being considered as a diagnosis. Two strategies were used. The selective CT strategy began with a screening compression US. Negative studies were followed up with a CTA, while patients with positive studies identifying a DVT were treated as though they had a PE and were anticoagulated. The universal CT strategy used CTA as the initial test, and anticoagulation was based on the CT result. Costs were estimated from the 2009 Medicare data for hospital reimbursement, and professional fees were obtained from the 2009 National Physician Fee Schedule. Clinical probabilities were obtained from existing published data, and sensitivity analyses were performed across plausible ranges for all clinical variables. RESULTS: In the base case, the selective CT strategy cost $1,457.70 less than the universal CT strategy and resulted in a gain of 0.0213 quality-adjusted life-years (QALYs). Sensitivity analyses confirm that the selective CT strategy is dominant above both a pretest probability for PE of 8.3% and a compression US specificity of 87.4%. CONCLUSIONS: A selective CT strategy using compression US is cost-effective for patients provided they have a high pretest probability of PE. This may reduce the need for, and decrease the adverse events associated with, CTAs.

Cost-effectiveness of telemetry for hospitalized patients with low-risk chest pain.

BACKGROUND: The majority of chest pain admissions originate in the emergency department (ED). Despite a low incidence of cardiac events, limited telemetry availability, and its questionable benefit, these patients are routinely admitted to a monitored setting. OBJECTIVES: The objectives were to analyze the cost-effectiveness of admission to telemetry versus admission to an unmonitored hospital bed in low-risk chest pain patients and explore when the use of telemetry may be cost-effective. METHODS: The authors constructed a decision analytic model to evaluate the scenario of an ED admission of an otherwise healthy 55-year-old patient with low-risk chest pain defined as an acute coronary syndrome (ACS) probability of 2%. Costs were estimated from 2009 Medicare data for hospital reimbursement and physician services, as well as published data on disability costs. Published studies were used to estimate the risk of ACS, cardiac arrest, time to defibrillation, survival, long-term disability, and quality of life. RESULTS: In the base case, telemetry was more effective (0.0044 quality-adjusted life-years [QALYs]) but more costly ($299.67) than a floor bed, resulting in a high marginal cost-effectiveness ratio (mCER) of $67,484.55 per QALY. In comprehensive sensitivity analyses, the mCER crossed below the willingness-to-pay (WTP) threshold of $50,000 per QALY when the following scenarios were met: the probability of ACS exceeds 3%, the probability of cardiac arrest is greater than 0.4%, the probability of shockable dysrhythmia is above 83%, the probability of delay in telemetry bed availability is below 52%, and the opportunity cost of delay to telemetry bed placement is below $119. CONCLUSIONS: Telemetry may be a "cost-effective" use of health care resources for chest pain patients when patients have a probability of ACS above 3% or for patients with a minimal delay and cost associated with obtaining a monitored bed. Further research is needed to better stratify low-risk chest pain patients to the appropriate inpatient setting and to understand the frequency and costs associated with delays in obtaining monitored beds.

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.