Emergency department medication dispensing reduces return visits and admissions.

OBJECTIVES: Return visits to the emergency department (ED) and subsequent readmissions are common for patients who are unable to fill their prescriptions. We sought to determine if dispensing medications to patients in an ED was a cost-effective way to decrease return ED visits and hospital admissions for skin and soft tissue infections (SSTIs). METHODS: A retrospective review of ED visits for SSTIs, during the 24 weeks before and after the implementation of a medication dispensing program, was conducted. Charts were analyzed for both ED return visits and hospital admissions within 7 days and 30 days of the initial ED visit. Return visits were further reviewed to determine if the clinical conditions on subsequent visits were related to the initial ED presentation. A cost analysis comparing the cost of treatment to cost savings for return visits was also performed. RESULTS: Before the implementation of the medication dispensing program, the return rate in 7 days for the same condition was 9.1% and the rate of admission was 2.8%. The return rate for the same condition in 8-30 days was 2.1% and the rate of admission was 1.0%. After the implementation of the medication dispensing program, the return rate for the same condition in 7 days was 8.0%, and the admission rate was 1.7%. The return rate for the same condition in 8-30 days was 0.8%, and the admission rate was 0%. The total cost of dispensed medications was $4050, while total cost savings were estimated to be $95,477. CONCLUSION: A medication dispensing program in the ED led to a reduction in return visits and admissions for SSTIs at both 7 days and 30 days. For a cost of only $4050, an estimated total of $95,477 was saved. A medication dispensing program is a cost-effective way to reduce return visits to the ED and subsequent admissions for certain conditions.

Emergency Department Management of the Covid-19 Pandemic.

BACKGROUND: Emergency departments (EDs) need to be prepared to manage crises and disasters in both the short term and the long term. The coronavirus disease 2019 (COVID-19) pandemic has necessitated a rapid overhaul of several aspects of ED operations in preparation for a sustained response. OBJECTIVE: We present the management of the COVID-19 crisis in 3 EDs (1 large academic site and 2 community sites) within the same health care system. DISCUSSION: Aspects of ED throughput, including patient screening, patient room placement, and disposition are reviewed, along with departmental communication procedures and staffing models. Visitor policies are also discussed. Special considerations are given to airway management and the care of psychiatric patients. Brief guidance around the use of personal protective equipment is also included. CONCLUSIONS: A crisis like the COVID-19 pandemic requires careful planning to facilitate urgent restructuring of many aspects of an ED. By sharing our departments' responses to the COVID-19 pandemic, we hope other departments can better prepare for this crisis and the next.

Impact of a Direct Bedding Initiative on Left Without Being Seen Rates.

BACKGROUND: Left without being seen (LWBS) rates have become a key metric of emergency department (ED) flow, and high rates have been associated with poor patient outcomes, especially at busy urban, academic hospitals. OBJECTIVE: To assess a triage intervention's impact on LWBS rates among Emergency Severity Index (ESI) level 2 patients especially at risk for adverse outcomes. METHODS: We conducted a retrospective review at an urban academic center of LWBS rates prior to and after a "direct bedding" intervention, which directed patients triaged to ESI level 2 to be immediately placed in any available ED area, including those typically reserved for lower-acuity complaints. Our primary analysis employs an adjusted difference-in-difference-in-difference (DDD) approach using controls from the previous year and a nearby affiliate community hospital that did not participate in the intervention. RESULTS: Mean daily patient volume increased from 275 to 298 arrivals after the intervention. In the primary DDD analysis, odds of LWBS were lower after the intervention (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.45-0.70, p < 0.001). LWBS was higher in the unadjusted analysis (unadjusted OR 1.39, 95% CI 1.31-1.49, p < 0.001), but still lower among ESI 1 or 2 patients targeted by the intervention (unadjusted OR 0.56, 95% CI 0.43-0.74, p < 0.001). CONCLUSIONS: "Direct bedding" of ESI 2 patients may expedite care for the sickest patients, reducing potential harm to patients who might otherwise LWBS, without compromising care for patients triaged to less acute ESI levels.

The content expert program: A structured approach to increase emergency medicine resident scholarly activity.

Objectives: The Accreditation Council for Graduate Medical Education requires residents to participate in scholarship and requires residency programs to provide an environment within which residents can acquire skills related to scholarly activities. However, consensus on the definition of scholarship and structure of program environments does not yet exist. We designed and implemented a content expert program (CEP) in 2015, in which each resident worked with a faculty advisor to develop a longitudinal scholarly activity linked to a core area of practice and, in doing so, became the department's "content expert." We hypothesized that the CEP would significantly increase the number of scholarly outputs per resident. Methods: The CEP was structured around an oversight committee composed of key faculty members, which guided development of CEP projects through regular meetings and formative feedback. Each resident generated one or more scholarly outputs from their content area. Outputs were categorized into educational, operational, research, and miscellaneous domains and further identified as intradepartmental, interdepartmental, or interdisciplinary collaborations. The number of outputs was compared to the baseline number of scholarly activities per resident at the study program using a Mann-Whitney U test. Results: A total of 187 scholarly outputs were generated by 76 residents, which equated to 31.2 outputs per year, or 2.5 outputs per resident. This was a significant increase compared to the program baseline of one output per resident (p = 0.003). Eighteen distinct types of outputs spanned four major categories. Of the outputs, 37 were interdepartmental, 42 were interdisciplinary, and 32 were intradepartmental. Conclusions: The CEP proved to be a sustainable way to significantly increase scholarly activity and additionally improved collaborative efforts. With the appropriate structure and willing faculty in place, such a program can enhance the practical education provided by residency programs.

Ridesharing as an Alternative to Ambulance Transport for Voluntary Psychiatric Patients in the Emergency Department.

INTRODUCTION: Emergency department (ED) crowding is a growing problem. Psychiatric patients have long ED lengths of stay awaiting placement and transportation to a psychiatric facility after disposition. METHODS: Retrospective analysis of length of ED stay after disposition for voluntary psychiatric patients before and after the use of Lyft ridesharing services for inter-facility transport. RESULTS: Using Lyft transport to an outside crisis center shortens time to discharge both statistically and clinically from 113 minutes to 91 minutes (p = 0.028) for voluntary psychiatric patients. Discharge time also decreased for involuntary patients from 146 minutes to 127 minutes (p = 0.0053). CONCLUSION: Ridesharing services may be a useful alternative to medical transportation for voluntary psychiatric patients.

Emergency Department-based Hepatitis A Vaccination Program in Response to an Outbreak.

INTRODUCTION: The Philadelphia Department of Public Health (PDPH) declared a public health emergency due to hepatitis A in August 2019. Our emergency department (ED) serves a population with many of the identified risk factors for hepatitis A transmission. This study examines the impact of an ED-based hepatitis A vaccination program, developed in partnership with the PDPH, on incidence of hepatitis A infection and hospital admission. METHODS: We conducted a retrospective review of all ED visits in the 12-week period centered around the implementation of the ED-based hepatitis A vaccination program. All adult patients presenting to the ED were offered vaccination, with vaccines supplied free of charge by the PDPH. We compared the incidence of diagnosis and of hospital admission for treatment of hepatitis A before and after implementation of the program. RESULTS: There were 10,033 total ED visits during the study period, with 5009 of them prior to the implementation of the vaccination program and 5024 after implementation. During the study period, 669 vaccines were administered. Before the vaccination program began, 73 patients were diagnosed with hepatitis A, of whom 67 were admitted. After implementation of the program, 38 patients were diagnosed with hepatitis A, of whom 31 were admitted. CONCLUSION: A partnership between an ED and the local public health department resulted in the vaccination of 669 patients in six weeks in the midst of an outbreak of a vaccine-preventable illness, with a corresponding drop in ED visits and hospital admission for acute hepatitis A.

Pitfalls of Extensive Documentation in the Emergency Department.

Background: The law mandates careful record-keeping in the emergency department, and clinical imperatives also support the value of complete and legible reports. A common assumption is that extensive documentation increases the yield of relative value units (RVUs) and higher levels of care, thereby maximizing reimbursement. However, overdocumentation presents certain risks, possibly impacts physician efficiency, and does not ensure that records are more readable and clinically useful. We examined the effect of increased documentation on actual reimbursement. Methods: We conducted a 12-month productivity analysis of patients per hour (pt/h), RVUs per hour (RVU/h), amounts of monies billed, and amounts of monies collected for all full-time supervising physicians in a university emergency medicine training program. Results: RVU/h vs pt/h yielded a positive linear relationship (R2=0.7571) and a strong correlation coefficient of 0.87. RVU/h vs revenue collection (amount actually paid) yielded a moderately positive linear relationship (R2=0.1752), with a correlation coefficient of 0.42. The relationship between pt/h and collections was weak (R2=0.0815), with a correlation coefficient of 0.29. A quartile comparison showed an inflection point, suggesting that after the third quartile, RVU/h did not appear to help generate significantly higher collections. Conclusion: The data, while not definitive, suggest that overly extensive documentation may increase RVU totals but, after a point, does not reliably increase revenue generation.

A Case Report of a Novel Harm Reduction Intervention Used to Detect Opioid Overdose in the Emergency Department.

INTRODUCTION: As over 130 people die daily from opioid overdose in the United States, harm reduction strategies have become increasingly important. Because public restrooms are a common site for opioid overdose, emergency department waiting room restrooms (EDWRR) should be considered especially high-risk areas. CASE REPORT: We present the case of a patient found after a presumed opioid overdose in our EDWRR. Staff were alerted to his condition by a reverse motion detector (RMD), and rapidly treated him with naloxone. CONCLUSION: The RMD is a novel intervention that can save lives and should be considered in EDs with a high incidence of opioid overdose.