Resource utilization across the continuum of HIV care: An emergency department-based cohort study.

BACKGROUND: The objective of this study was to determine the healthcare resource utilization for people living with HIV (PLWH) presenting to the emergency department (ED) across the HIV Care Continuum. METHODS: This prospective study enrolled PLWH presenting to an urban ED between June 2016 and March 2017. Subjects were categorized as being linked to care, retained in care, on antiretroviral therapy (ART), and virally suppressed (<200 copies/ml). Data on ED visit rates, duration of stay, and hospital admission rates were compared to local metrics. RESULTS: Overall, 94.3% of 159 enrollees had been linked to care, 75.5% retained in care, 81.1% on ART, and 62.8% virally suppressed. Compared to the general population of the city and of the ED, participants had a higher ED visit rate (3.0 v. 1.2 visits per person-per year) in the past two years, a higher median duration of ED stay (12.6 v. 7.6 h), and a higher hospital admission rate (36.5% v. 24.9%) during their index ED visit. Viral suppression was negatively associated with admission (OR = 0.35, 95% CI: 0.17, 0.72). Forty-eight (30.2%) participants who had at least eight ED visits in the past two years were more likely to have a diagnosed mental health disorder (79.2% v. 62.2%, p=0.036). CONCLUSIONS: Our results showed that PLWH use more ED resources than the general population and a better engagement in HIV care is linked to lesser ED resource utilization for PLWH, indicating the importance of improved HIV care engagement in healthcare utilization management.

Applying the Haddon Matrix to Hospital Earthquake Preparedness and Response.

Since its 1960s origins, the Haddon matrix has served as a tool to understand and prevent diverse mechanisms of injuries and promote safety. Potential remains for broadened application and innovation of the matrix for disaster preparedness. Hospital functionality and efficiency are particularly important components of community vulnerability in developed and developing nations alike. Given the Haddon matrix's user-friendly approach to integrating current engineering concepts, behavioral sciences, and policy dimensions, we seek to apply it in the context of hospital earthquake preparedness and response. The matrix's framework lends itself to interdisciplinary planning and collaboration between social and physical sciences, paving the way for a systems-oriented reduction in vulnerabilities. Here, using an associative approach to integrate seemingly disparate social and physical science disciplines yields innovative insights about hospital disaster preparedness for earthquakes. We illustrate detailed examples of pre-event, event, and post-event engineering, behavioral science, and policy factors that hospital planners should evaluate given the complex nature, rapid onset, and broad variation in impact and outcomes of earthquakes. This novel contextual examination of the Haddon matrix can enhance critical infrastructure disaster preparedness across the epidemiologic triad, by integrating essential principles of behavioral sciences, policy, law, and engineering to earthquake preparedness.

Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis.

Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.

Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine.

BACKGROUND: Early efforts to incorporate telemedicine into Emergency Medicine focused on connecting remote treatment clinics to larger emergency departments (EDs) and providing remote consultation services to EDs with limited resources. Owing to continued ED overcrowding, some EDs have used telemedicine to increase the number of providers during surges of patient visits and offer scheduled "home" face-to-face, on-screen encounters. In this study, we used remote on-screen telemedicine providers in the "screening-in-triage" role. OBJECTIVE: This study aimed to compare the efficiency and patient safety of in-person screening and telescreening. METHODS: This cohort study, matched for days and proximate hours, compared the performance of real-time remote telescreening and in-person screening at a single urban academic ED over 22 weeks in the spring and summer of 2016. The study involved 337 standard screening hours and 315 telescreening hours. The primary outcome measure was patients screened per hour. Additional outcomes were rates of patients who left without being seen, rates of analgesia ordered by the screener, and proportion of patients with chest pain receiving or prescribed a standard set of tests and medications. RESULTS: In-person screeners evaluated 1933 patients over 337 hours (5.7 patients per hour), whereas telescreeners evaluated 1497 patients over 315 hours (4.9 patients per hour; difference=0.8; 95% CI 0.5-1.2). Split analysis revealed that for the final 3 weeks of the evaluation, the patient-per-hour rate differential was neither clinically relevant nor statistically discernable (difference=0.2; 95% CI -0.7 to 1.2). There were fewer patients who left without being seen during in-person screening than during telescreening (2.6% vs 3.8%; difference=-1.2; 95% CI -2.4 to 0.0). However, compared to prior year-, date-, and time-matched data on weekdays from 1 am to 3 am, a period previously void of provider screening, telescreening decreased the rate of patients LWBS from 25.1% to 4.5% (difference=20.7%; 95% CI 10.1-31.2). Analgesia was ordered more frequently by telescreeners than by in-person screeners (51.2% vs 31.6%; difference=19.6%; 95% CI 12.1-27.1). There was no difference in standard care received by patients with chest pain between telescreening and in-person screening (29.4% vs 22.4%; difference=7.0%; 95% CI -3.4 to 17.4). CONCLUSIONS: Although the efficiency of telescreening, as measured by the rate of patients seen per hour, was lower early in the study period, telescreening achieved the same level of efficiency as in-person screening by the end of the pilot study. Adding telescreening during 1-3 am on weekdays dramatically decreased the number of patients who left without being seen compared to historic data. Telescreening was an effective and safe way for this ED to expand the hours in which patients were screened by a health care provider in triage.

Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review.

OBJECTIVES: To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU. DATA SOURCES: PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017. STUDY SELECTION: Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization. DATA EXTRACTION: Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration's criteria. DATA SYNTHESIS: Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7-8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13-31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies. CONCLUSIONS: Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

Emergency department resource utilization during Ramadan: distinct and reproducible patterns over a 4-year period in Abu Dhabi.

OBJECTIVES: Emergency Department (ED) patient arrivals vary daily and change considerably during holidays, posing challenges to resource allocation. Ramadan, during which observant Muslims follow a daily fasting period for ∼30 days, could represent a unique annual circumstance that predictably alters ED arrivals in predominantly Muslim populations. Our study examined an adult and pediatric ED in the United Arab Emirates to determine whether arrival patterns and patient characteristics differed during Ramadan. METHODS: Hourly arrivals, census (number of patients in ED at any given time), and visit characteristics were retrospectively compared for Ramadan versus non-Ramadan periods over 4 years (2010-2013). Hourly arrivals and census were plotted using two-way repeated-measures analysis of variance. Differences in characteristics were examined using the χ-test and Wilcoxon rank sum tests. RESULTS: Ramadan adult and pediatric ED arrival patterns differed significantly (P<0.001) from non-Ramadan days, with sharp decreases after the fast was broken around 6 p.m. (sunset), followed by steep increases by 8:30 pm. The median daily adult arrivals were similar [143 (Ramadan) vs. 148 (non-Ramadan); P=0.060], with slightly decreased length-of-stay (7%; P<0.001) during Ramadan. The median daily pediatric arrivals were lower during Ramadan (43 vs. 57; P<0.001), with decreased length-of-stay (20%; P<0.001). Arrival pattern shifts led to significant census redistribution to evening hours. Patient characteristics were similar during both periods. CONCLUSION: A distinct, predictable pattern of arrivals emerged during Ramadan. EDs serving predominantly Muslim populations or anticipating increases in Muslim patients in their catchment region may benefit from advanced planning for efficient distribution of provider hours during Ramadan.

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments.

STUDY OBJECTIVE: A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland. METHODS: We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015). RESULTS: The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. CONCLUSION: There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland.

Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital.

Importance: The capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients. Objective: To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital. Design, Setting, and Participants: In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016. Main Outcomes and Measures: Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate. Results: Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%. Conclusions and Relevance: Our estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.

The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department.

BACKGROUND: Interruptions to nursing workload may contribute to procedural failures and clinical errors impacting quality/safety of care, but the impact of interruptions on the duration of these activities has not been closely scrutinised. This study analyses the effect of interruptions to care provided by nurses and clinical technicians on the length of clinical procedures and interventions (excluding the length of the interruption). METHODS: An observational time study of the effect of interruptions on common nursing interventions in the emergency department (ED) of a large academic medical centre was conducted. This study used direct observations of nurses and clinical technicians while delivering care to patients. RESULTS: The average time spent on an uninterrupted intervention was 296.47 s (median:185.15, SD:319.05), while interrupted interventions took 682.02 s (median:589.63, SD:504.59). Controlling for intervention type and other potential confounding factors using multiple linear regression found that interrupted interventions were 121.36 s (95% CI 79.57 to 163.15) longer, a 19 percentage point increase (95% CI 11.31 to 26.89), than an intervention without (excluding the length of the interruption). Family/patient interruptions effected duration the most while staff interruptions affected the intervention time the least. DISCUSSION: Our findings are consistent with outcomes of studies in non-healthcare domains, but are contrary to a study of ED physicians, suggesting differential responses to interruptions by physicians and nurses. Future studies on interruptions in healthcare should thus be discipline specific. Though the effect of interruptions on intervention length is only about 2 min, in an ED setting, this can increase patient risks and costs. To better focus efforts to reduce interruptions future research should focus on further separation of interruption type (eg, urgent vs routine or unnecessary).

An Analysis of the Relationship Between the Heat Index and Arrivals in the Emergency Department.

BACKGROUND: Heatwaves are one of the most deadly weather-related events in the United States and account for more deaths annually than hurricanes, tornadoes, floods, and earthquakes combined. However, there are few statistically rigorous studies of the effect of heatwaves on emergency department (ED) arrivals. A better understanding of this relationship can help hospitals plan better and provide better care for patients during these types of events. METHODS:  A retrospective review of all ED patient arrivals that occurred from April 15 through August 15 for the years 2008 through 2013 was performed. Daily patient arrival data were combined with weather data (temperature and humidity) to examine the potential relationships between the heat index and ED arrivals as well as the length of time patients spend in the ED using generalized additive models. In particular the effect the 2012 heat wave that swept across the United States, and which was hypothesized to increase arrivals was examined. RESULTS:  While there was no relationship found between the heat index and arrivals on a single day, a non-linear relationship was found between the mean three-day heat index and the number of daily arrivals. As the mean three-day heat index initially increased, the number of arrivals significantly declined. However, as the heat index continued to increase, the number of arrivals increased. It was estimated that there was approximately a 2% increase in arrivals when the mean heat index for three days approached 100°F. This relationship was strongest for adults aged 18-64, as well as for patients arriving with lower acuity. Additionally, a positive relationship was noted between the mean three-day heat index and the length of stay (LOS) for patients in the ED, but no relationship was found for the time from which a patient was first seen to when a disposition decision was made. No significant relationship was found for the effect of the 2012 heat wave on ED arrivals, though it did have an effect on patient LOS. CONCLUSION:  A single hot day has only a limited effect on ED arrivals, but continued hot weather has a cumulative effect. When the heat index is high (~90°F) for a number of days in a row, this curtails peoples activities, but if the heat index is very hot (~100°F) this likely results in an exacerbation of underlying conditions as well as heat-related events that drives an increase in ED arrivals. Periods of high heat also affects the length of stay of patients either by complicating care or by making it more difficult to discharge patients.

Interventions to mitigate emergency department and hospital crowding during an infectious respiratory disease outbreak: results from an expert panel.

OBJECTIVE: To identify and prioritize potential Emergency Department (ED) and hospital-based interventions which could mitigate the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential data sources that may be useful for triggering decisions to implement these high priority interventions. DESIGN: Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine appropriate "triggers" for implementation of the high priority interventions in the context of four different infectious respiratory disease scenarios that vary by patient volumes (high versus low) and illness severity (high versus low). SETTING: One day in-person conference held November, 2011. PARTICIPANTS: Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED operations, and hospital operations. MAIN OUTCOME MEASURE: Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, we created a prioritized list of potential data sources which could be useful to trigger interventions. RESULTS: High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital utilization metrics. CONCLUSIONS: We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various outbreak scenarios. The data sources identified to "trigger" the implementation of these high priority interventions consist mainly of sources available at the local, institutional level.

Critical resources for hospital surge capacity: an expert consensus panel.

BACKGROUND: Hospital surge capacity (HSC) is dependent on the ability to increase or conserve resources. The hospital surge model put forth by the Agency for Healthcare Research and Quality (AHRQ) estimates the resources needed by hospitals to treat casualties resulting from 13 national planning scenarios. However, emergency planners need to know which hospital resource are most critical in order to develop a more accurate plan for HSC in the event of a disaster. OBJECTIVE: To identify critical hospital resources required in four specific catastrophic scenarios; namely, pandemic influenza, radiation, explosive, and nerve gas. METHODS: We convened an expert consensus panel comprised of 23 participants representing health providers (i.e., nurses and physicians), administrators, emergency planners, and specialists. Four disaster scenarios were examined by the panel. Participants were divided into 4 groups of five or six members, each of which were assigned two of four scenarios. They were asked to consider 132 hospital patient care resources- extracted from the AHRQ's hospital surge model- in order to identify the ones that would be critical in their opinion to patient care. The definition for a critical hospital resource was the following: absence of the resource is likely to have a major impact on patient outcomes, i.e., high likelihood of untoward event, possibly death. For items with any disagreement in ranking, we conducted a facilitated discussion (modified Delphi technique) until consensus was reached, which was defined as more than 50% agreement. Intraclass Correlation Coefficients (ICC) were calculated for each scenario, and across all scenarios as a measure of participant agreement on critical resources. For the critical resources common to all scenarios, Kruskal-Wallis test was performed to measure the distribution of scores across all scenarios. RESULTS: Of the 132 hospital resources, 25 were considered critical for all four scenarios by more than 50% of the participants. The number of hospital resources considered to be critical by consensus varied from one scenario to another; 58 for the pandemic influenza scenario, 51 for radiation exposure, 41 for explosives, and 35 for nerve gas scenario. Intravenous crystalloid solution was the only resource ranked by all participants as critical across all scenarios. The agreement in ranking was strong in nerve agent and pandemic influenza (ICC= 0.7 in both), and moderate in explosives (ICC= 0.6) and radiation (ICC= 0.5). CONCLUSION: In four disaster scenarios, namely, radiation, pandemic influenza, explosives, and nerve gas scenarios; supply of as few as 25 common resources may be considered critical to hospital surge capacity. The absence of any these resources may compromise patient care. More studies are needed to identify critical hospital resources in other disaster scenarios.