Head injury serum markers for assessing response to trauma: Design of the HeadSMART study.

BACKGROUND: Accurate diagnosis and risk stratification of traumatic brain injury (TBI) at time of presentation remains a clinical challenge. The Head Injury Serum Markers for Assessing Response to Trauma study (HeadSMART) aims to examine blood-based biomarkers for diagnosing and determining prognosis in TBI. METHODS: HeadSMART is a 6-month prospective cohort study comparing emergency department patients evaluated for TBI (exposure group) to (1) emergency department patients evaluated for traumatic injury without head trauma and (2) healthy persons. Study methods and characteristics of the first 300 exposure participants are discussed. RESULTS: Of the first 300 participants in the exposure arm, 70% met the American Congress of Rehabilitation Medicine criteria for TBI, with the majority (80.1%) classified as mild TBI. The majority of subjects in the exposure arm had Glasgow Coma Scale scores of 13-15 (98.0%), normal head computed tomography (81.3%) and no prior history of concussion (71.7%). CONCLUSION: With systematic phenotyping, HeadSMART will facilitate diagnosis and risk-stratification of the heterogeneous group of individuals currently diagnosed with TBI.

Impact of antibiotic choices made in the emergency department on appropriateness of antibiotic treatment of urinary tract infections in hospitalized patients.

BACKGROUND: Overuse of antibiotics to treat urinary tract infections (UTIs) is common in hospitalized patients and may begin in the emergency department (ED). METHODS: For a 4-week period we reviewed medical records of all patients admitted to the hospital who initiated treatment for a UTI in the ED. RESULTS: According to study criteria, initiation of antibiotics was inappropriate for 55 of 94 patients (59% [95% confidence interval {CI}, 48%-69%]), and continuation after admission was inappropriate for 54 of 80 patients (68% [95% CI, 57%-78%]). CONCLUSION: Failure to reevaluate the need for antibiotics initiated in the ED to treat UTIs may lead to overuse of antibiotics in hospitalized patients.

Effect of an emergency department-based electronic system for musculoskeletal consultation on facilitating care for common injuries.

Access to musculoskeletal consultation in the emergency department (ED) is a nationwide problem. In addition, consultation from a subspecialist may be delayed or may not be available, which can slow down the ED flow and reduce patient satisfaction. The purpose of this study was to review the 1-year results of a change in the authors' institutional practice to reduce subspecialty consultation for select musculoskeletal problems while still ensuring adequate patient follow-up in orthopedic or plastic surgery clinics for patients not seen by these services in the ED. The authors hypothesized that select injuries could be safely managed in the ED by using an electronic system to ensure appropriate follow-up care. Using Kaizen methodology, a multidisciplinary group (including ED staff, orthopedics, plastic surgery, pediatrics, nursing, radiology, therapy, and administration) met to improve care for select musculoskeletal injuries. A system was agreed on in which ED providers managed select musculoskeletal injuries without subspecialist consultation. Follow-up was organized using an electronic system, which facilitated communication between the ED staff and the secretarial staff of the subspecialist departments. Over a 1-year period, 150 patients were treated using this system. Charts and radiographs were reviewed for missed injuries. Radiographic review revealed 2 missed injuries. One patient had additional back pain and a lumbar spine fracture was found during the subspecialist follow-up visit; it was treated nonoperatively. Another patient appeared to have scapholunate widening on the injury radiograph that was not appreciated in the ED. Of the 150 patients, 51 were seen in follow-up by a subspecialist at the authors' institution. An electronic system to organize follow-up with a subspecialist allowed the ED providers to deliver safe and effective care for simple musculoskeletal injuries.

Evidence-based diagnosis and thrombolytic treatment of cardiac arrest or periarrest due to suspected pulmonary embolism.

When a previously healthy adult experiences atraumatic cardiac arrest, providers must quickly identify the etiology and implement potentially lifesaving interventions such as advanced cardiac life support. A subset of these patients develop cardiac arrest or periarrest due to pulmonary embolism (PE). For these patients, an early, presumptive diagnosis of PE is critical in this patient population because administration of thrombolytic therapy may significantly improve outcomes. This article reviews thrombolysis as a potential treatment option for patients in cardiac arrest or periarrest due to presumed PE, identifies features associated with a high incidence of PE, evaluates thrombolytic agents, and systemically reviews trials evaluating thrombolytics in cardiac arrest or periarrest. Despite potentially improved outcomes with thrombolytic therapy, this intervention is not without risks. Patients exposed to thrombolytics may experience major bleeding events, with the most devastating complication usually being intracranial hemorrhage. To optimize the risk-benefit ratio of thrombolytics for treatment of cardiac arrest due to PE, the clinician must correctly identify patients with a high likelihood of PE and must also select an appropriate thrombolytic agent and dosing protocol.

Factors associated with emergency department length of stay for patients with hip fracture.

Time to surgery, which includes time in the emergency department (ED), is important for all patients with hip fracture. We hypothesized that patients with hip fracture spend significantly more time in the ED than do patients with the top 5 most common conditions. In addition, we hypothesized that there are patient, physician, and hospital factors that affect the length of time spent in the ED. We retrospectively reviewed our institution's hip fracture database and identified 147 elderly patients with hip fractures who presented to our ED from December 18, 2005, through April 30, 2009. We reviewed their records for patient, practitioner, and hospital factors of interest associated with ED time and for 6 specified time intervals. Average working, boarding (waiting for an inpatient room), and total times were calculated and compared with respective averages for admitted ED patients with the top 5 most common conditions. Univariate and multivariate analyses were performed before and after adjusting for confounders (significance, P = .05). The mean total ED time (7 hours and 25 minutes) and working time (4 hours and 31 minutes) for patients with hip fracture were similar to the respective overall averages for admitted ED patients. However, the average boarding time for patients with hip fracture was 2 hours 44 minutes, longer than that for other patients admitted through the ED. Factors significantly associated with longer ED times were a history of hypertension, history of atrial fibrillation, the number of computed tomography scans ordered, and the occupancy rate. Admission to the hip fracture service decreased working time but not overall time. Substantial multidisciplinary work among the ED, hospital admission services, and physicians is needed to dramatically decrease the boarding time and thus the overall time to surgery.

Does providing prescription information or services improve medication adherence among patients discharged from the emergency department? A randomized controlled trial.

STUDY OBJECTIVE: We determine whether prescription information or services improve the medication adherence of emergency department (ED) patients. METHODS: Adult patients treated at one of 3 EDs between November 2010 and September 2011 and prescribed an antibiotic, central nervous system, gastrointestinal, cardiac, or respiratory drug at discharge were eligible. Subjects were randomly assigned to usual care or one of 3 prescription information or services intervention groups: (1) practical services to reduce barriers to prescription filling (practical prescription information or services); (2) consumer drug information from MedlinePlus (MedlinePlus prescription information or services); or (3) both services and information (combination prescription information or services). Self-reported medication adherence, measured by primary adherence (prescription filling) and persistence (receiving medicine as prescribed) rates, was determined during a telephone interview 1 week postdischarge. RESULTS: Of the 3,940 subjects enrolled and randomly allocated to treatment, 86% (N=3,386) completed the follow-up interview. Overall, primary adherence was 88% and persistence was 48%. Across the sites, primary adherence and persistence did not differ significantly between usual care and the prescription information or services groups. However, at site C, subjects who received the practical prescription information or services (odds ratio [OR]=2.4; 95% confidence interval [CI] 1.4 to 4.3) or combination prescription information or services (OR=1.8; 95% CI 1.1 to 3.1) were more likely to fill their prescription compared with usual care. Among subjects prescribed a drug that treats an underlying condition, subjects who received the practical prescription information or services were more likely to fill their prescription (OR=1.8; 95% CI 1.0 to 3.1) compared with subjects who received usual care. CONCLUSION: Prescription filling and receiving medications as prescribed was not meaningfully improved by offering patients patient-centered prescription information and services.

A randomized controlled trial of the effect of service delivery information on patient satisfaction in an emergency department fast track.

OBJECTIVES: The objective was to determine the effect on patient satisfaction of providing patients with predicted service completion times. METHODS: A randomized controlled trial was conducted in an urban, community teaching hospital. Emergency department (ED) patients triaged to fast track on weekdays between October 26, 2009, and December 30, 2009, from 9 am to 5 pm were eligible. Patients were randomized to: 1) usual care (n = 342), 2) provided ED process information (n = 336), or 3) provided ED process information plus predicted service delivery times (n = 333). Patients in group 3 were given an "average" and "upper range" estimate of their waiting room times and treatment times. The average and upper range predictions were calculated from quantile regression models that estimated the 50th and 90th percentiles of the waiting room time and treatment time distributions for fast track patients at the study site based on 2.5 years of historical data. Trained research assistants administered the interventions after triage. Patients completed a brief survey at discharge that measured their satisfaction with overall care, the quality of the information they received, and the timeliness of care. Satisfaction ratings of very good versus good, fair, poor, and very poor were modeled using logistic regression as a function of study group; actual service delivery times; and other patient, clinical, and temporal covariates. The study also modeled satisfaction ratings of fair, poor, and very poor compared to good and very good ratings as a function of the same covariates. RESULTS: Survey completion rates and patient, clinical, and temporal characteristics were similar by study group. Median waiting room time was 70 minutes (interquartile range [IQR] = 40 to 114 minutes), and median treatment time was 52 minutes (IQR = 31 to 81 minutes). Neither intervention affected any of the satisfaction outcomes. Satisfaction was significantly associated with actual waiting room time, individual providers, and patient age. Every 10-minute increase in waiting room time corresponded with an 8% decrease (odds ratio [OR] = 0.92; 95% confidence interval [CI] = 0.89 to 0.95) in the odds of reporting very good satisfaction with overall care. The odds of reporting very good satisfaction with care were lower for several triage nurses and fast track nurses, compared to the triage nurse and fast track nurse who treated the most study patients. Each 10-minute increase in waiting room time was also associated with a 10% increase in the odds of reporting very poor, poor, or fair satisfaction with overall care (OR = 1.10; 95% CI = 1.06 to 1.14). The odds of reporting very poor, poor, or fair satisfaction with overall care also varied significantly among the triage nurses, fast track doctors, and fast track nurses. The odds of reporting very poor, poor, or fair satisfaction with overall care were significantly lower among patients aged 35 years and older compared to patients aged 18 to 34 years. CONCLUSIONS: Satisfaction with overall care was influenced by waiting room time and the clinicians who treated them and not by service completion time estimates provided at triage.

A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model.

STUDY OBJECTIVE: We inform the future development of a new geriatric emergency management practice model. We perform a systematic review of the existing evidence for emergency department (ED)-based case management models designed to improve the health, social, and health service utilization outcomes for noninstitutionalized older patients within the context of an index ED visit. METHODS: This was a systematic review of English-language articles indexed in MEDLINE and CINAHL (1966 to 2010), describing ED-based case management models for older adults. Bibliographies of the retrieved articles were reviewed to identify additional references. A systematic qualitative case study analytic approach was used to identify the core operational components and outcome measures of the described clinical interventions. The authors of the included studies were also invited to verify our interpretations of their work. The determined patterns of component adherence were then used to postulate the relative importance and effect of the presence or absence of a particular component in influencing the overall effectiveness of their respective interventions. RESULTS: Eighteen of 352 studies (reported in 20 articles) met study criteria. Qualitative analyses identified 28 outcome measures and 8 distinct model characteristic components that included having an evidence-based practice model, nursing clinical involvement or leadership, high-risk screening processes, focused geriatric assessments, the initiation of care and disposition planning in the ED, interprofessional and capacity-building work practices, post-ED discharge follow-up with patients, and evaluation and monitoring processes. Of the 15 positive study results, 6 had all 8 characteristic components and 9 were found to be lacking at least 1 component. Two studies with positive results lacked 2 characteristic components and none lacked more than 2 components. Of the 3 studies with negative results demonstrating no positive effects based on any outcome tested, one lacked 2, one lacked 3, and one lacked 4 of the 8 model components. CONCLUSION: Successful models of ED-based case management models for older adults share certain key characteristics. This study builds on the emerging literature in this area and leverages the differences in these models and their associated outcomes to support the development of an evidence-based normative and effective geriatric emergency management practice model designed to address the special care needs and thereby improve the health and health service utilization outcomes of older patients.

The effect of triage diagnostic standing orders on emergency department treatment time.

STUDY OBJECTIVE: Triage standing orders are used in emergency departments (EDs) to initiate evaluation when there is no bed available. This study evaluates the effect of diagnostic triage standing orders on ED treatment time of adult patients who presented with a chief complaint for which triage standing orders had been developed. METHODS: We conducted a retrospective nested cohort study of patients treated in one academic ED between January 2007 and August 2009. In this ED, triage nurses can initiate full or partial triage standing orders for patients with chest pain, shortness of breath, abdominal pain, or genitourinary complaints. We matched patients who received triage standing orders to those who received room orders with respect to clinical and temporal factors, using a propensity score. We compared the median treatment time of patients with triage standing orders (partial or full) to those with room orders, using multivariate linear regression. RESULTS: Of the 15,188 eligible patients, 25% received full triage standing orders, 56% partial triage standing orders, and 19% room orders. The unadjusted median ED treatment time for patients who did not receive triage standing orders was 282 minutes versus 230 minutes for those who received a partial triage standing order or full triage standing orders (18% decrease). Controlling for other factors, triage standing orders were associated with a 16% reduction (95% confidence interval -18% to -13%) in the median treatment time, regardless of chief complaint. CONCLUSION: Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common chief complaints. This intervention warrants further evaluation in other EDs and with different clinical conditions and tests.

Successful sonographic visualisation of the abdominal aorta differs significantly among a diverse group of credentialed emergency department providers.

BACKGROUND: The aims of this study were to examine the association between emergency department (ED) providers' experience with bedside ultrasound after achieving credentialing for abdominal aortic aneurysm (AAA) sonography, and their successful visualisation rate of the abdominal aorta among consecutive patients who presented asymptomatically but with risk factors for AAA. METHODS: Study coordinators enrolled asymptomatic men > 50 years presenting to a single ED with AAA risk factors. One of 20 AAA credentialed ED sonographers screened each subject for AAA. Screening forms and ultrasound images were reviewed for quality assurance. Multivariate logistic regression was used to estimate OR of visualisation and correct measurement among providers with varying experience, adjusted for bowel gas and body mass index (BMI). RESULTS: During the 12 week enrolment, 278 patients were eligible and 196 (70%) enrolled. ED sonographers accurately visualised the entire abdominal aorta of 140 subjects (71.4%), did not completely visualise 40 (20.4%) and incorrectly measured 16 (8.2%). After controlling for bowel gas and BMI, providers with < 1 year of experience (OR 6.7, 95% CI 2.0 to 22.2) and with 1-3 years experience post credentialing for AAA (OR 9.6, 95% CI 2.2 to 43.2) were significantly less likely to visualise and accurately measure the aorta compared to providers with >3 years experience. CONCLUSION: AAA sonography performance varied markedly among a diverse group of already credential ED sonographers. The most experienced providers demonstrated best performance. The present results suggest that some providers might require > 25 proctored scans to ensure competency and training, and training on technically difficult patients should be part of the credentialing process.

Hospitalist bed management effecting throughput from the emergency department to the intensive care unit.

RATIONALE: Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes. OBJECTIVE: To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the "active bed management" (ABM) intervention. METHODS: A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow. MEASUREMENT: Throughput time for patients presenting to the ED requiring ICU admission was analyzed. MAIN RESULTS: The ED census was higher during the intervention period as compared with the control period, 17 573 versus 16 148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (+/-14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant. CONCLUSION: Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.

Ethical issues of cardiopulmonary resuscitation: comparison of emergency physician practices from 1995 to 2007.

OBJECTIVES: The objectives were to determine current practice among emergency physicians (EPs) regarding the initiation and termination of cardiopulmonary resuscitative (CPR) efforts and to compare responses to those from a similar study performed in 1996. METHODS: This anonymous self-administered survey was mailed to 4,991 randomly selected EPs. Main outcome measures included responses regarding current practices related to advance directives and initiation and termination of resuscitative attempts. Results from 1995 and 2007 surveys were compared, using 95% confidence intervals (CIs) of the difference between groups. RESULTS: Among 928 respondents (18% response rate), most (86%) honor legal advance directives, an increase over 78% reported in 1996 (8% increase, 95% CI = 5% to 11%). Few honor unofficial documents (7%) or verbal reports (12%) of advance directives. Many (58%) make decisions regarding resuscitation because of fear of litigation or criticism. Most respondents (62%) attempt resuscitation in 10% or more of cases of cardiac arrest. A majority (56%) have attempted more than 10 resuscitations in the past 3 years, despite expectations that such efforts would be futile. Factors reported to be "very important" in making resuscitation decisions were advance directives (78%), witnessed arrest (77%), downtime (73%), family wishes (40%), presenting rhythm (38%), age (28%), and prearrest state of health (25%). A significant majority of respondents (80%) indicated that ideally, legal concerns should not influence physician practices regarding resuscitation, but that in the current environment, legal concerns do influence practice (92%). Other than the increase in respondents who honor legal advance directives, these results do not differ substantially from responses in 1996. CONCLUSIONS: Most EPs attempt to resuscitate patients in cardiopulmonary arrest regardless of poor outcomes, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than professional judgment of medical benefit. Most results did not differ significantly from the previous study of 1995, although more physicians honor legal advance directives than previously noted.

Routine screening for asymptomatic abdominal aortic aneurysm in high-risk patients is not recommended in emergency departments that are frequently crowded.

OBJECTIVES: The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high-risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population. METHODS: A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June-August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers' opinions) and the prevalence of AAA (aortic diameter of > or =3.0 cm) in the study sample. RESULTS: During the 12-week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening. CONCLUSIONS: Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high-risk patients.

Active bed management by hospitalists and emergency department throughput.

BACKGROUND: When emergency departments are overcrowded, ambulances are diverted. Interventions focused primarily on emergency departments have had limited success. OBJECTIVE: To discover whether an active bed management, quality improvement initiative could reduce ambulance diversion hours and emergency department throughput times. DESIGN: Pre-post study that compared institutional data from November 2006 to February 2007 (intervention period) with data from November 2005 to February 2006 (control period). SETTING: Johns Hopkins Bayview Medical Center, Baltimore, Maryland. PATIENTS: All adult patients registered in the emergency department during the study periods. INTERVENTION: Active bed management is a hospitalist-led, multifaceted intervention that consists of proactive management of hospital and departmental resources, including twice-daily bed management rounds in the intensive care unit and regular visits to the emergency department to assess congestion and flow; assignment of all admissions to the department of medicine and facilitating transfer from the emergency department to the appropriate care setting; and support from the "bed director," who can mobilize additional resources in real time to augment hospital capacity to address emergency department throughput problems. MEASUREMENTS: Emergency department throughput times and ambulance diversion hours. RESULTS: The emergency department census was 8.8% higher during the intervention period than in the control period (17 573 patients vs. 16 148 patients). Throughput for patients who were admitted decreased by 98 minutes (SD, 10) (from 458 minutes in the control period to 360 minutes during the intervention period). Throughput for patients who were not admitted did not change (274 minutes vs. 269 minutes). The percentage of hours that the emergency department was on "yellow alert" (ambulance diversion because of emergency department crowding) decreased 6%, and the percentage of hours on "red alert" (ambulance diversion due to lack of intensive care unit beds in the hospital) decreased 27%. Staffing, length of stay, case-mix index, intensive care unit transfer rates, and mortality rates were stable across the 2 periods. LIMITATIONS: Pre-post designs are less effective than randomized, controlled trials on the study design hierarchy, and unidentified external forces may have influenced the results. The study was done at a single hospital, and the findings may not be generalizable to other institutions. CONCLUSION: Emergency department throughput and diversion status improved with the implementation of an active bed management process coordinated by hospitalists.

Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma?

Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.

Hospitalists and an innovative emergency department admission process.

After treatment in an emergency department (ED), patients often wait several hours for hospital admission, resulting in dissatisfaction and increased wait times for both admitted and other ED patients. We implemented a new direct admission system based on telephone consultation between ED physicians and in-house hospitalists. We studied this system, measuring admission times, length of stay, and mortality. Postintervention, admission times averaged 18 minutes for transfer to the ward compared to 2.5 hours preintervention, while pre- and postintervention length of stay and mortality rates remained similar.

Referral of medically uninsured emergency department patients to primary care.

OBJECTIVE: To examine the impact primary care referral has on subsequent emergency department (ED) utilization. METHODS: Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital-based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral. RESULTS: Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self-pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p < 0.001). There was no significant difference in pre- or post-ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001). CONCLUSIONS: For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.