Using a pacifier to decrease sudden infant death syndrome: an emergency department educational intervention.

Background. Pacifier use decreases the risk of sudden infant death syndrome (SIDS). An emergency department (ED) visit may provide an opportunistic 'teachable moment' for parents. Objectives. To test the hypotheses (1) that caregivers were less familiar with the role of pacifiers in sudden infant death (SIDS) prevention than other recommendations, and (2) that an ED educational intervention would increase pacifier use in infants younger than six months, and (3) that otitis media would not occur more frequently in pacifier users. Methods. We did an intervention-group-only longitudinal study in a county hospital ED. We measured pacifier use infants and baseline knowledge of SIDs prevention recommendations in caregivers. We followed up three months later to determine pacifier use, and 12 months later to determine episodes of otitis media. Results. We analyzed data for 780 infants. Parents knew of advice against co-sleeping in 469/780 (60%), smoking in 660/776 (85%), and prone sleeping in 613/780 (79%). Only 268/777 (35%) knew the recommendation to offer a pacifier at bedtime. At enrollment 449/780 (58%) did not use a pacifier. Of 210/338 infants aged less than 6 months followed up 41/112 (37%) non-users had started using a pacifier at bedtime (NNT 3). Over the same period, 37/98 (38%) users had discontinued their pacifier. Otitis media did not differ between users and non-users at 12 months. Conclusion. Caregiver knowledge of the role of pacifiers in SIDS prevention was less than for other recommendations. Our educational intervention appeared to increase pacifier use. Pacifier use was not associated with increased otitis media.

Referral without access: for psychiatric services, wait for the beep.

STUDY OBJECTIVE: We examine access to care for acute depression by insurance status compared to access for acute medical conditions in 9 metropolitan areas in the United States. METHODS: Using an audit study design, trained research assistants posing as patients referred from a local emergency department (ED) for treatment of depression called each clinic twice, with differing insurance status. The main outcome measure was the ability to schedule a mental health appointment within 2 weeks of the ED visit. RESULTS: In 45% of 322 calls to mental health clinics, the research assistant reached an answering machine compared with 8% of calls to medical clinics. As a result, only 31% of callers with depression vignettes were able to determine whether they could get an appointment versus 78% of callers with medical complaints. When they reached appointment personnel by telephone, 57% of depression callers successfully arranged an appointment (39% within 14 days). Among depression callers who reached appointment personnel, 67% of privately insured and 33% of Medicaid callers were able to make an appointment, for overall appointment rates of 22% and 12%, respectively. Appointment success for the uninsured was comparable to that of Medicaid patients. The high percentage of callers who encountered answering machines prevented us from completing the designed analysis of paired calls to individual clinics. CONCLUSION: Our findings indicate that the process for obtaining urgent follow-up appointments is systematically different for patients seeking behavioral health care than for those with physical complaints. The use of voicemail, in lieu of having a person answer the telephone, is much more prevalent in behavioral than physical health settings. More work is needed to determine the effect of this practice on depressed individuals and vulnerable populations.

Nonprice barriers to ambulatory care after an emergency department visit.

STUDY OBJECTIVE: Availability of timely follow-up care is essential in emergency medicine. We describe nonprice barriers to care experienced by callers reporting to be emergency department (ED) patients in need of follow-up care. METHODS: This was a secondary analysis of data collected during a survey of ambulatory clinics in 9 US cities. Research assistants called a random sample of 603 ambulatory clinics, generated from actual ED referral lists. Callers identified themselves as new patients referred by the local ED. Outcome measures were the percentage of callers experiencing failed appointment attempts for a variety of reasons and inconvenience factors associated with the appointment process: number and amount of time spent on hold, voicemail, repeated calls, and total telephone time. RESULTS: Only 242 (23%) of 1065 total calls resulted in an appointment within one week, for an ultimate caller success rate of 40% (242/603 pseudopatient scenarios). Independent of insurance status, 43% of 603 initial calls to ED referral numbers were unsuccessful: 27% of initial call failures were due to clinic closures, busy signals, voicemail, or personnel too busy to take the call; 6% wrong numbers; 4% disconnected or extended holds; and 6% out of practice scope. If they reached clinic personnel, 55% of callers were placed on hold; average hold time was 2.43 minutes (median 1.35 minutes). Answering system time averaged 1.17 minutes (median 0.68 minutes; range 0.02 to 13.90 minutes). On average, it required 1.7 calls to reach appointment staff and 8% of clinic contacts required 4 or more attempts. Total telephone time averaged 11.1 minutes for successful appointments. CONCLUSION: There are important nonprice barriers to obtaining follow-up appointments for urgent conditions, independent of insurance status.

The effect of crowding on access and quality in an academic ED.

BACKGROUND: Emergency department crowding has the potential to cause undesirable outcomes. We evaluated ED access and provider and patient assessments of quality. METHODS: This multimethod study, done in an urban academic ED, included descriptive analysis of administrative records, paired physician and nurse provider surveys, and pre- or postpatient surveys regarding expectations and experiences. Our outcomes were rates and characteristics of patients who left without being seen (LWBS), provider ratings of crowding/compromised care, and patient satisfaction. RESULTS: During data collection periods, 11743 patients registered, and 9% LWBS. Patients who LWBS tended to be younger than 45 years (relative risk [RR] = 1.7; 95% confidence interval [CI], 1.5-1.9), of nonurgent/stable triage acuity (RR = 3.1; 95% CI, 2.5-3.8), and without insurance (RR = 1.5; 95% CI, 1.3-1.7). Seventy-four percent of all patients had insurance, and 28% were private. Doctors and nurses had 81% agreement (kappa = 0.54) in their assessment of crowded conditions, which were temporally associated with LWBS rates (P < .01). In 47% of 57 shifts, at least 1 provider felt that crowding was compromising quality of care. Of 423 sequential ED waiting room patients approached, 310 (73%) enrolled and 174 (56%) of these completed phone follow-up. On average, patients felt that they should be seen within 1 hour but expected to wait for 2.1 hours. Patient's perceived that wait times on follow-up averaged 3.5 hours, 5+ hours for LWBS patients. Visit satisfaction was inversely related to patient's perceived wait times. CONCLUSIONS: We find that ED crowding increased LWBS rates and patient satisfaction. Systemwide changes in ED organization will be necessary for the ED to fulfill its role as a safety net provider and meet public health needs during disaster surge capacity.

Resuscitating the physician-patient relationship: emergency department communication in an academic medical center.

STUDY OBJECTIVE: We characterize communication in an urban, academic medical center emergency department (ED) with regard to the timing and nature of the medical history survey and physical examination and discharge instructions. METHODS: Audiotaping and coding of 93 ED encounters (62 medical history surveys and physical examinations, 31 discharges) with a convenience sample of 24 emergency medicine residents, 8 nurses, and 93 nonemergency adult patients. RESULTS: Patients were 68% women and 84% black, with a mean age of 45 years. Emergency medicine providers were 70% men and 80% white. Of 62 medical history surveys and physical examinations, time spent on the introduction and medical history survey and physical examination averaged 7 minutes 31 seconds (range 1 to 20 minutes). Emergency medicine residents introduced themselves in only two thirds of encounters, rarely (8%) indicating their training status. Despite physician tendency (63%) to start with an open-ended question, only 20% of patients completed their presenting complaint without interruption. Average time to interruption (usually a closed question) was 12 seconds. Discharge instructions averaged 76 seconds (range 7 to 202 seconds). Information on diagnosis, expected course of illness, self-care, use of medications, time-specified follow-up, and symptoms that should prompt return to the ED were each discussed less than 65% of the time. Only 16% of patients were asked whether they had questions, and there were no instances in which the provider confirmed patient understanding of the information. CONCLUSION: Academic EDs present unique challenges to effective communication. In our study, the physician-patient encounter was brief and lacking in important health information. Provision of patient-centered care in academic EDs will require more provider education and significant system support.