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.

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.

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.

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.

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.