Characteristics of Medicaid enrollees with frequent ED use.

BACKGROUND: Medicaid enrollees are disproportionately represented among patients with frequent Emergency Department (ED) visits, yet prior studies investigating frequent ED users have focused on patients with all insurance types. METHODS: This was a single center, retrospective study of Medicaid-insured frequent ED users (defined as ≥4 ED visits/year not resulting in hospital admission) to assess patients' sociodemographic and clinical characteristics and evaluate differences in these characteristics by frequency of use (4-6, 7-17, and ≥18 ED visits). RESULTS: Twelve percent (n = 1619) of Medicaid enrollees who visited the ED during the 1-year study period were frequent ED users, accounting for 38% of all ED visits (n = 10,337). Most frequent ED users (n = 1165, 72%) had 4-6 visits; 416 (26%) had 7-17 visits, and 38 (2%) had ≥18 visits. Overall, 67% had a primary care provider and 56% had at least one chronic medical condition. The most common ED diagnosis among patients with 4-6 visits was abdominal pain (7%); among patients with 7-17 and ≥18 ED visits, the most common diagnosis was alcohol-related disorders (11% and 36%, respectively). Compared with those who had 4-6 visits, patients with ≥18 visits were more likely to be homeless (7% vs 42%, P < .05) and suffer from alcohol abuse (15% vs 42%, P < .05). CONCLUSION: One out of 8 Medicaid enrollees who visited the ED had ≥4 visits in a year. Efforts to reduce frequent ED use should focus on reducing barriers to accessing primary care. More tailored interventions are needed to meet the complex needs of adults with ≥18 visits per year.

Republished: Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

OBJECTIVE: The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. METHODS: We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. RESULTS: Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. CONCLUSIONS: The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

OBJECTIVE: The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. METHODS: We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. RESULTS: Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. CONCLUSIONS: The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

Project Access-New Haven: improving access to specialty care for patients without insurance.

BACKGROUND: Poor access to specialty care among uninsured adults threatens the delivery of quality health care and may contribute to the misuse and overuse of emergency departments and hospitals. INTERVENTION: We sought to improve access to specialty care through a program called Project Access-New Haven (PA-NH),which engages specialty physicians and hospitals to volunteer in a coordinated-care model for the uninsured. Patient navigators guide patients through the health-care network and help to alleviate administrative obstacles. RESULTS: Project Access-New Haven has been operational since August 2010. With >200 specialty physicians volunteering and strong commitments from local hospitals, comprehensive specialty care has been provided to 78 patients. Average wait-time for appointments is 17 days. CONCLUSION: PA-NH provides timely medical care and patient navigation foruninsured patientswith specialty-care needs. In the process, more physicians are participating in the care of vulnerable populations. Further data are needed to assess the potential cost-savings of PA-NH.

What can we learn from patient dissatisfaction? An analysis of dissatisfying events at an academic medical center.

BACKGROUND: Patient satisfaction is typically measured by quantitative surveys using predetermined domains. However, dissatisfaction may be an entity distinct from satisfaction, may have different determinants, and may better reflect problems in healthcare delivery. OBJECTIVE: The aim of this study was to describe domains of dissatisfaction experienced by patients during hospitalization. SETTING: The setting was a U.S. urban academic medical center. PATIENTS: The patients were adults discharged between July 1, 2007 and June 30, 2008 INTERVENTION: The intervention was a postdischarge telephone interview: "If there was one thing we could have done to improve your experience in the hospital, what would it have been?" MEASUREMENTS: The measurements were standard qualitative analysis of suggestions for improvement. RESULTS: We randomly selected 976 of 9,764 interviews. A total of 439/976 (45.0%) included at least one suggestion for improvement. We identified six major domains of dissatisfaction: ineptitude (7.7%), disrespect (6.1%), waits (15.8%), ineffective communication (7.4%), lack of environmental control (15.6%), and substandard amenities (6.9%). These domains corresponded to six implicit expectations for quality hospital care: safety, treatment with respect and dignity, minimized wait times, effective communication, control over physical surroundings, and high-quality amenities. Some of these expectations, such as for safe care, effective communication between providers, and lack of disrespect, may not be adequately captured in existing patient satisfaction assessments. CONCLUSIONS: The results represent patient-generated priorities for quality improvement in healthcare. These priorities are not all consistently represented in standard patient satisfaction surveys and quality improvement initiatives. Patient input is critical to assessing the quality of hospital care and to identifying areas for improvement.