Masking for COVID-19 Is Associated with Decreased Emergency Department Utilization for Non-COVID Viral Illnesses and Respiratory Conditions in Maryland.

BACKGROUND: Masking, which is known to decrease the transmission of respiratory viruses, was not widely practiced in the United States until the coronavirus disease 2019 (COVID-19) pandemic. This provides a natural experiment to determine whether the percentage of community masking was associated with decreases in emergency department (ED) visits due to non-COVID viral illnesses (NCVIs) and related respiratory conditions. METHODS: In this observational study of ED encounters in a 11-hospital system in Maryland during 2019-2020, year-on-year ratios for all complaints were calculated to account for "lockdowns" and the global drop in ED visits due to the pandemic. Encounters for specific complaints were identified using the International Classification of Diseases, version 10. Encounters with a positive COVID test were excluded. Linear regression was used to determine the association of publicly available masking data with ED visits for NCVI and exacerbations of asthma and chronic obstructive pulmonary disease (COPD), after adjusting for patient age, sex, and medical history. RESULTS: There were 285,967 and 252,598 ED visits across the hospital system in 2019 and 2020, respectively. There was a trend toward an association between the year-on-year ratio for all ED visits and the Maryland stay-at-home order (parameter estimate = -0.0804, P = .10). A 10% percent increase in the prevalence of community masking was associated with a 17.0%, 8.8%, and 9.4% decrease in ED visits for NCVI and exacerbations of asthma exacerbations and chronic obstructive pulmonary disease, respectively (P < .001 for all). CONCLUSIONS: Increasing the prevalence of masking is associated with a decrease in ED visits for viral illnesses and exacerbations of asthma and COPD. These findings may be valuable for future public health responses, particularly in future pandemics with respiratory transmission or in severe influenza seasons.

Emergency department care coordination strategies and perceived impact under Maryland's hospital payment reforms.

BACKGROUND: Emergency department (ED) care coordination plays an important role in facilitating care transitions across settings. We studied ED care coordination processes and their perceived effectiveness in Maryland (MD) hospitals, which face strong incentives to reduce hospital-based care through global budgets. METHODS: We conducted a qualitative study using semi-structured interviews to examine ED care coordination processes and perceptions of effectiveness. Interviews were conducted from January through October 2019 across MD hospital-based EDs. Results were reviewed to assign analytic domains and identify emerging themes. Descriptive statistics of ED care coordination staffing and processes were also calculated. RESULTS: A total of 25 in-depth interviews across 18 different EDs were conducted with ED physician leadership (n = 14) and care coordination staff (CCS) (n = 11). Across all EDs, there was significant variation in the hours and types of CCS coverage and the number of initiatives implemented to improve care coordination. Participants perceived ED care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient providers was a significant barrier. The majority of ED physician leaders perceived MD's policy reform as having a mixed impact, with improved care transitions and overall patient care as benefits, but increased physician workloads and worsened ED throughput as negative effects. CONCLUSIONS: EDs have responded to the value-based care incentives of MD's global budgeting program with investments to enhance care coordination staffing and a variety of initiatives targeting specific patient populations. Although the observed care coordination initiatives were broadly perceived to produce positive results, MD's global budgeting policies were also perceived to produce barriers to optimizing ED care. Further research is needed to determine the association of the various strategies to improve ED care coordination with patient outcomes to inform practice leaders and policymakers on the efficacy of the various approaches.

The Effects of Global Budgeting on Emergency Department Admission Rates in Maryland.

STUDY OBJECTIVE: In 2014, Maryland launched a population-based payment model that replaced fee-for-service payments with global budgets for all hospital-based services. This global budget revenue program gives hospitals strong incentives to tightly control patient volume and meet budget targets. We examine the effects of the global budget revenue model on rates of admission to the hospital from emergency departments (EDs). METHODS: We used medical record and billing data to examine adult ED encounters from January 1, 2012, to December 31, 2015, in 25 hospital-based EDs, including 10 Maryland global budget revenue hospitals, 10 matched non-Maryland hospitals (primary control), and 5 Maryland Total Patient Revenue hospitals (secondary control). Total Patient Revenue hospitals adopted global budgeting in 2010 under a pilot Maryland program targeting rural hospitals. We conducted difference-in-differences analyses for overall ED admission rates, ED admission rates for ambulatory-care-sensitive conditions and non-ambulatory-care-sensitive conditions, and for clinical conditions that commonly lead to admission. RESULTS: In 3,175,210 ED encounters, the ED admission rate for Maryland global budget revenue hospitals decreased by 0.6% (95% confidence interval -0.8% to -0.4%) compared with that for non-Maryland controls after global budget revenue implementation, a 3.0% relative decline, and decreased by 1.9% (95% confidence interval -2.2% to -1.7%) compared with that for Total Patient Revenue hospitals, a 9.5% relative decline. Relative declines in ED admission rates were similar for ambulatory-care-sensitive-condition and non-ambulatory-care-sensitive-condition encounters. Admission rate declines varied across clinical conditions. CONCLUSION: Implementation of the global budget revenue model led to statistically significant although modest declines in ED admission rates within its first 2 years, with declines in ED admissions most pronounced among certain clinical conditions.

Impact of Global Budget Revenue Policy on Emergency Department Efficiency in the State of Maryland.

INTRODUCTION: On January 1, 2014, the State of Maryland implemented the Global Budget Revenue (GBR) program. We investigate the impact of GBR on length of stay (LOS) for inpatients in emergency departments (ED) in Maryland. METHODS: We used the Hospital Compare data reports from the Centers for Medicare and Medicaid Services (CMS) and CMS Cost Reports Hospital Form 2552-10 from January 1, 2012-March 31, 2016, with GBR hospitals from Maryland and hospitals from West Virginia (WV), Delaware (DE), and Rhode Island (RI). We implemented difference-in-differences analysis and investigated the impact of GBR implementation on the LOS or ED1b scores of Maryland hospitals using a mixed-effects model with a state-level fixed effect, a hospital-level random effect, and state-level heterogeneity. RESULTS: The GBR impact estimator was 9.47 (95% confidence interval [CI], 7.06 to 11.87, p-value<0.001) for Maryland GBR hospitals, which implies, on average, that GBR implementation added 9.47 minutes per year to the time that hospital inpatients spent in the ED in the first two years after GBR implementation. The effect of the total number of hospital beds was 0.21 (95% CI, 0.089 to 0.330, p-value = 0 .001), which suggests that the bigger the hospital, the longer the ED1b score. The state-level fixed effects for WV were -106.96 (95% CI, -175.06 to -38.86, p-value = 0.002), for DE it was 6.51 (95% CI, -8.80 to 21.82, p-value=0.405), and for RI it was -54.48 (95% CI, -82.85 to -26.10, p-value<0.001). CONCLUSION: Our results indicate that GBR implementation has had a statistically significant negative impact on the efficiency measure ED1b of Maryland hospital EDs from January 2014 to April 2016. We also found that the significant state-level fixed effect implies that the same inpatient might experience different ED processing times in each of the four states that we studied.

Resource Utilization in Non-Academic Emergency Departments with Advanced Practice Providers.

INTRODUCTION: Advanced practice providers (APP), including physicians' assistants and nurse practitioners, have been increasingly incorporated into emergency department (ED) staffing over the past decade. There is scant literature examining resource utilization and the cost benefit of having APPs in the ED. The objectives of this study were to compare resource utilization in EDs that use APPs in their staffing model with those that do not and to estimate costs associated with the utilized resources. METHODS: In this five-year retrospective secondary data analysis of the Emergency Department Benchmarking Alliance (EDBA), we compared resource utilization rates in EDs with and without APPs in non-academic EDs. Primary outcomes were hospital admission and use of computed tomography (CT), radiography, ultrasound, and magnetic resonance imaging (MRI). Costs were estimated using the 2014 physician fee schedule and inpatient payments from the Centers for Medicare and Medicaid Services. We measured outcomes as rates per 100 visits. Data were analyzed using a mixed linear model with repeated measures, adjusted for annual volume, patient acuity, and attending hours. We used the adjusted net difference to project utilization costs between the two groups per 1000 visits. RESULTS: Of the 1054 EDs included in this study, 79% employed APPs. Relative to EDs without APPs, EDs staffing APPs had higher resource utilization rates (use per 100 visits): 3.0 more admissions (95% confidence interval [CI], 2.0-4.1), 1.7 more CTs (95% CI, 0.2-3.1), 4.5 more radiographs (95% CI, 2.2-6.9), and 1.0 more ultrasound (95% CI, 0.3-1.7) but comparable MRI use 0.1 (95% CI, -0.2-0.3). Projected costs of these differences varied among the resource utilized. Compared to EDs without APPs, EDs with APPs were estimated to have 30.4 more admissions per 1000 visits, which could accrue $414,717 in utilization costs. CONCLUSION: EDs staffing APPs were associated with modest increases in resource utilization as measured by admissions and imaging studies.

Impact of Health Policy Changes on Emergency Medicine in Maryland Stratified by Socioeconomic Status.

INTRODUCTION: On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD's Medicare waiver ushered in a Global Budget Revenue (GBR) structure for hospital reimbursement. Our objective was to analyze the impact of these policy changes on emergency department (ED) utilization, hospitalization practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population. METHODS: We collected monthly mean data including patient volume, hospitalization percentages, payer mix, and professional revenue from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED's patient population as an explanatory variable and stratified our results by SES. RESULTS: Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% confidence interval [CI] [-1.58-1.24], p=.817). Hospitalization percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI [-2.47%-1.38%], p<.001). The percentage of uninsured patients decreased from 20.4% to 11.9%. This 8.5% change was significant (95% CI [-9.20%-7.80%], p<.001). The professional revenue per relative value unit increased significantly by $3.97 (95% CI [3.20-4.74], p<.001). When stratified by the median patient income of each ED, changes in each outcome were significantly more pronounced in EDs of lower SES. CONCLUSION: Health policy changes at the federal and state levels have resulted in significant changes to emergency medicine practice and finances in MD. Admission and observation percentages have been reduced, fewer patients are uninsured, and professional revenue has increased. All changes are significantly more pronounced in EDs with patients of lower SES.

Cognitive health and risk of ED revisit in underserved older adults.

OBJECTIVE: The objective was to examine associations between cognitive health and unplanned emergency department (ED) revisits 30, 60, and 90 days after the initial visit. METHODS: Sociodemographic, clinical, and cognitive measures were collected on 110 white and African American adults, 65 years and older, who sought care in an inner-city ED. The information was collected via face-to-face interviews and review of the electronic medical record. Returns to the study-site ED 30, 60, and 90 days later were identified through a search of the electronic medical record. RESULTS: The sample was mostly female (70.9%) and African American (73.6%), with an average age of 75 years (SD = 7.4). About half (56.4%) had 12 or more years of formal schooling. The overall cognitive score of 17.5 (SD 5.1) was 4.5 points less than standardized norms for persons 65 years and older. Each 1-point increase in cognitive score was associated with 24% and 21% decreased odds of 60-day (odds ratio [OR] = 0.76; 95% confidence interval [CI], 0.57-1.00) and 90-day revisit to the ED (OR = 0.79; 95% CI, 0.62-0.99), respectively. Cognitive health and odds of 30-day revisit (OR = 0.96; 95% CI, 0.72-1.26) had a nonsignificant association. CONCLUSIONS: Our sample of older, mostly female African Americans showed poorer cognitive health compared with standardized norms. However, higher cognitive health scores were linked to lower risk for unplanned ED revisit 60 and 90 days later. A clearer understanding of biological and nonbiological pathways that connect cognitive health to revisit risk in disadvantaged older populations might improve health outcomes, including the avoidance of return trips to the ED.

The impact of a freestanding ED on a regional emergency medical services system.

OBJECTIVE: The objective of the study is to examine the effect of the opening of a freestanding emergency department (FED) on the surrounding emergency medical services (EMS) system through an examination of EMS system metrics such as ambulance call volume, ambulance response times, and turnaround times. METHODS: This study is based on data from the county's computer-aided dispatch center, the FED, and the Maryland Health Services Cost Review Commission. The analysis involved a pre/post design, with a 6-month washout period. The preintervention period was April to October 2010, and the postintervention period was April to October 2011. Data were analyzed using standard t tests. RESULTS: The average daily number of EMS-related calls received in the computer-aided dispatch center was lower after the FED opened (16.3 [95% confidence interval {CI}, 15.7-16.9] vs 15.8 [95% CI, 14.9-16.9]). One-fourth of all patients were transported by ambulance to the FED after it opened. Use of the FED and adjacent hospitals increased by 8647 visits (15.8%) during the study period. Turnaround time for the county's ALS units decreased from 26.8 (95% CI, 26.2-27.5) to 25.1 (95% CI, 24.3-25.8) minutes. The ambulance out-of-service interval decreased from 87.3 (95% CI, 86.0-88.5) to 81.1 (95% CI, 79.7-82.4) minutes. Based on change in out-of-service this study had a small effect size (Cohen's d = 0.33). CONCLUSIONS: The opening of an FED was associated with a modest improvement in time-specific EMS system metrics: a decrease in ambulance turnaround time and shorter out-of-service intervals.

Drivers of ED efficiency: a statistical and cluster analysis of volume, staffing, and operations.

STUDY OBJECTIVE: The percentage of patients leaving before treatment is completed (LBTC) is an important indicator of emergency department performance. The objective of this study is to identify characteristics of hospital operations that correlate with LBTC rates. METHODS: The Emergency Department Benchmarking Alliance 2012 and 2013 cross-sectional national data sets were analyzed using multiple regression and k-means clustering. Significant operational variables affecting LBTC including annual patient volume, percentage of high-acuity patients, percentage of patients admitted to the hospital, number of beds, academic status, waiting times to see a physician, length of stay (LOS), registered nurse (RN) staffing, and physician staffing were identified. LBTC was regressed onto these variables. Because of the strong correlation between waiting times measured as door to first provider (DTFP), we regressed DTFP onto the remaining predictors. Cluster analysis was applied to the data sets to further analyze the impact of individual predictors on LBTC and DTFP. RESULTS: LOS and the time from DTFP were both strongly associated with LBTC rate (P<.001). Patient volume is not significantly associated with LBTC rate (P=.16). Cluster analysis demonstrates that physician and RN staffing ratios correlate with shorter DTFP and lower LBTC. CONCLUSION: Volume is not the main driver of LBTC. DTFP and LOS are much more strongly associated. We show that operational factors including LOS and physician and RN staffing decisions, factors under the control of hospital and physician executives, correlate with waiting time and, thus, in determining the LBTC rate.

Statistical process control: separating signal from noise in emergency department operations.

BACKGROUND: Statistical process control (SPC) is a visually appealing and statistically rigorous methodology very suitable to the analysis of emergency department (ED) operations. OBJECTIVE: We demonstrate that the control chart is the primary tool of SPC; it is constructed by plotting data measuring the key quality indicators of operational processes in rationally ordered subgroups such as units of time. Control limits are calculated using formulas reflecting the variation in the data points from one another and from the mean. SPC allows managers to determine whether operational processes are controlled and predictable. We review why the moving range chart is most appropriate for use in the complex ED milieu, how to apply SPC to ED operations, and how to determine when performance improvement is needed. DISCUSSION: SPC is an excellent tool for operational analysis and quality improvement for these reasons: 1) control charts make large data sets intuitively coherent by integrating statistical and visual descriptions; 2) SPC provides analysis of process stability and capability rather than simple comparison with a benchmark; 3) SPC allows distinction between special cause variation (signal), indicating an unstable process requiring action, and common cause variation (noise), reflecting a stable process; and 4) SPC keeps the focus of quality improvement on process rather than individual performance. CONCLUSION: Because data have no meaning apart from their context, and every process generates information that can be used to improve it, we contend that SPC should be seriously considered for driving quality improvement in emergency medicine.

The impact of electronic health record implementation on emergency physician efficiency and patient throughput.

BACKGROUND: In emergency departments (EDs), the implementation of electronic health records (EHRs) has the potential to impact the rapid assessment and management of life threatening conditions. In order to quantify this impact, we studied the implementation of EHRs in the EDs of a two hospital system. METHODS: using a prospective pre-post study design, patient processing metrics were collected for each ED physician at two hospitals for 7 months prior and 10 months post-EHR implementation. Metrics included median patient workup time, median length of stay, and the composite outcome indicator "processing time." RESULTS: median processing time increased immediately post-implementation and then returned to, and surpassed, the baseline level over 10 months. Overall, we see significant decreases in processing time as the number of patients treated increases. CONCLUSIONS: implementation of new EHRs into the ED setting can be expected to cause an initial decrease in efficiency. With adaptation, efficiency should return to baseline levels and may eventually surpass them. IMPLICATIONS: while EDs can expect long term gains from the implementation of EHRs, they should be prepared for initial decreases in efficiency and take preparatory measures to avert adverse effects on the quality of patient care.

Development of a university-based emergency department network: lessons learned.

BACKGROUND: As part of the growth of emergency medical care in our state, our university-based emergency medicine practice developed a network of affiliated emergency department (ED) practices. The original practices were academic and based on a faculty practice model; more recent network development incorporated a community practice model less focused on academics. OBJECTIVE: This article discusses the growth of that network, with a focus on the recent addition of a county-wide two-hospital emergency medicine practice. During the transition of the two EDs from a contract management group to the university network, six critical areas in need of restructuring were identified: 1) departmental leadership, 2) recruitment and retention of clinical staff members, 3) staffing strategies, 4) relationships with key constituents, 5) clinical operations, supplies, and equipment, and 6) compensation structure. The impact of changes was measured by comparison of core measures, efficiency metrics, patient volumes, admissions, and transfers to the academic medical center before and after the implementation of our practice model. CONCLUSION: Our review and modification of these components significantly improved the quality and efficiency of care at the community hospital system. The consistent presence of board certified emergency physicians optimized utilization of clinical resources in the community hospital and the academic health system. This dynamic led to a mutually beneficial merger of these major state healthcare systems.

Evaluation and management of acute cervical spine trauma.

The evaluation and management of cervical spine injuries is a core component of the practice of emergency medicine. This article focuses on evaluation and management of blunt cervical spine trauma by the emergency physician. Pertinent anatomy of the cervical spine and specific cervical spine fractures are discussed, with an emphasis on unstable injuries and associated spinal cord pathology. The association of vertebral artery injury with cervical spine fracture is addressed, followed by a review of the most recent literature on prehospital care. Initial considerations in the emergency department, including cervical spine stabilization and airway management, are reviewed. The most current recommendations for cervical spine imaging with regard to indications and modalities are covered. Finally, emergency department management and disposition of patients with spinal cord injuries are reviewed.

Chronic methadone therapy complicated by torsades de pointes: a case report.

Methadone is commonly used by patients presenting to the Emergency Department (ED). The common, acute side effects of central nervous system depression and respiratory depression are easily recognizable by treating physicians as attributable to methadone; however, the cardiac toxicity of chronic methadone use recently has only been recognized. Both chronic use of large doses and a recent increase in the daily dose of methadone have been associated with QT prolongation and subsequent development of torsades de pointes. We describe the case of a 40-year-old woman whose methadone dose recently had been increased to 135 mg per day. She then presented to the ED with symptomatic torsades de pointes. She was stabilized in the ED by cardioversion and infusions of magnesium sulfate and lidocaine. The markedly prolonged corrected QT interval significantly shortened after discontinuing methadone. Inpatient cardiology evaluation found no other cause for the dysrhythmia. She was definitively treated with reduction of the daily methadone dose and an implanted cardioverter-defibrillator.

Orthopedic trauma: office management of major joint injury.

Orthopedic injuries are common reasons for visits to primary care physicians. Careful history and physical examination with intelligent use of imaging technology will arrive at the correct diagnosis in most patients. Many conditions may be definitively managed by the office internist. Others maybe initially stabilized and referred to orthopedic surgeons for definitive care. Nondisplaced fractures, tendon injuries, sprains, and overuse syndromes are entities within the purview of the primary care physician. Familiarity and confidence with diagnosis and management of these conditions in the office is optimal for the care of the adult patient.

Thyroid disease in the emergency department: a clinical and laboratory review.

Emergency physicians regularly treat patients with thyroid disorders. Until the 1950s, clinical evaluation was the only available diagnostic tool. Since then, increasingly sophisticated laboratory assays have been developed to confirm thyroid pathology. Thyroid physiology, fundamental to interpreting thyroid function tests, is based on a classic negative feedback mechanism involving the hypothalamic-pituitary-thyroid axis. Primary hypothyroidism in developed countries is most commonly caused by Hashimoto's disease. Secondary and tertiary etiologies are uncommon and the result of hypothalamic and pituitary pathology. Clinical presentations range from subclinical disease to myxedema coma. Thyrotoxicosis has many etiologies. A hyperadrenergic state precipitates characteristic signs and symptoms. Thyroid storm and thyrotoxic periodic paralysis are emergent complications. Third generation assays have made thyroid function testing practical for emergency physicians. An ultrasensitive thyroid stimulating hormone level is the most useful. A free thyroxine level is the preferred study for confirming a thyroid disorder. Confounding factors may affect thyroid function interpretation.

Scurvy: historical review and current diagnostic approach.

Scurvy, a deficiency of vitamin C, now most often occurs in disadvantaged groups seen frequently in EDs: alcoholics with poor nutrition, the isolated elderly, and the institutionalized. Its prominent clinical features are lethargy; purpuric lesions, especially affecting the legs; myalgia; and, in advancing disease, bleeding from the gums with little provocation. Common misdiagnoses are vasculitis, blood dyscrasias, and ulcerative gingivitis. Untreated, scurvy is inevitably fatal as a result of infection or sudden death. Fortunately, individuals with scurvy, even those with advanced disease, respond favorably to administration of vitamin C.

Community-acquired pneumonia in the emergency department: a practical approach to diagnosis and management.

Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. Key critical thinking and application of published findings allow for intelligent empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard ED treatment. Coverage for atypical organisms improves patient response and outcome. Finally, identification and treatment of the complications of pneumonia and accompanying sepsis must be considered by the ED physician when evaluating critically ill patients.