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2.
Acad Emerg Med ; 2018 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-29575248

RESUMO

OBJECTIVES: The objectives were to examine whether responses to the Stopping Elderly Accidents, Death, and Injuries (STEADI) questions responses predicted adverse events after an older adult emergency department (ED) fall visits and to identify factors associated with such recurrent fall. METHODS: We conducted a prospective study at two urban, teaching hospitals. We included patients aged ≥ 65 years who presented to the ED for an accidental fall. Data were gathered for fall-relevant comorbidities, high-risk medications for falls, and the responses to 12 questions from the STEADI guideline recommendation. Our outcomes were the number of 6-month adverse events that were defined as mortality, ED revisit, subsequent hospitalization, recurrent falls, and a composite outcome. RESULTS: There were 548 (86.3%) patients who completed follow-up and 243 (44.3%) patients experienced an adverse event after a fall within 6 months. In multivariate analysis, seven questions from the STEADI guideline predicted various outcomes. The question "Had previous fall" predicted recurrent falls (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.52 to 3.97), the question "Feels unsteady when walking sometimes" (OR = 2.34, 95% CI = 1.44 to 3.81), and "Lost some feeling in their feet" predicted recurrent falls. In addition to recurrent falls risk, the supplemental questions "Use or have been advised to use a cane or walker," "Take medication that sometimes makes them feel light-headed or more tired than usual," "Take medication to help sleep or improve mood," and "Have to rush to a toilet" predicted other outcomes. CONCLUSION: A STEADI score of ≥4 did not predict adverse outcomes although seven individual questions from the STEADI guidelines were associated with increased adverse outcomes within 6 months. These may be organized into three categories (previous falls, physical activity, and high-risk medications) and may assist emergency physicians to evaluate and refer high-risk fall patients for a comprehensive falls evaluation.

3.
West J Emerg Med ; 18(5): 785-793, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28874929

RESUMO

INTRODUCTION: One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. METHODS: We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. RESULTS: Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9-68.8]) to 68.8 (95% CI [57.8-79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75-84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). CONCLUSION: ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/tendências , Ferimentos e Lesões/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência/estatística & dados numéricos , Serviços Médicos de Emergência/tendências , Feminino , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Fatores de Risco , Estados Unidos/epidemiologia , Ferimentos e Lesões/etiologia
4.
Ann Emerg Med ; 70(4): 516-521.e2, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28688769

RESUMO

STUDY OBJECTIVE: We seek to describe the risk during 6 months and specific risk factors for recurrent falls, emergency department (ED) revisits, subsequent hospitalizations, and death within 6 months after a fall-related ED presentation. METHODS: This was a secondary analysis of a retrospective cohort of elderly fall patients who presented to the ED from one urban teaching hospital. We included patients aged 65 years and older who had an ED fall visit in 2012. We examined the frequency and risk factors of adverse events (composite of recurrent falls, ED revisits, subsequent hospitalization, and death, selected a priori) at 6 months. RESULTS: Our study included 350 older adults. Adverse events steadily increased, from 7.7% at 7 days, 21.4% at 30 days, and 50.3% at 6 months. Within 6 months, 22.6% of patients had at least one recurrent fall, 42.6% revisited the ED, 31.1% had subsequent hospitalizations, and 2.6% died. In multivariable logistic regression analysis, psychological or sedative drug use predicted recurrent falls, ED revisits, subsequent hospitalizations, and adverse events. CONCLUSION: More than half of fall patients had an adverse event within 6 months of presenting to the ED after a fall. The risk during 6 months of these adverse events increased with psychological or sedative drug use. Larger future studies should confirm this association and investigate methods to minimize recurrent falls through management of such medications.


Assuntos
Acidentes por Quedas/mortalidade , Demência/complicações , Diabetes Mellitus Tipo 2/complicações , Serviço Hospitalar de Emergência/estatística & dados numéricos , Transtornos Neurológicos da Marcha/complicações , Avaliação Geriátrica , Hipnóticos e Sedativos/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Acidentes por Quedas/estatística & dados numéricos , Idoso de 80 Anos ou mais , Comorbidade , Demência/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Feminino , Transtornos Neurológicos da Marcha/mortalidade , Humanos , Masculino , Prevalência , Estudos Retrospectivos , Medição de Risco , Estados Unidos/epidemiologia
5.
Geriatr Orthop Surg Rehabil ; 8(4): 231-237, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29318085

RESUMO

Objective: We sought to understand older patients' perspectives about their fall, fall risk factors, and attitude toward emergency department (ED) fall-prevention interventions. Methods: We conducted semistructured interviews between July 2015 and January 2016 of community-dwelling, nondemented patients in the ED, who presented with a fall to an urban, teaching hospital. Interviews were halted once we achieve thematic saturation with the data coded and categorized into themes. Results: Of the 63 patients interviewed, patients blamed falls on the environment, accidents, a medical condition, or themselves. Three major themes were generated: (1) patients blamed falls on a multitude of things but never acknowledged a possible multifactorial rationale, (2) patients have variable level of concerns regarding their current fall and future fall risk, and (3) patients demonstrated a range of receptiveness to ED interventions aimed at preventing falls but provided little input as to what those interventions should be. Conclusions: Many older patients who fall do not understand their fall risk. However, based on the responses provided, older adults tend to be more receptive to intervention and more concerned about their future fall risk, making the ED an appropriate setting for intervention.

7.
Acad Emerg Med ; 23(10): 1161-1169, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27286291

RESUMO

OBJECTIVE: Hip fractures cause significant morbidity and mortality. Determining the optimal diagnostic strategy for the subset of patients with potential occult hip fracture remains challenging. We determined the most cost-effective strategy for the diagnosis of occult hip fractures from the choices of performing only computed tomography (CT), performing only magnetic resonance imaging (MRI), performing CT and if negative performing MRI (MRI-selective strategy) or discharging the patient without advanced imaging. METHODS: We developed a decision-analytic model to compare outcomes and costs of different diagnostic strategies for the diagnosis of an occult hip fracture from a societal perspective. Model inputs were derived from charge data, Medicare reimbursements, and the literature. Strategies with an incremental cost-effectiveness ratio (ICER) below $100,000 per quality-adjusted life-year (QALY) gained were considered cost-effective. We tested the robustness of our results using probabilistic sensitivity analysis. RESULTS: Compared to a CT strategy, MRI provides an additional 0.05 QALY at an incremental cost of $1,227 and ICER of $25,438/QALY. For facilities without MRI capability, if the cost of transfer is below $1,228, transferring the patient to a MRI-capable facility is the most cost-effective strategy. Above this cost, employing a CT and if negative transfer to a MRI-capable facility strategy was more cost-effective. When the cost of a transfer reached more than $4,039, it became more cost-effective to only obtain a CT. CONCLUSION: MRI is a cost-effective strategy for the diagnosis of an occult hip fracture. For facilities without MRI capability, the most cost-effective strategy depends on the cost of the interfacility transfer.


Assuntos
Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Fraturas do Quadril/diagnóstico por imagem , Imagem por Ressonância Magnética/economia , Tomografia Computadorizada por Raios X/economia , Idoso , Fraturas do Quadril/mortalidade , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Sensibilidade e Especificidade
8.
Am J Emerg Med ; 34(8): 1394-9, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27133925

RESUMO

OBJECTIVE: Falls among older adults are a public health problem and are multifactorial. We sought to determine whether falls predict more serious conditions in older adult patients presenting to the emergency department (ED) with a "nonspecific complaint" (NSC). A secondary objective was to examine what factors predicted serious conditions among older adult patients with a fall. METHODS: This study was a secondary analysis of a prospective delayed-type cross-sectional diagnostic study that included a 30-day follow-up. We included patients 65 years and older who presented to the ED from May 2007 and July 2011 with a NSC and had an Emergency Severity Index score of 2 or 3. We then compared the serious conditions among older adults who presented to the ED with a fall with those who did not fall in a cohort of patients with NSC. RESULTS: We had 1111 patients enrolled in our study; 518 (47%) of them had fallen. We found that 310 (60%) of elderly fall patients vs 349 (59%) of nonfall patients had a 30-day serious condition (P=.74). In multiple logistic regression analysis, falls did not predict serious conditions or 30-day mortality among all NSC patients. Among fall patients, male sex, diuretic use, and generalized weakness predicted serious conditions. CONCLUSION: Fall patients share many features with nonfall NSC patient. However, falls did not increase the risk of serious conditions. Falls in the elderly could be considered under the broader entity of NSC.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Serviço Hospitalar de Emergência , Avaliação Geriátrica , Debilidade Muscular/diagnóstico , Cooperação do Paciente , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Debilidade Muscular/epidemiologia , Estudos Prospectivos , Fatores de Risco , Suíça/epidemiologia , Fatores de Tempo
9.
Emerg Med J ; 33(1): 17-22, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25805897

RESUMO

BACKGROUND: We sought to determine the prevalence of delirium in a Thai emergency department (ED). The secondary objective was to identify risk factors and short-term outcomes in delirious elderly ED patients. METHODS: This was a prospective cross-sectional study in the ED of an urban tertiary care hospital. Patients aged ≥65 years who presented to the ED were included. We excluded patients who had severe dementia, were not responsive to verbal stimuli, had severe trauma and were blind, deaf, aphasic or unable to speak Thai. Delirium was determined using the Confusion Assessment Method for the Intensive Care Unit. We collected 30-day mortality rate, hospital length of stay and revisit rate as short-term outcomes. RESULTS: We had a final sample size of 232 patients; 27 (12%) were delirious in the ED, of which 16 (59%) were not recognised to be delirious by the emergency physician. Multivariable logistic regression analysis showed dementia (adjusted OR (AOR) 13.1; 95% CI 2.9 to 59.6), auditory impairment (AOR 4.8; 95% CI 1.6 to 13.8) and ED diagnosis of metabolic derangement (AOR 6.5; 95% CI 1.6 to 26.8) were associated with delirium in the ED. Delirium was associated with a higher mortality rate than those without delirium (15% vs 2%, p=0.004). CONCLUSIONS: In one middle-income country, elderly ED patients were delirious >10% of the time. Delirium was underdiagnosed and was associated with an increased 30-day mortality rate. Delirium screening needs to be improved, potentially focusing on high-risk patients.


Assuntos
Delírio/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Delírio/diagnóstico , Delírio/etiologia , Feminino , Avaliação Geriátrica/métodos , Humanos , Masculino , Programas de Rastreamento/métodos , Prevalência , Estudos Prospectivos , Fatores de Risco , Tailândia/epidemiologia
11.
Am J Emerg Med ; 33(8): 1012-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25983268

RESUMO

INTRODUCTION: Falls among older adults (aged ≥65 years) are the leading cause of both injury deaths and emergency department (ED) visits for trauma. We examine the characteristics and prevalence of older adult ED fallers as well as the recurrent ED visit and mortality rate. METHODS: This was a retrospective analysis of a cohort of elderly fall patients who presented to the ED between 2005 and 2011 of 2 urban, level 1 trauma, teaching hospitals with approximately 80000 to 95000 annual visits. We examined the frequency of ED revisits and death at 3 days, 7 days, 30 days, and 1 year controlling for certain covariates. RESULTS: Our cohort included 21340 patients. The average age was 78.6 years. An increasing proportion of patients revisited the ED over the course of 1 year, ranging from 2% of patients at 3 days to 25% at 1 year. Death rates increased from 1.2% at 3 days to 15% at 1 year. A total of 10728 patients (50.2%) returned to the ED at some point during our 7-year study period, and 36% of patients had an ED revisit or death within 1 year. In multivariate logistic regression, male sex and comorbidities were associated with ED revisits and death. CONCLUSION: More than one-third of older adult ED fall patients had an ED revisit or died within 1 year. Falls are one of the geriatric syndromes that contribute to frequent ED revisits and death rates. Future research should determine whether falls increase the risk of such outcomes and how to prevent future fall and death.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Análise Multivariada , Prevalência , Estudos Retrospectivos , Fatores Sexuais
12.
Acad Emerg Med ; 22(4): 461-7, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25773899

RESUMO

OBJECTIVES: The objective was to examine whether the emergency department (ED) evaluation of older adult fallers is concordant with the Geriatric Emergency Department Guidelines. METHODS: This study was a chart review of randomly selected older adult ED fall patients from one urban academic teaching hospital. Patients 65 years and older who had ED fall visits in 2012 and who had primary care physicians within our hospital network during the past 3 years were included. Transferred patients were excluded. The data collection instrument was adapted from ED fall evaluation recommendations. RESULTS: There were 350 patients in this study. The mean (±SD) patient age was 80.1 (±8.8) years, 124 (35%) were male, 327 (93%) were white, and 298 (85%) were community dwelling. The range with which history and physical examination findings were concordant with fall guidelines was 1% to 85%. Cause and location of fall were the two most frequently reported history items (85 and 81%, respectively), while asking about baseline vision was only reported 1% of the time. Evaluating for sensory deficits and muscle strength were the two most frequently reported physical examinations (63 and 48%, respectively), while balance was evaluated with the lowest frequency (1%). Patients who received more guideline-recommended evaluations were older with more comorbid conditions and were transferred to an observation unit or admitted to the hospital more frequently. Overall, more than half of these elderly patients (56%) were discharged from the ED to their place of preadmission residence. CONCLUSIONS: The current ED evaluation of older adult fallers is discordant with general and ED-specific fall guidelines. Future studies are warranted to investigate ways to successfully implement fall evaluation guidelines.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Avaliação Geriátrica/métodos , Fidelidade a Diretrizes/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/normas , Feminino , Hospitais de Ensino , Hospitais Urbanos , Humanos , Masculino , Alta do Paciente
13.
Ann Emerg Med ; 66(2): 125-30, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25805116

RESUMO

STUDY OBJECTIVE: We describe the prevalence of vital sign communication errors during emergency department (ED) handoffs. Our secondary objective is to evaluate the association between handoff behaviors and ED crowding on vital sign handoff errors. METHODS: This was a prospective observational study of ED handoffs conducted at an urban academic hospital. We observed a prespecified convenience sample of ED shift rounds and included all patients whose care was subject to a handoff during ED shift change. The primary outcome was vital sign communication errors, defined as the failure to communicate an episode of medical-record-documented hypotension or hypoxia during ED shift rounds. Trained research assistants used a standardized data collection tool to collect data through direct observation and electronic health record abstraction. We report descriptive statistics and results of a logistic regression model constructed with generalized estimating equations to describe the association between handoff and rounds-level characteristics and handoff errors. RESULTS: We observed 1,163 patient handoffs during 130 ED shift rounds. Of 117 patients with episodes of hypotension and 156 patients with hypoxia, 66 (42%) and 116 (74%) were not communicated at rounds, respectively. One hundred sixty-six handoffs (14%) included a vital sign communication error of omission. In multivariate analysis, no handoff or rounds characteristic, including the ED occupancy rate, was associated with omission errors of vital sign communication. CONCLUSION: Providers omitted communication of patient hypotension or hypoxia in nearly 1 in 7 ED handoffs. These communication errors do not appear to be related to ED crowding or care interruptions.


Assuntos
Comunicação , Serviço Hospitalar de Emergência , Transferência da Responsabilidade pelo Paciente , Melhoria de Qualidade , Sinais Vitais , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Hipotensão/fisiopatologia , Hipóxia/fisiopatologia , Erros Médicos/prevenção & controle , Erros Médicos/estatística & dados numéricos , Transferência da Responsabilidade pelo Paciente/normas , Estudos Prospectivos
14.
Am J Cardiol ; 115(5): 681-6, 2015 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-25586333

RESUMO

Recent studies have highlighted differences in how older patients respond to high-risk pulmonary embolism (PE) and treatment. However, guidelines for PE risk stratification and treatment are not based on age, and data are lacking for older patients. We characterized the impact of age on clinical features, risk stratification, treatment, and outcomes in a sample of patients with PE in the emergency department. We performed an observational cohort study of 547 consecutive patients with PE in the emergency department from 2005 to 2011 in an urban tertiary hospital. We used bivariate proportions and multivariable logistic regression to compare clinical presentation, risk category, treatment, and outcomes in patients ≥65 years with those <65 years. The mean age was 58 ± 17 years, 276 (50%) were women, and 210 (38%) were ≥65 years. PE was more severe in patients ≥65 years (massive 14% vs 5%, submassive 48% vs 25%, and low risk 38% vs 70%, p <0.0001), with submassive PE being the most common presentation in patients ≥65 years. However, subanalysis removing natriuretic peptides from the definition of submassive PE negated this finding. Treatment with parenteral anticoagulation (88% vs 90%, p = 0.32), thrombolytic therapy (5% vs 4%, p = 0.87), and inferior vena cava filter (4% vs 4%, p = 0.73) were similar among age groups. Patients ≥65 years had higher 30-day mortality (11% vs 3%, p <0.001). In conclusion, patients ≥65 years present with more severe PE and have higher mortality, although treatment patterns were similar to younger patients. Age-specific guideline definitions of submassive PE may better identify high-risk patients.


Assuntos
Fatores Etários , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/etiologia , Medição de Risco , Terapia Trombolítica , Filtros de Veia Cava
15.
Am J Emerg Med ; 32(9): 1033-6, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25027202

RESUMO

BACKGROUND: Hospital crowding and emergency department (ED) boarding are large and growing problems. To date, there has been a paucity of information regarding the quality of care received by patients boarding in the ED compared with the care received by patients on an inpatient unit. We compared the rate of delays and adverse events at the event level that occur while boarding in the ED vs while on an inpatient unit. METHODS: This study was a secondary analysis of data from medical record review and administrative databases at 2 urban academic teaching hospitals from August 1, 2004, through January 31, 2005. We measured delayed repeat cardiac enzymes, delayed partial thromboplastin time level checks, delayed antibiotic administration, delayed administration of home medications, and adverse events. We compared the incidence of events during ED boarding vs while on an inpatient unit. RESULTS: Among 1431 patient medical records, we identified 1016 events. Emergency department boarding was associated with an increased risk of home medication delays (risk ratio [RR], 1.54; 95% confidence interval [CI], 1.26-1.88), delayed antibiotic administration (RR, 2.49; 95% CI, 1.72-3.52), and adverse events (RR, 2.36; 95% CI, 1.15-4.72). On the contrary, ED boarding was associated with fewer delays in repeat cardiac enzymes (RR, 0.17; 95% CI, 0.09-0.27) and delayed partial thromboplastin time checks (RR, 0.54; 95% CI, 0.27-0.96). CONCLUSION: Compared with inpatient units, ED boarding was associated with more medication-related delays and adverse events but fewer laboratory-related delays. Until we can eliminate ED boarding, it is critical to identify areas for improvement.


Assuntos
Tratamento Farmacológico/normas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Laboratórios Hospitalares/estatística & dados numéricos , Centros Médicos Acadêmicos/estatística & dados numéricos , Idoso , Diagnóstico Tardio/estatística & dados numéricos , Testes Diagnósticos de Rotina/normas , Testes Diagnósticos de Rotina/estatística & dados numéricos , Feminino , Humanos , Laboratórios Hospitalares/normas , Tempo de Internação/estatística & dados numéricos , Masculino , Auditoria Médica , Tempo de Tromboplastina Parcial , Qualidade da Assistência à Saúde/estatística & dados numéricos , Fatores de Tempo
16.
Am J Emerg Med ; 31(10): 1512-5, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24035051

RESUMO

STUDY OBJECTIVE: To determine whether frequent emergency department (ED) users are more likely to make at least one and a majority of visits for mental health, alcohol, or drug-related complaints compared to non-frequent users. METHODS: We performed a retrospective cohort study exploring frequent ED use and ED diagnosis at a single, academic hospital and included all ED patients between January 1 and December 31, 2010. We compared differences in ED visits with a primary International Classification of Diseases, 9th Revision visit diagnosis of mental health, alcohol or drug-related diagnoses between non-frequent users (<4 visits during previous 12-months) and frequent (repeat [4-7 visits], highly frequent [8-18 visits] and super frequent [≥19 visits]) users in univariate and multivariable analyses. RESULTS: Frequent users (2496/65201 [3.8%] patients) were more likely to make at least one visit associated with mental health, alcohol, or drug-related diagnoses. The proportion of patients with a majority of visits related to any of the three diagnoses increased from 5.8% among non-frequent users (3616/62705) to 9.4% among repeat users (181/1926), 13.1% among highly frequent users (62/473), and 25.8% (25/97 patients) in super frequent users. An increasing proportion of visits with alcohol-related diagnoses was observed among repeat, highly frequent, and super frequent users but was not found for mental health or drug-related complaints. CONCLUSION: Frequent ED users were more likely to make a mental health, alcohol or drug-related visit, but a majority of visits were only noted for those with alcohol-related diagnoses. To address frequent ED use, interventions focusing on managing patients with frequent alcohol-related visits may be necessary.


Assuntos
Alcoolismo/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Transtornos Mentais/terapia , Transtornos Relacionados ao Uso de Substâncias/terapia , Centros Médicos Acadêmicos/estatística & dados numéricos , Adulto , Feminino , Hospitais Urbanos/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos
17.
Am J Emerg Med ; 31(7): 1121-3, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23702071

RESUMO

INTRODUCTION: Health care costs continue to rise; reducing unnecessary laboratory testing may reduce costs. The goal of this study was to calculate the frequency and estimated costs of repeat normal laboratory testing of patients transferred to a tertiary care emergency department (ED). METHODS: This was a retrospective cohort study of patients transferred to a tertiary care, level -one trauma ED with an annual census of 90,000 patients. We defined "repeat normal testing" as laboratory tests repeated within 8 hours that were normal at both the sending hospital and the receiving tertiary care hospital. We estimated the charges associated with repeat normal laboratory testing for 11 common ED tests: basic metabolic panel, calcium, magnesium, phosphorus, lipase, thyroids stimulating hormone, prothrombin time, partial thromboplastin time, complete blood count, liver function test, and urine analysis. RESULTS: Two hundred thirty-two patients were transferred to the receiving tertiary care hospital from within the hospital's network from May 1, 2011, to October 31, 2011. On average, each transferred patient had one repeat normal laboratory test (245/232=1.06). For all laboratory tests, repeat normal testing occurred at least 40% of the time. Extrapolating the data, the total yearly estimated charges of all repeat normal testing was $580,526. CONCLUSION: This study provides the first analysis of the frequency of repeated laboratory testing for all transferred ED patients and indicates that repeat normal testing represents a significant cost. Future research needs to determine if such repeat testing is indeed clinically appropriate or redundant.


Assuntos
Técnicas de Laboratório Clínico/economia , Serviço Hospitalar de Emergência/economia , Custos Hospitalares/estatística & dados numéricos , Transferência de Pacientes/economia , Procedimentos Desnecessários/economia , Adulto , Técnicas de Laboratório Clínico/estatística & dados numéricos , Estudos de Coortes , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Massachusetts , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Desnecessários/estatística & dados numéricos
18.
West J Emerg Med ; 14(2): 85-9, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23599838

RESUMO

INTRODUCTION: The American College of Emergency Physicians (ACEP) Task Force on Boarding described high-impact initiatives to decrease crowding. Furthermore, some emergency departments (EDs) have implemented a novel initiative we term "vertical patient flow," i.e. segmenting patients who can be safely evaluated, managed, admitted or discharged without occupying a traditional ED room. We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.). METHODS: We surveyed the physician leadership of all U.S. academic EDs from March to May 2010 using a 2-minute online survey. Academic ED was defined by the primary site of an emergency residency program. RESULTS: We had a response rate of 73% (106/145) and a completion rate of 71% (103/145). The most prevalent hospital-based initiative was inpatient discharge coordination (46% [47/103] of respondents) while the least fully initiated was surgical schedule smoothing (11% [11/103]). The most prevalent ED-based initiative was fast track (79% [81/103]) while the least initiated was physician triage (12% [12/103]). Vertical patient flow had been implemented in 29% (30/103) of responding EDs while an additional 41% (42/103) reported partial/in progress implementation. CONCLUSION: We found great variability in the extent academic EDs have implemented ACEP's established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow. Future studies should examine barriers to implementing these crowding initiatives and how they affect outcomes such as patient safety, ED throughput and patient/provider satisfaction.

19.
J Emerg Med ; 44(2): 423-33, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23164558

RESUMO

BACKGROUND: Controversy exists regarding the need for contrast agents for emergency abdominal computed tomography (CT). OBJECTIVES: We surveyed United States (US) academic Emergency Departments (EDs) to document national practice. We hypothesized variable contrast use for abdominal/pelvic CT, including variance from the American College of Radiology's (ACR) Appropriateness Criteria(®), an evidence-based guideline. METHODS: A survey was sent to physician leaders of US academic EDs, defined as primary site of an Emergency Medicine residency program. Respondents were asked about their institutions' use of oral, intravenous (i.v.), and rectal contrast for various abdominal/pelvic CT indications. Responses were compared with the approach given the highest appropriateness rating by the American College of Radiology. RESULTS: One hundred and six of 152 (70%) surveys were completed. Intravenous contrast was the most frequently cited contrast. At least 90% of respondents reported using i.v. contrast in 12 of 18 indications. Oral contrast use was more variable. In no indication did ≥90% of respondents indicate use of oral contrast, and in only two indications did ≥90% avoid its use. Rectal contrast was rarely used. The most common indications for which no contrast agent was used were suspected renal colic (79%), viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%). CONCLUSIONS: Contrast practices for abdominal/pelvic CT vary nationally, according to a survey of US academic EDs. For multiple indications, the contrast practices of a substantial number of respondents deviated from those recommendations given the highest clinical appropriateness rating by the American College of Radiology.


Assuntos
Meios de Contraste/administração & dosagem , Serviço Hospitalar de Emergência , Pelve/diagnóstico por imagem , Padrões de Prática Médica/estatística & dados numéricos , Radiografia Abdominal , Centros Médicos Acadêmicos , Administração Oral , Administração Retal , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Infusões Intravenosas , Guias de Prática Clínica como Assunto , Inquéritos e Questionários , Tomografia Computadorizada por Raios X , Estados Unidos
20.
Med Care Res Rev ; 69(6): 679-98, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22922635

RESUMO

Concern exists regarding care patients receive while boarding (staying in the emergency department [ED] after a decision to admit has been made). This exploratory study compares care for such ED patients under "Inpatient Responsibility" (IPR) and "ED Responsibility" (EDR) models using mixed methods. The authors abstracted quantitative data from 1,431 patient charts for ED patients admitted to two academic hospitals in 2004-2005 and interviewed 10 providers for qualitative data. The authors compared delays using logistic regression and used provider interviews to explore reasons for quantitative findings. EDR patients had more delays to receiving home medications over the first 26 hours of admission but fewer while boarding; EDR patients had fewer delayed cardiac enzymes checks. Interviews revealed that culture, resource prioritization, and systems issues made care for boarded patients challenging. A theoretically better responsibility model may not deliver better care to boarded patients because of cultural, resource prioritization, and systems issues.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Hospitalização/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Modelos Organizacionais , Admissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/organização & administração , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitais de Ensino , Hospitais Urbanos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Responsabilidade Social , Estados Unidos
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