A descriptive study of screening and navigation on health-related social needs in a safety-net hospital emergency department.

BACKGROUND: Health-related social needs (HRSN) have been associated with worse clinical outcomes, increased Emergency Department (ED) utilization and higher healthcare costs. The ED is uniquely positioned to bring HRSN screening to the bedside and develop effective interventions. We evaluated whether navigation services for high-risk patients led to the resolution of HRSN. METHODS: Navigators screened a convenience sample of patients for HRSN with the Accountable Health Communities Screening Tool from October 2019 to January 2022. Patients with HRSN were considered high-risk if they had at least two ED visits in the previous 12 months. Patients who were high-risk were eligible for navigation including community referrals and one-on-one close follow-up. The HRSN status (resolved, in-progress, unable to resolve) was queried from the Centers for Medicare and Medicaid database. The state hospital association provided data on ED visits and inpatient hospitalizations within 6 months of the screening visit. RESULTS: Of 185,470 ED visits, HRSN screening occurred in 4050 (2%). HRSN were self-reported in 48% (1944) of patient visits, with 71% of these (1379) considered high-risk. 15% of high-risk patients with HRSN opted out of navigation. Food insecurity was the most identified HRSN (35%) followed by housing instability (26%), transportation needs (24%) and utility assistance (15%). Food insecurity was the most resolved HRSN (39%, in-progress 32%) followed by utility assistance (37%, in-progress 26%), transportation needs (35%, in-progress 35%) and housing instability (28%, in-progress 36%). High-risk visits in which the patient or guardian accepted navigation were less likely to be associated with an ED visit within 6 months of the screening visit (51%) compared to high-risk patients in which the patient or guardian opted out of navigation (61%, p < 0.001), but there was no difference in inpatient hospitalizations (p = 0.427). CONCLUSIONS: During the study period, one-third of HRSN were successfully resolved with another one-third in-progress. Navigation in high-risk patients was associated with fewer subsequent ED visits.

Temporal associations between emergency department and telehealth volumes during the COVID-19 pandemic: A time-series analysis from 2 academic medical centers.

BACKGROUND: The COVID-19 pandemic compelled healthcare systems to rapidly adapt to changing healthcare needs as well as identify ways to reduce COVID transmission. The relationship between pandemic-related trends in emergency department (ED) visits and telehealth urgent care visits have not been studied. METHODS: We performed an interrupted time series analysis to evaluate trends between ED visits and telehealth urgent medical care visits at two urban healthcare system in Colorado. We performed pairwise comparisons between baseline versus each COVID-19 surge and all three surges combined, for both ED and telehealth encounters at each site and used Wilcoxon rank sum test to compare median values. RESULTS: During the study period, 595,350 patient encounters occurred. We saw ED visits decline in correlation with rising telehealth visits during each COVID surge. CONCLUSIONS: During initial COVID surges, ED visits declined while telehealth visits rose in inverse correlation with falling ED visits, suggesting that some patients shifted their preferred location for clinical care. As EDs cope with future staffing during the ongoing COVID pandemic, telehealth represents an opportunity for emergency physicians and a means to align patients desires for virtual care with ED volumes and staffing.

Bouncing Back Elsewhere: Multilevel Analysis of Return Visits to the Same or a Different Hospital After Initial Emergency Department Presentation.

STUDY OBJECTIVE: Analyses of 72-hour emergency department (ED) return visits are frequently used for quality assurance purposes and have been proposed as a means of measuring provider performance. These analyses have traditionally examined only patients returning to the same hospital as the initial visit. We use a health information exchange network to describe differences between ED visits resulting in 72-hour revisits to the same hospital and those resulting in revisits to a different site. METHODS: We examined data from a 31-hospital health information exchange of all ED visits during a 5-year period to identify 72-hour return visits and collected available encounter, patient, and hospital variables. Next, we used multilevel analysis of encounter-level, patient-level, and hospital-level data to describe differences between initial ED visits resulting in different-site and same-site return visits. RESULTS: We identified 12,621,159 patient visits to the 31 study EDs, including 841,259 same-site and 107,713 different-site return visits within 72 hours of initial ED presentation. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the initial-visit characteristics' predictive relationship that any return visit would be at a different site: daytime visit (OR 1.10; 95% CI 1.07 to 1.12), patient-hospital county concordance (OR 1.40; 95% CI 1.36 to 1.44), male sex (OR 1.27; 95% CI 1.24 to 1.30), aged 65 years or older (OR 0.55; 95% CI 0.53 to 0.57), sites with an ED residency (OR 0.41; 95% CI 0.40 to 0.43), sites at an academic hospital (OR 1.12; 95% CI 1.08 to 1.15), sites with high density of surrounding EDs (OR 1.73; 95% CI 1.68 to 1.77), and sites with a high frequency of same-site return visits (OR 0.10; 95% CI 0.10 to 0.11). CONCLUSION: This analysis describes how ED encounters with early revisits to the same hospital differ from those with revisits to a second hospital. These findings challenge the use of single-site return-visit frequency as a quality measure, and, more constructively, describe how hospitals can use health information exchange to more accurately identify early ED return visits and to support programs related to these revisits.

Correction: Correction to 'Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning' [Annals of Emergency Medicine 69 (2017) 98-107.e6].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Does the National Resident Match Program Rank List Predict Success in Emergency Medicine Residency Programs?

BACKGROUND: Emergency medicine (EM) residency programs use nonstandardized criteria to create applicant rank lists. One implicit assumption is that predictive associations exist between an applicant's rank and their future performance as a resident. To date, these associations have not been sufficiently demonstrated. OBJECTIVES: We hypothesized that a strong positive correlation exists between the National Resident Match Program (NRMP) match-list applicant rank, the United States Medical Licensing Examination (USMLE) Step 1 and In-Training Examination (ITE) scores, and the graduating resident rank. METHODS: A total of 286 residents from five EM programs over a 5-year period were studied. The applicant rank (AR) was derived from the applicant's relative rank list position on each programs' submitted NRMP rank list. The graduation rank (GR) was determined by a faculty consensus committee. GR was then correlated to AR using a Spearman's partial rank correlation. Additional correlations were sought with a ranking of the USMLE Step Score (UR) and the ITE Score (IR). RESULTS: Combining data for all five programs, weak positive correlations existed between GR and AR, UR, and IR. The majority of correlations ranged between. When comparing GR and AR, there was a weak correlation of 0.13 (p = 0.03). CONCLUSION: Our study found only weak correlations between GR and AR, UR, and IR, suggesting that those variables may not be strong predictors of resident performance. This has important implications for EM programs considering the resources devoted to applicant evaluation and ranking.

A conceptual framework for improved analyses of 72-hour return cases.

For more than 25 years, emergency medicine researchers have examined 72-hour return visits as a marker for high-risk patient visits and as a surrogate measure for quality of care. Individual emergency departments frequently use 72-hour returns as a screening tool to identify deficits in care, although comprehensive departmental reviews of this nature may consume considerable resources. We discuss the lack of published data supporting the use of 72-hour return frequency as an overall performance measure and examine why this is not a valid use, describe a conceptual framework for reviewing 72-hour return cases as a screening tool, and call for future studies to test various models for conducting such quality assurance reviews of patients who return to the emergency department within 72 hours.

A novel program to improve patient safety by integrating peer review into the emergency medicine residency curriculum.

BACKGROUND: Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error. DISCUSSION: To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the month's case reviews are presented, learning points discussed, and corrective actions are proposed. CONCLUSION: By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome.

Hepatic artery pseudoaneurysm rupture: a case report and review of the literature.

BACKGROUND: Ruptured hepatic artery pseudoaneurysm, a type of visceral artery aneurysm, is a rare condition that is life threatening if not diagnosed and treated rapidly in the emergency department (ED). Patients presenting with this condition require aggressive resuscitation. Endovascular embolization is the first-line treatment option. OBJECTIVES: We present a case of spontaneously ruptured hepatic artery pseudoaneurysm and provide a review of the current literature on this topic, focusing on appropriate ED management. CASE REPORT: A 41-year-old woman with a history of systemic lupus erythematosus and multiple hepatic bilomas presented to the ED in critical condition with sudden onset of severe abdominal pain and hemodynamic instability. She was found to have a ruptured hepatic artery pseudoaneurysm with marked hemoperitoneum on computed tomography angiography. She was aggressively resuscitated and successfully managed via endovascular embolization. CONCLUSION: Ruptured hepatic artery pseudoaneurysm is a life-threatening condition that must be rapidly diagnosed and managed in the ED. Visceral artery aneurysm rupture is a diagnosis that should be considered in any patient presenting to the ED with hemodynamic instability and abdominal pain. Definitive management is with endovascular embolization.

More Than Suicide: Mortality After Emergency Psychiatric Care and Implications for Practice.

BACKGROUND: Emergency departments (EDs) provide vital mental health services. ED patients with behavioral health presentations, particularly suicidal ideation, are at increased risk of death by suicide, medical illness, trauma, or overdose. Causes of death for patients who receive specialty emergency psychiatric services remain undescribed. OBJECTIVE: We describe the incidence and cause of death after care in a psychiatric emergency service (PES). METHODS: Mortality data were obtained for all adult patients treated in a safety net ED from April 2016 to June 2020. Causes of death were categorized as medical, external (accidents, overdoses, and homicide), or suicide and compared between PES patients and ED patients who were not treated in the PES. Correlates of mortality were described for PES patients. RESULTS: We analyzed 164,422 encounters including 6063 PES visits. Mortality in the 30 days after discharge was 0.3% among PES patients and 0.6% among medical ED patients. At both 30 and 365 days, PES patients were more likely to die by suicide than medical ED patients, and ED patients were more likely to die by medical causes. Among PES patients who died within 365 days, 46% died by medical causes, 32% by external causes, and 23% by suicide. In multivariable analyses, age was associated with all-cause, medical, and external mortality after a PES visit; opioid and stimulant use disorders were associated with all-cause and external mortality. CONCLUSIONS: Most patients who die after receiving emergency psychiatric care die by medical and external causes such as accidents, overdose, and homicide. Patients who are older and have opioid or stimulant use disorders are at higher risk of nonsuicide mortality. We propose interventions to reimagine emergency psychiatric care and address nonsuicide mortality among psychiatric patients treated in emergency and crisis settings.

Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work.

OBJECTIVES: We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions. METHODS: We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives. RESULTS: Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%). CONCLUSION: Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.