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Research Forum Abstracts
208
Home Hospitalization Unit: An Alternative to Standard Inpatient Hospitalization From the Emergency Department
Salazar A, Estrada C, Porta R, Lolo M, Tomas S, Alvarez M/Hospital Mutua de Terrassa, Terrassa, Spain
Study Objectives: Home hospitalization units are currently emerging worldwide as an alternative to inpatient hospital care. The aim of the present study was to evaluate the clinical parameters and to assess the characteristics of the patients admitted to a home hospitalization unit after a first ED visit. Methods: Design: A descriptive, retrospective study. Setting: The study took place in the ED of a 500-bed teaching hospital, with a population in the metropolitan area of 350,000, which attends about 125,000 emergency visits per year. Home hospitalization unit admits patients from the ED when hospitalization is imminent. Type of Participants: The hospital computer registration database was used to identify all patients presenting to our ED in a 1-year period from January 1st, 2005 to December 31st, 2005 and finally admitted to home hospitalization unit. Variables of interest were age, sex, diagnostic, mean length of stay and readmission rate. A cohort composed of 466 patients admitted to home hospitalization unit was identified as making 3.1 % of the total 14,683 in-hospital admissions from the ED. Results: Of the 466 patients, 250 (53.6%) were admitted to home hospitalization unit directly from the ED. Mean age was 71 years. One hundred and fifty-eight were male (63%). The most common diagnoses were as follows: acute exacerbation of chronic obstructive pulmonary disease (127/250 patients, 50.8%), acute exacerbation of chronic heart failure (32/250 patients, 12.8%), pneumonia (24/250 patients, 9.8%), urinary tract infection (20/250 patients, 8%) and legs deep venous thrombosis (14/250 patients, 5.6%). Mean length of stay was 7 days. Hospital readmission rate within 30 days after unit discharge was 9%. Conclusion: In our experience, a home hospitalization unit proved to be an effective and safe measure for certain acutely ill older persons who required acute hospitalization and a helpful intervention to ED overcrowding that alleviated from in-hospital bed crises.
209
Risk Factor Documentation for Life-Threatening Disease in US Emergency Department Patients
Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; The Sullivan Group, Inc, Oakbrook Terrace, IL; Cook County Hospital/Rush Medical College, Chicago, IL
Study Objectives: The Emergency Department (ED) represents a high risk environment for both medical errors and malpractice litigation. Failure to diagnose and treat serious disease is one cause of medical error in emergency medicine (EM). Risk factor documentation for life threatening diseases is an opportunity to improve diagnostic yield. This study describes these documentations in a 3 year experience of a national quality assessment effort in US emergency departments. Methods: An explicit review of the audit chart database from the Sullivan Group’s Emergency Medicine Risk Initiative (EMRI) was conducted for ED visits occurring between 1/1/2003 and 12/31/2005 representing 287 separate EDs. The EMRI is a national ED chart review and quality assessment product designed to review provider compliance with EM quality indicators in ten chief complaint categories. ED charts are reviewed by trained individual hospital staff using a template web-based system and collated into a central national data repository. Auditors recorded documentation of risk factors for coronary artery disease, thoracic aortic dissection, pulmonary embolism, subarchnoid hemorrhage, ectopic pregnancy, abdominal aortic aneurysm and c-spine fracture from corresponding chief complaint charts (i.e. ectopic pregnancy risk factors in a patient with a vaginal bleeding chief
Volume , . : October
complaint). Data was stratified by year, complaint category, visit documentation type, and ED provider medical degree. Results: During the study period 91,286 ED visits and 173,122 individual data points were reviewed. Medical physicians (MD) evaluated 83.6% of visits, osteopathic physicians (DO) 13.5% of visits, nurse practitioners (NP) 0.9% of visits, and physician assistants (PA) 2.0% of visits. Overall, ED providers documented disease risk factors in 46.8% of visits with an appropriate chief complaint. Documentation varied amongst risk factors audited; coronary artery disease risk was documented the most (85%, p ⬍ 0.0001) (Table). Risk factor documentation also varied by provider and ED visit documentation type, with NPs (48.9%) and template-based provider (50.2%) records associated with the highest risk factor documentation. Risk factor documentation increased each year, from 41.1% in 2003 to 52.1% in 2005 (p ⬍ 0.0001). Conclusion: In a national sample from 2003-2005, documentation of life threatening disease risk factors occurred in less than half of appropriate ED visits. Risk factor documentation was highest amongst nurse practitioners and templatebased documentation systems, and increased during each audited year.
210
The Effect of Future Demographic Changes on Emergency Medicine
Roskos ER, Wilber ST/Summa Health System/NEOUCOM, Akron, OH
The demographic changes affecting the US population over the next half-century have been widely publicized. The aging of the “baby-boomer” generation will increase the proportion of older residents; which will be compounded by an increasing life span. Study Objective: We analyzed existing data sources to determine how this demographic trend might affect emergency medicine. Methods: This retrospective, observational study used data from the 2003 National Hospital Ambulatory Medical Care Survey (NHAMCS), US Census estimates for 2003, and US Census projections through 2050. For each data set, 5year age categories were created. From the NHAMCS, we derived the estimated number of ED visits, the percent visits triaged as emergent, the average length of stay (LOS), the percent admitted and admitted to the ICU, the mean number of diagnostic tests per patient for each 5-year age category. The population-based rate of ED visits was calculated by dividing the number of ED visits by the population in each 5-year age group. This visit rate was used to project the number and proportion of ED visits in each 5-year age group, as well as the impact of demographic changes on pertinent emergency department parameters noted above, using 2003 proportions and means. For brevity, we present data for 2030 (25 years from now) here. Results: In 2003, patients 65 and older comprised 15.4% of all ED visits, by 2030, these patients will make up 24.1% of visits, a relative increase of 56%. Patients 75 and older comprised 9.1% of ED visits in 2003 and will make up 13.9% of visits in 2030, a 52.8% relative increase. Patients 85 and older comprised 3.2% of ED visits in 2003 and will make up 5.3% of visits in 2030, a 67% relative increase. The number of patients triaged as emergent will increase from 13.8% in 2003 to 15.0% in 2030, an 8.6% relative increase. The number of diagnostic tests per patient will increase from 4.9 per patient in 2003 to 5.1 per patient in 2030, an increase of 3.7%. The average LOS will increase from 193.7 minutes in 2003 to 199.6 minutes in 2030, a 3.0% relative increase. The proportion of admitted patients will increase from 13.1% in 2003 to 15.9% in 2030, a 21.6% relative increase, and the proportion of patient admitted to the ICU will increase from 1.3% in 2003 to 1.6% in 2030, a 23.1% relative increase. Conclusions: Demographic changes will have a substantial impact on the practice of emergency medicine over the next 25 years. An increased proportion of visits by older patients will increase the severity and complexity of emergency department care. Future work will create projections that include the rate of increase in ED utilization over time, since patients 65 and older have had a 26% increase in ED utilization over the last 10 years.
Annals of Emergency Medicine S65
208
Home Hospitalization Unit: An Alternative to Standard Inpatient Hospitalization From the Emergency Department
Salazar A, Estrada C, Porta R, Lolo M, Tomas S, Alvarez M/Hospital Mutua de Terrassa, Terrassa, Spain
Study Objectives: Home hospitalization units are currently emerging worldwide as an alternative to inpatient hospital care. The aim of the present study was to evaluate the clinical parameters and to assess the characteristics of the patients admitted to a home hospitalization unit after a first ED visit. Methods: Design: A descriptive, retrospective study. Setting: The study took place in the ED of a 500-bed teaching hospital, with a population in the metropolitan area of 350,000, which attends about 125,000 emergency visits per year. Home hospitalization unit admits patients from the ED when hospitalization is imminent. Type of Participants: The hospital computer registration database was used to identify all patients presenting to our ED in a 1-year period from January 1st, 2005 to December 31st, 2005 and finally admitted to home hospitalization unit. Variables of interest were age, sex, diagnostic, mean length of stay and readmission rate. A cohort composed of 466 patients admitted to home hospitalization unit was identified as making 3.1 % of the total 14,683 in-hospital admissions from the ED. Results: Of the 466 patients, 250 (53.6%) were admitted to home hospitalization unit directly from the ED. Mean age was 71 years. One hundred and fifty-eight were male (63%). The most common diagnoses were as follows: acute exacerbation of chronic obstructive pulmonary disease (127/250 patients, 50.8%), acute exacerbation of chronic heart failure (32/250 patients, 12.8%), pneumonia (24/250 patients, 9.8%), urinary tract infection (20/250 patients, 8%) and legs deep venous thrombosis (14/250 patients, 5.6%). Mean length of stay was 7 days. Hospital readmission rate within 30 days after unit discharge was 9%. Conclusion: In our experience, a home hospitalization unit proved to be an effective and safe measure for certain acutely ill older persons who required acute hospitalization and a helpful intervention to ED overcrowding that alleviated from in-hospital bed crises.
209
Risk Factor Documentation for Life-Threatening Disease in US Emergency Department Patients
Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; The Sullivan Group, Inc, Oakbrook Terrace, IL; Cook County Hospital/Rush Medical College, Chicago, IL
Study Objectives: The Emergency Department (ED) represents a high risk environment for both medical errors and malpractice litigation. Failure to diagnose and treat serious disease is one cause of medical error in emergency medicine (EM). Risk factor documentation for life threatening diseases is an opportunity to improve diagnostic yield. This study describes these documentations in a 3 year experience of a national quality assessment effort in US emergency departments. Methods: An explicit review of the audit chart database from the Sullivan Group’s Emergency Medicine Risk Initiative (EMRI) was conducted for ED visits occurring between 1/1/2003 and 12/31/2005 representing 287 separate EDs. The EMRI is a national ED chart review and quality assessment product designed to review provider compliance with EM quality indicators in ten chief complaint categories. ED charts are reviewed by trained individual hospital staff using a template web-based system and collated into a central national data repository. Auditors recorded documentation of risk factors for coronary artery disease, thoracic aortic dissection, pulmonary embolism, subarchnoid hemorrhage, ectopic pregnancy, abdominal aortic aneurysm and c-spine fracture from corresponding chief complaint charts (i.e. ectopic pregnancy risk factors in a patient with a vaginal bleeding chief
Volume , . : October
complaint). Data was stratified by year, complaint category, visit documentation type, and ED provider medical degree. Results: During the study period 91,286 ED visits and 173,122 individual data points were reviewed. Medical physicians (MD) evaluated 83.6% of visits, osteopathic physicians (DO) 13.5% of visits, nurse practitioners (NP) 0.9% of visits, and physician assistants (PA) 2.0% of visits. Overall, ED providers documented disease risk factors in 46.8% of visits with an appropriate chief complaint. Documentation varied amongst risk factors audited; coronary artery disease risk was documented the most (85%, p ⬍ 0.0001) (Table). Risk factor documentation also varied by provider and ED visit documentation type, with NPs (48.9%) and template-based provider (50.2%) records associated with the highest risk factor documentation. Risk factor documentation increased each year, from 41.1% in 2003 to 52.1% in 2005 (p ⬍ 0.0001). Conclusion: In a national sample from 2003-2005, documentation of life threatening disease risk factors occurred in less than half of appropriate ED visits. Risk factor documentation was highest amongst nurse practitioners and templatebased documentation systems, and increased during each audited year.
210
The Effect of Future Demographic Changes on Emergency Medicine
Roskos ER, Wilber ST/Summa Health System/NEOUCOM, Akron, OH
The demographic changes affecting the US population over the next half-century have been widely publicized. The aging of the “baby-boomer” generation will increase the proportion of older residents; which will be compounded by an increasing life span. Study Objective: We analyzed existing data sources to determine how this demographic trend might affect emergency medicine. Methods: This retrospective, observational study used data from the 2003 National Hospital Ambulatory Medical Care Survey (NHAMCS), US Census estimates for 2003, and US Census projections through 2050. For each data set, 5year age categories were created. From the NHAMCS, we derived the estimated number of ED visits, the percent visits triaged as emergent, the average length of stay (LOS), the percent admitted and admitted to the ICU, the mean number of diagnostic tests per patient for each 5-year age category. The population-based rate of ED visits was calculated by dividing the number of ED visits by the population in each 5-year age group. This visit rate was used to project the number and proportion of ED visits in each 5-year age group, as well as the impact of demographic changes on pertinent emergency department parameters noted above, using 2003 proportions and means. For brevity, we present data for 2030 (25 years from now) here. Results: In 2003, patients 65 and older comprised 15.4% of all ED visits, by 2030, these patients will make up 24.1% of visits, a relative increase of 56%. Patients 75 and older comprised 9.1% of ED visits in 2003 and will make up 13.9% of visits in 2030, a 52.8% relative increase. Patients 85 and older comprised 3.2% of ED visits in 2003 and will make up 5.3% of visits in 2030, a 67% relative increase. The number of patients triaged as emergent will increase from 13.8% in 2003 to 15.0% in 2030, an 8.6% relative increase. The number of diagnostic tests per patient will increase from 4.9 per patient in 2003 to 5.1 per patient in 2030, an increase of 3.7%. The average LOS will increase from 193.7 minutes in 2003 to 199.6 minutes in 2030, a 3.0% relative increase. The proportion of admitted patients will increase from 13.1% in 2003 to 15.9% in 2030, a 21.6% relative increase, and the proportion of patient admitted to the ICU will increase from 1.3% in 2003 to 1.6% in 2030, a 23.1% relative increase. Conclusions: Demographic changes will have a substantial impact on the practice of emergency medicine over the next 25 years. An increased proportion of visits by older patients will increase the severity and complexity of emergency department care. Future work will create projections that include the rate of increase in ED utilization over time, since patients 65 and older have had a 26% increase in ED utilization over the last 10 years.
Annals of Emergency Medicine S65