- Email: [email protected]
223 Effect of the Affordable Care Act Medicaid Expansion on Psychiatric Boarding Times in the Emergency Department
Research Forum Abstracts school as a proxy for cognitive rest, and time off before returning to sports as a proxy for physical rest. We hypothesized that the majority of providers would recommend a concussion management strategy that is based on cognitive rest. Methods: PEM providers (attendings, fellows, and clinical associates) and pediatric primary care clinic attendings from an urban tertiary care pediatric hospital and affiliated outpatient clinic were surveyed. Surveys were completed by 61 providers. The survey consisted of two clinical scenarios of pediatric closed head injuries—a female scenario with a mild concussion and male scenario with a moderate concussion. Practitioners were asked two questions for each scenario regarding their management recommendations for returning to school and returning to sports/activity. Data was collected and analyzed using the Redcap software system. A Fisher’s exact test analysis was performed to compare the management of the two scenarios. Results: 61/151 (40%) providers completed the survey, including 46/78 (59%) PEM physicians. In the female/mild concussion scenario, 43/61 providers (70.5%) recommended time off from school compared to 53/61 providers (86.9%) in the male/ moderate concussion scenario (p <0.0001). In the mild concussion scenario, the majority of providers (50.8%) recommended clearance by a physician before returning to sports, compared to 72.1% in the moderate concussion scenario. Overall, 69% of providers indicated they would prescribe (some degree of) rest in both the mild and moderate concussion scenarios. Conclusions: In both hypothetical concussion scenarios (mild vs. moderate concussion), a substantial majority of providers recommended a management strategy that included some degree of a delay of return to school. Providers were significantly more likely to suggest time off from school in the moderate concussion scenario. Given recent evidence suggesting that cognitive rest may not be associated with reduced risk of prolonged concussion syndrome, recommendations of periods of cognitive rest, particularly absences from school, should be approached cautiously. Additional investigations, including prospective studies investigating the relationship between provider concussion management recommendations, cognitive rest, and prolonged concussion symptoms are warranted.
222
The Pediatric Blast Injury: Out-of-Hospital and Emergency Department Resuscitation and Resource Utilization in Iraq and Afghanistan
Schauer S, April MD, Naylor JF, Hill G, Arana AA, Oh JS, Delorenzo RA/US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; San Antonio Military Medical Center, JBSA Fort Sam Houston, TX; 28th Combat Support Hospital, Fort Bragg, NC; Dell Children’s Hospital, Austin, TX; Walter Reed Army Medical Center, Bethesda, MD; University of Texas Health Science Center at San Antonio, San Antonio, TX
Study Objectives: Pediatric trauma care is a significant challenge in the deployed setting in accordance with medical rules of engagement. Traumatic injuries due to explosives are largely unique to the combat-zone setting. Thus, little data exist specific to care of the pediatric patient with trauma due to explosion. We describe the out-ofhospital and emergency department (ED) care of the pediatric explosive injury. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by age based on Centers for Disease Control age groupings: <1, 1-4, 5-9, 10-14, 15-17. Descriptive and inferential statistics were utilized. Results: From January 2007 to January 2016, there were 3,439 pediatric trauma encounters in the registry. Of those, 1,480 (43.0%) had explosive listed as the primary mechanism of injury. Amputation rates increased with age (p¼0.001). The most common intervention in the out-of-hospital setting was external warming followed by wound dressings and tourniquets. In the ED, the most common interventions were external warming, vascular access and imaging. Composite injury severity scores and mortality were not significant across age groups (p¼0.866, p¼0.319, respectively). Conclusions: While not necessarily the target population for care by military physicians, it is not uncommon for gravely injured pediatric patients to receive care in US battlefield hospitals. It is therefore essential for future planning purposes to further understand these patients, their needs, and the resources required to care for them.
223
Effect of the Affordable Care Act Medicaid Expansion on Psychiatric Boarding Times in the Emergency Department
Moore PQ, Christian E, Hardwick J, Kysia R/The University of Chicago Medical Center, Chicago, IL; Cook County Health and Hospitals System, Chicago, IL
Study Objectives: The enactment of the Affordable Care Act (ACA) led to a dramatic change in the balance between insured and uninsured. In February 2013, the ACA’s Medicaid expansion program was launched as “CountyCare” in a large urban area. Objectives: To analyze the effect of a large shift in insurance status on psychiatric boarding times in the 80-bed emergency department (ED) of a tertiary-care, safety-net hospital. Our hypothesis was that the advent of CountyCare would be associated with a decrease in psychiatric boarding times for all-comers regardless of insurance status, and that psychiatric boarding times for patients with CountyCare would be shorter than those for uninsured patients. Methods: This is a quasi-experimental, retrospective, single-center cohort study of all adult patients (age 18) admitted from the ED to any psychiatric hospital between February 1, 2013 and December 31, 2014. Exclusion criteria included any charts with missing triage or discharge time data, and any erroneous entries. The study was approved by the hospital’s institutional review board. Boarding times were generated based on the difference of patient checkout and arrival times. Patient insurance status was aggregated into four groups: uninsured, private, CountyCare, and other public insurance. Due to unequal variances between group boarding times, a Welch procedure was performed to test for statistically significant boarding time mean differences between the insurance status groups, and a Games Howell posteriori test was conducted to reveal any significant boarding time differences between CountyCare and each other insurance status group. Data were analyzed using Microsoft Excel 2011. Results: 1,674 patients were included in the study. The mean boarding time and number of enrollees are shown in Figure 1. The Welch procedure indicated that there was a statistically significant difference between boarding times for the four insurance status
Volume 70, no. 4s : October 2017
Annals of Emergency Medicine S89
Research Forum Abstracts groups, [F(3, 165) ¼ 75.06, p <.001]. Further, post hoc comparisons using the Games and Howell test revealed CountyCare boarding times were ten hours and thirty minutes less than the uninsured group, five hours and thirty minutes less than the other public insurance group, and nine hours and twenty-two minutes less than the private insurance group, 95 CIs [-12:23,-8:44], [-6:43, -3:23], and [-15:45, -3:00], respectively. Conclusions: We conclude that mean ED boarding times for all patients admitted to psychiatric hospitals decreased as the number of CountyCare enrollees increased. While there may be confounding factors that affected the change in boarding time, our data suggest that the increased percentage of patients with insurance may have helped decrease mean wait times for psychiatric patients in the ED. We also conclude that patients with CountyCare insurance had statistically significantly shorter boarding times than uninsured patients and patients with other public insurance. This implies that patients who are newly insured as a result of the ACA Medicaid expansion may have quicker access to psychiatric facilities. Comparisons between CountyCare patients and privately insured patients are limited due to a small privately insured sample.
Results: 161 patients were entered into the study. 95 (58%) were female and mean age of all was 15 (95% CI 15-16) with an IRQ of 13-17. The number of patients seen after release was 94 vs 68 before for a proportion of 0.58 (95% CI 0.5 to 0.68; p value < 0.05). There was no statistically significant change in numbers of patients presenting before/after with regards to SI (p 0.53), SA (p 0.43) or SI/SA combination (p 0.45). There was no significant difference in age before or after 15 vs 15.4 mean difference 0.4 (95% CI -0.3 to 1.2, p 0.28). There was no difference in admission rates before and after, difference in proportions 0.009 (95% CI -0.14 to 0.16; p value 1.0). The peak in Google searches for the show occurred between 4/08-4/18/2017 with a second smaller peak on 5/8/2017 while peak presentations to the ED occurred 5/1-5/11/20017. There did not appear to be a graphic change in searches for “How to commit suicide” on Google during the study period. Conclusions: There was a statistically significant increase in presentations to the emergency department for psychiatric evaluation post release of “13 Reason Why.” However, we found no change in SI/SA presentations or admission rates in the pre- vs post-release period. This preliminary data shows media may have profound influence on patients in this age range. Further studies are warranted to determine if this is a positive or negative effect.
225
Does Telepsychiatry Help Disposition Psychiatric Patients Faster?
LeBaron J, Ron V, Chary M, Siegal J/New York Presbyterian Queens, Flushing, NY
224
“13 Reasons Why” Pediatric Psychiatric Presentations to an Emergency Department in Relation to Release Date
Salo D, Kairam N, Sherrow L, Fiesseler F, Patel D, Wali A/Morristown Medical Center, Morristown, NJ
Study Objectives: Among young Americans suicide is the third leading cause of death according to the US Centers for Disease Control and Prevention with 157,000 people in the 10-24 age range seeking medical care for self-inflicted injuries each year. The release of “13 Reasons Why” www.netflix.com/title/80117470, has caused controversy amongst parents, mental health professionals, educators, and producers of the show. Proponents feel it serves as a catalyst for conversation and can bring light to issues people with mental illness face. Opponents state it may sensationalize or glamorize suicide in vulnerable populations making suicide seem romantic or acceptable, as well as giving the notion that suicide can be a way to teach others a lesson. We hypothesized that with the release of “13 Reasons Why” on March 31, 2017 there may be an increase in the numbers of patients between 11 and 18 years of age presenting to the emergency department with chief complaint or final diagnosis of mood disorder, depression, or suicide attempt/ideation. We further hypothesized that admission rates for psychiatric illness during this time period would be higher. Methods: Retrospective Cohort Protocol: We compared the number of presentations to the emergency department for mood disorders, suicide or depression classified by ICD 9 codes for the 41-day period before and after the release of “13 Reasons Why” (Feb 18, 2017- May 11, 2017). Data was collected from the EDIMS charting system at an urban teaching hospital with an adult/pediatric visit of 85,000. We examined chief complaint, SI and or SA, admission rate, and age differences using appropriate statistical tests with a significant p value of 0.05. We also used Google Trends to determine peak interest in the show as related to searches for “13 Reasons Why” on www.google.com and to determine if an increase in searches for “How to commit suicide” occurred.
S90 Annals of Emergency Medicine
Study Objectives: The purpose of our study was to determine whether telepsychiatry decreased length of stay for patients who were medically cleared for discharge as compared to consulting house psychiatry. Methods: The study was a retrospective chart review of all patients presenting to the ED of an urban level 1 trauma center who received a psychiatric evaluation in the ED. The first study period, January 2016 through March 2016, enrolled 73 patients who were evaluated by house psychiatry. The second study period, May 1st, 2016 through July 31st, 2016, enrolled 59 patients who were evaluated by telepsychiatry. Telepsychiatry provided coverage between 4pm to 8am during weekdays and all hours on weekends. Patients in the first time period were chosen based on need for psychiatric consultation in the ED during the hours that telepyschiatry would have been covering in the second study period. Results: The median age was 40 +/- 14 in both groups. The sexes of the two groups were comparable (52% vs 47% male; p¼0.42 Z-test for two proportions). The spectrum of diagnoses were not statistically different (resampling, p¼0.068) Alcohol-related disorders (F10), anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders (F40-48) were the most frequent ICD 10 diagnostic clusters in both groups. For patients for whom psychiatry was consulted for clearance for discharge, the time to discharge decreased from 844 +/- 7 minutes without telepsychiatry to 631 +/- 13 minutes (MannWhitney U test, p¼0.014). The overall time to disposition did not significantly change (1111.0 +/- 595 minutes vs 1130 +/- 440 minutes; p¼0.62 two-sample Kolmogorov-Smirnov test). In the first period two patients were observed, as compared with six in the second period (p¼0.152; Fisher’s exact test). Limitations of the study include the retrospective nature of the study and the lack of continued follow-up on patients evaluated in our ED. Conclusions: Telepsychiatry decreases the time for psychiatric clearance for patients able to be discharged home. It does not decrease the time to disposition for patients needing psychiatric hospitalization, transfer to long-term psychiatric facilities, or continued observation. Rates of disposition were similar between the telepsychiatry and face to face consultation groups.
226
Adverse Childhood Events Scores in Opioid Misusing Patients Presenting to the Emergency Department
Brucker K/Indiana University School of Medicine, Indianapolis, IN
Study Objectives: As with so many public health crises, the opioid epidemic is hitting emergency departments (EDs) and emergency medical services (EMS) particularly hard. Drug-related overdose are now the leading cause of accidental death in the United States. One largely unmeasured driver of ED visits for substance misuse is exposure to childhood trauma as measured by the Adverse Childhood Events (ACE) score. Research shows exposure to childhood trauma is common and patients with these exposures are at significantly elevated risk of many adverse health outcomes, including use of injection drugs.
Volume 70, no. 4s : October 2017
222
The Pediatric Blast Injury: Out-of-Hospital and Emergency Department Resuscitation and Resource Utilization in Iraq and Afghanistan
Schauer S, April MD, Naylor JF, Hill G, Arana AA, Oh JS, Delorenzo RA/US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; San Antonio Military Medical Center, JBSA Fort Sam Houston, TX; 28th Combat Support Hospital, Fort Bragg, NC; Dell Children’s Hospital, Austin, TX; Walter Reed Army Medical Center, Bethesda, MD; University of Texas Health Science Center at San Antonio, San Antonio, TX
Study Objectives: Pediatric trauma care is a significant challenge in the deployed setting in accordance with medical rules of engagement. Traumatic injuries due to explosives are largely unique to the combat-zone setting. Thus, little data exist specific to care of the pediatric patient with trauma due to explosion. We describe the out-ofhospital and emergency department (ED) care of the pediatric explosive injury. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by age based on Centers for Disease Control age groupings: <1, 1-4, 5-9, 10-14, 15-17. Descriptive and inferential statistics were utilized. Results: From January 2007 to January 2016, there were 3,439 pediatric trauma encounters in the registry. Of those, 1,480 (43.0%) had explosive listed as the primary mechanism of injury. Amputation rates increased with age (p¼0.001). The most common intervention in the out-of-hospital setting was external warming followed by wound dressings and tourniquets. In the ED, the most common interventions were external warming, vascular access and imaging. Composite injury severity scores and mortality were not significant across age groups (p¼0.866, p¼0.319, respectively). Conclusions: While not necessarily the target population for care by military physicians, it is not uncommon for gravely injured pediatric patients to receive care in US battlefield hospitals. It is therefore essential for future planning purposes to further understand these patients, their needs, and the resources required to care for them.
223
Effect of the Affordable Care Act Medicaid Expansion on Psychiatric Boarding Times in the Emergency Department
Moore PQ, Christian E, Hardwick J, Kysia R/The University of Chicago Medical Center, Chicago, IL; Cook County Health and Hospitals System, Chicago, IL
Study Objectives: The enactment of the Affordable Care Act (ACA) led to a dramatic change in the balance between insured and uninsured. In February 2013, the ACA’s Medicaid expansion program was launched as “CountyCare” in a large urban area. Objectives: To analyze the effect of a large shift in insurance status on psychiatric boarding times in the 80-bed emergency department (ED) of a tertiary-care, safety-net hospital. Our hypothesis was that the advent of CountyCare would be associated with a decrease in psychiatric boarding times for all-comers regardless of insurance status, and that psychiatric boarding times for patients with CountyCare would be shorter than those for uninsured patients. Methods: This is a quasi-experimental, retrospective, single-center cohort study of all adult patients (age 18) admitted from the ED to any psychiatric hospital between February 1, 2013 and December 31, 2014. Exclusion criteria included any charts with missing triage or discharge time data, and any erroneous entries. The study was approved by the hospital’s institutional review board. Boarding times were generated based on the difference of patient checkout and arrival times. Patient insurance status was aggregated into four groups: uninsured, private, CountyCare, and other public insurance. Due to unequal variances between group boarding times, a Welch procedure was performed to test for statistically significant boarding time mean differences between the insurance status groups, and a Games Howell posteriori test was conducted to reveal any significant boarding time differences between CountyCare and each other insurance status group. Data were analyzed using Microsoft Excel 2011. Results: 1,674 patients were included in the study. The mean boarding time and number of enrollees are shown in Figure 1. The Welch procedure indicated that there was a statistically significant difference between boarding times for the four insurance status
Volume 70, no. 4s : October 2017
Annals of Emergency Medicine S89
Research Forum Abstracts groups, [F(3, 165) ¼ 75.06, p <.001]. Further, post hoc comparisons using the Games and Howell test revealed CountyCare boarding times were ten hours and thirty minutes less than the uninsured group, five hours and thirty minutes less than the other public insurance group, and nine hours and twenty-two minutes less than the private insurance group, 95 CIs [-12:23,-8:44], [-6:43, -3:23], and [-15:45, -3:00], respectively. Conclusions: We conclude that mean ED boarding times for all patients admitted to psychiatric hospitals decreased as the number of CountyCare enrollees increased. While there may be confounding factors that affected the change in boarding time, our data suggest that the increased percentage of patients with insurance may have helped decrease mean wait times for psychiatric patients in the ED. We also conclude that patients with CountyCare insurance had statistically significantly shorter boarding times than uninsured patients and patients with other public insurance. This implies that patients who are newly insured as a result of the ACA Medicaid expansion may have quicker access to psychiatric facilities. Comparisons between CountyCare patients and privately insured patients are limited due to a small privately insured sample.
Results: 161 patients were entered into the study. 95 (58%) were female and mean age of all was 15 (95% CI 15-16) with an IRQ of 13-17. The number of patients seen after release was 94 vs 68 before for a proportion of 0.58 (95% CI 0.5 to 0.68; p value < 0.05). There was no statistically significant change in numbers of patients presenting before/after with regards to SI (p 0.53), SA (p 0.43) or SI/SA combination (p 0.45). There was no significant difference in age before or after 15 vs 15.4 mean difference 0.4 (95% CI -0.3 to 1.2, p 0.28). There was no difference in admission rates before and after, difference in proportions 0.009 (95% CI -0.14 to 0.16; p value 1.0). The peak in Google searches for the show occurred between 4/08-4/18/2017 with a second smaller peak on 5/8/2017 while peak presentations to the ED occurred 5/1-5/11/20017. There did not appear to be a graphic change in searches for “How to commit suicide” on Google during the study period. Conclusions: There was a statistically significant increase in presentations to the emergency department for psychiatric evaluation post release of “13 Reason Why.” However, we found no change in SI/SA presentations or admission rates in the pre- vs post-release period. This preliminary data shows media may have profound influence on patients in this age range. Further studies are warranted to determine if this is a positive or negative effect.
225
Does Telepsychiatry Help Disposition Psychiatric Patients Faster?
LeBaron J, Ron V, Chary M, Siegal J/New York Presbyterian Queens, Flushing, NY
224
“13 Reasons Why” Pediatric Psychiatric Presentations to an Emergency Department in Relation to Release Date
Salo D, Kairam N, Sherrow L, Fiesseler F, Patel D, Wali A/Morristown Medical Center, Morristown, NJ
Study Objectives: Among young Americans suicide is the third leading cause of death according to the US Centers for Disease Control and Prevention with 157,000 people in the 10-24 age range seeking medical care for self-inflicted injuries each year. The release of “13 Reasons Why” www.netflix.com/title/80117470, has caused controversy amongst parents, mental health professionals, educators, and producers of the show. Proponents feel it serves as a catalyst for conversation and can bring light to issues people with mental illness face. Opponents state it may sensationalize or glamorize suicide in vulnerable populations making suicide seem romantic or acceptable, as well as giving the notion that suicide can be a way to teach others a lesson. We hypothesized that with the release of “13 Reasons Why” on March 31, 2017 there may be an increase in the numbers of patients between 11 and 18 years of age presenting to the emergency department with chief complaint or final diagnosis of mood disorder, depression, or suicide attempt/ideation. We further hypothesized that admission rates for psychiatric illness during this time period would be higher. Methods: Retrospective Cohort Protocol: We compared the number of presentations to the emergency department for mood disorders, suicide or depression classified by ICD 9 codes for the 41-day period before and after the release of “13 Reasons Why” (Feb 18, 2017- May 11, 2017). Data was collected from the EDIMS charting system at an urban teaching hospital with an adult/pediatric visit of 85,000. We examined chief complaint, SI and or SA, admission rate, and age differences using appropriate statistical tests with a significant p value of 0.05. We also used Google Trends to determine peak interest in the show as related to searches for “13 Reasons Why” on www.google.com and to determine if an increase in searches for “How to commit suicide” occurred.
S90 Annals of Emergency Medicine
Study Objectives: The purpose of our study was to determine whether telepsychiatry decreased length of stay for patients who were medically cleared for discharge as compared to consulting house psychiatry. Methods: The study was a retrospective chart review of all patients presenting to the ED of an urban level 1 trauma center who received a psychiatric evaluation in the ED. The first study period, January 2016 through March 2016, enrolled 73 patients who were evaluated by house psychiatry. The second study period, May 1st, 2016 through July 31st, 2016, enrolled 59 patients who were evaluated by telepsychiatry. Telepsychiatry provided coverage between 4pm to 8am during weekdays and all hours on weekends. Patients in the first time period were chosen based on need for psychiatric consultation in the ED during the hours that telepyschiatry would have been covering in the second study period. Results: The median age was 40 +/- 14 in both groups. The sexes of the two groups were comparable (52% vs 47% male; p¼0.42 Z-test for two proportions). The spectrum of diagnoses were not statistically different (resampling, p¼0.068) Alcohol-related disorders (F10), anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders (F40-48) were the most frequent ICD 10 diagnostic clusters in both groups. For patients for whom psychiatry was consulted for clearance for discharge, the time to discharge decreased from 844 +/- 7 minutes without telepsychiatry to 631 +/- 13 minutes (MannWhitney U test, p¼0.014). The overall time to disposition did not significantly change (1111.0 +/- 595 minutes vs 1130 +/- 440 minutes; p¼0.62 two-sample Kolmogorov-Smirnov test). In the first period two patients were observed, as compared with six in the second period (p¼0.152; Fisher’s exact test). Limitations of the study include the retrospective nature of the study and the lack of continued follow-up on patients evaluated in our ED. Conclusions: Telepsychiatry decreases the time for psychiatric clearance for patients able to be discharged home. It does not decrease the time to disposition for patients needing psychiatric hospitalization, transfer to long-term psychiatric facilities, or continued observation. Rates of disposition were similar between the telepsychiatry and face to face consultation groups.
226
Adverse Childhood Events Scores in Opioid Misusing Patients Presenting to the Emergency Department
Brucker K/Indiana University School of Medicine, Indianapolis, IN
Study Objectives: As with so many public health crises, the opioid epidemic is hitting emergency departments (EDs) and emergency medical services (EMS) particularly hard. Drug-related overdose are now the leading cause of accidental death in the United States. One largely unmeasured driver of ED visits for substance misuse is exposure to childhood trauma as measured by the Adverse Childhood Events (ACE) score. Research shows exposure to childhood trauma is common and patients with these exposures are at significantly elevated risk of many adverse health outcomes, including use of injection drugs.
Volume 70, no. 4s : October 2017