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223: Impact of Insurance Status on Frequent Users to the Emergency Department
Research Forum Abstracts
223
Impact of Insurance Status on Frequent Users to the Emergency Department
Brauer E, Miller J, Shields R, Wickenheiser K, Stokes-Buzzelli S/Henry Ford Hospital, Detroit, MI; Wayne State School of Medicine, Detroit, MI
Study Objectives: A common assumption is that a lack of health insurance is a primary reason for frequent use of emergency department (ED) services. In light of the recent federal health care reform to broaden the insured population, we sought to compare the impact of adequate health insurance with other social factors on frequent users to the ED. Methods: This prospective observational study consisting of questionnaires was conducted in an urban ED with an annual census of 95,000 patients and an uninsured rate of 20%. A convenience sample of frequent-users ⱖ 18-years old were enrolled over a 12-month period. A frequent-user was defined as ⬎ 9 ED visits in the previous 12 months. Patients were excluded because of intoxication, altered mental status, or acute psychosis. Informed consent was obtained, and the study was approved by the institutional review board. Descriptive statistics, Chi-squared analysis and student’s t-test were calculated for the data set. Results: A total of 115 patients were enrolled, with an average age of 44 years and median number of 18⫾13 ED visits over the previous 12 months. 57% were male. 78% of frequent users reported adequate health insurance coverage, and 22% reported inadequate coverage, a rate comparable to that of the overall ED census (20% uninsured). The ED was identified as the primary site for obtaining health care in 84% of the underinsured and 72% of the insured frequent users. Underinsured frequent users had similar rates of annual ED use compared to well-insured patients (20 versus 18 visits per year). Underinsured frequent users were more likely to report no access to primary care services in the past 6 months (36% versus 14%, p⬍ 0.03), and were more likely to report the cost of clinic visits (60% versus 20%, p⬍0.01) and prescription medications (68% versus 24%, p⬍0.01) as burdensome. Additionally, underinsured frequent users were more likely be homeless (40% versus 3%, p⬍0.01). Conclusion: In an urban setting, frequent users that reported inadequate health insurance repeatedly used the ED as their sole site for health care and reported the costs of clinic visits and prescription medications as major barriers to seeking primary care service.
224
A Prospective, Randomized Comparison of Ultrasonography-Guided and Non UltrasonographyGuided Peritonsillar Abscess Drainage by Emergency Physicians
Costantino TG, Dehnkamp W, Goett H, Satz W/Temple University, Philadelphia, PA
Study Objectives: Traditionally, emergency physicians have used blind needle aspiration to drain peritonsillar abscesses. When this failed, static imaging studies (CT) and/or consultation with another service to perform the drainage was obtained. Recently, some emergency physicians have used ultrasonography to guide peritonsillar abscess drainage. This study seeks to determine which initial approach would lead to greater successful drainage. Methods: This was a prospective, randomized, controlled study of all adult patients who presented to the emergency department (ED) between November 2008 and March 2010 at an urban academic hospital who had an apparent peritonsillar abscess after physical exam and who were about to undergo needle aspiration. These patients were randomized to receive ultrasonography (US) or to undergo landmark (LM) drainage. All providers were at least 2nd year emergency medicine residents and had met ACEP guidelines for ultrasonography training. The ultrasonography was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the ultrasonography also performed the needle aspiration to maintain spatial relationship. The landmark technique was performed using visual landmarks in a superior to inferior approach until pus was obtained or 3 sticks were performed. Topical anesthesia and antibiotics were standardized. The primary endpoint was successful aspiration of purulent material. Secondary endpoints were diagnostic accuracy based on final diagnosis on follow-up within 1 week, frequency of specialist consultation, and need for additional imaging studies. Frequency data were analyzed using the Fisher Exact method. Results: There were 23 patients enrolled, 12 of which had ultrasonography guidance performed. The median age was 25 with a range of 19 to 50. There were 6 abscesses and 6 cases of cellulitis in the US arm and 7 abscesses and 4 cases of cellulitis in the LM arm. The results showed:
S74 Annals of Emergency Medicine
Successful aspiration by emergency physician: US 100% (95% CI: 56% to 100%) versus LM 42% (16% to 75%) p ⫽ 0.05 Overall Successful diagnosis: US 100% (72% to 100%) versus LM 63% (35% to 85%) p ⫽ 0.04 ENT consult rate: US 8% (0% to 37.5%) versus LM 55% (28% to 79%) p⫽0.03 Additional imaging required (all were CT scans): US 0% (0% to 28%) versus LM 45% (21%-72%) p ⫽ 0.01 ED LOS (minutes): US 176 (112-256) versus LM 265(180-351) p⫽0.14 Conclusion: Ultrasonography guidance increases the rate of successful aspiration of peritonsillar abscesses by emergency physicians. It can also aid in the diagnosis of peritonsillar cellulitis, which was surprisingly high in this population, and thereby avoid unnecessary aspiration attempts. Ultrasonography also decreased the need for specialist consultation and additional imaging studies which may lead to improved ED throughput.
225
The Use of a Novel Device Improves Real-Time Ultrasonography-Guided IV Access
Ferre RM, Hunt P, Palma J, Smith J/Palmetto Health Richland, Columbia, SC
Study Objective: Real-time ultrasonography guided intravenous (USGIV) access improves success and decreases complications of central intravenous access. However, the ability to perform this procedure requires skill and practice. The purpose of this study was to determine if a novel ultrasonography device improved emergency medicine residents (EMR) first-pass success rate compared with the traditional technique. Methods: This prospective, randomized, crossover study was approved by our IRB. A novel ultrasonography probe (Soma Development, LLC, Greenville, SC) which uses a small phased array transducer with an integrated needle guide and Hall effect sensor to graphically represent projected needle path and real-time needle position, was demonstrated to residents 1-2 weeks before study enrollment. EMR used the Soma device and traditional technique 1-2 times on a peripheral vein phantom during the introductory demonstration. The number of USGIV access procedures performed prior to the study was obtained for each EMR, who were then block randomized to start with either the Soma device or with the traditional technique. The traditional technique involved a two-handed technique with a 10-5 MHz linear transducer of a SonoSite M-turbo (SonoSite Inc., Bothel, WA). Each EMR performed USGIV access on three different simulated veins (peripheral, internal jugular and subclavian) in both the long and short vessel axis using Blue Phantom ™ models. Successful needle placement was confirmed by fluid aspiration. Primary outcome was first pass success rate. Secondary outcomes included: total time to intravenous access, needle tip visualization at time of vessel puncture, posterior wall vessel puncture, number of forward needle passes, and number of attempts. Data was collected using a standardized form and entered into an 2007 Excel spreadsheet (Microsoft Corp., Redmond, WA) where statistical analysis was performed using Pearson’s chi-square for non-parametric data and Student’s t-test for parametric data. Results: Twenty-four EMR participated (7 PGY-1, 7 PGY-2, 10 PGY-3). The mean number of USGIV performed by all EMR before the study was 23.75 (range 6-57). A total of 288 USGIV attempts were analyzed. There were 4 failures to obtain USGIV access with the traditional technique and none with the Soma device. First pass success rate for all USGIV attempts was significantly better with the Soma device (99.3%) versus 37.1% for the traditional technique, x2⫽127, p⬍0.001. This statistical significance for first pass success rate remained true in subgroup analysis of all vessels: peripheral (Soma 100% versus traditional 36.2%, x2⫽45, p⬍0.001), subclavian (Soma 97.9% versus traditional 21.7%, x2⫽56, p⬍0.001), and internal jugular (Soma 100% versus traditional 53.2%, x2⫽30, p⬍0.001). Needle tip visualization at vessel entry was significantly better for the Soma device 100% versus 39.8% for the traditional technique, x2⫽125, p⬍0.001. Time to obtain USGIV access was also significantly better with the Soma device 15.1 seconds versus traditional 52.3 seconds, t⫽7.35, df⫽286, p⬍0.001. Conclusion: USGIV access performed by EMR with the Soma device significantly improves first-pass success rate for peripheral, subclavian, and internal jugular veins compared with the traditional two-hand technique in a phantom model.
Volume , . : September
223
Impact of Insurance Status on Frequent Users to the Emergency Department
Brauer E, Miller J, Shields R, Wickenheiser K, Stokes-Buzzelli S/Henry Ford Hospital, Detroit, MI; Wayne State School of Medicine, Detroit, MI
Study Objectives: A common assumption is that a lack of health insurance is a primary reason for frequent use of emergency department (ED) services. In light of the recent federal health care reform to broaden the insured population, we sought to compare the impact of adequate health insurance with other social factors on frequent users to the ED. Methods: This prospective observational study consisting of questionnaires was conducted in an urban ED with an annual census of 95,000 patients and an uninsured rate of 20%. A convenience sample of frequent-users ⱖ 18-years old were enrolled over a 12-month period. A frequent-user was defined as ⬎ 9 ED visits in the previous 12 months. Patients were excluded because of intoxication, altered mental status, or acute psychosis. Informed consent was obtained, and the study was approved by the institutional review board. Descriptive statistics, Chi-squared analysis and student’s t-test were calculated for the data set. Results: A total of 115 patients were enrolled, with an average age of 44 years and median number of 18⫾13 ED visits over the previous 12 months. 57% were male. 78% of frequent users reported adequate health insurance coverage, and 22% reported inadequate coverage, a rate comparable to that of the overall ED census (20% uninsured). The ED was identified as the primary site for obtaining health care in 84% of the underinsured and 72% of the insured frequent users. Underinsured frequent users had similar rates of annual ED use compared to well-insured patients (20 versus 18 visits per year). Underinsured frequent users were more likely to report no access to primary care services in the past 6 months (36% versus 14%, p⬍ 0.03), and were more likely to report the cost of clinic visits (60% versus 20%, p⬍0.01) and prescription medications (68% versus 24%, p⬍0.01) as burdensome. Additionally, underinsured frequent users were more likely be homeless (40% versus 3%, p⬍0.01). Conclusion: In an urban setting, frequent users that reported inadequate health insurance repeatedly used the ED as their sole site for health care and reported the costs of clinic visits and prescription medications as major barriers to seeking primary care service.
224
A Prospective, Randomized Comparison of Ultrasonography-Guided and Non UltrasonographyGuided Peritonsillar Abscess Drainage by Emergency Physicians
Costantino TG, Dehnkamp W, Goett H, Satz W/Temple University, Philadelphia, PA
Study Objectives: Traditionally, emergency physicians have used blind needle aspiration to drain peritonsillar abscesses. When this failed, static imaging studies (CT) and/or consultation with another service to perform the drainage was obtained. Recently, some emergency physicians have used ultrasonography to guide peritonsillar abscess drainage. This study seeks to determine which initial approach would lead to greater successful drainage. Methods: This was a prospective, randomized, controlled study of all adult patients who presented to the emergency department (ED) between November 2008 and March 2010 at an urban academic hospital who had an apparent peritonsillar abscess after physical exam and who were about to undergo needle aspiration. These patients were randomized to receive ultrasonography (US) or to undergo landmark (LM) drainage. All providers were at least 2nd year emergency medicine residents and had met ACEP guidelines for ultrasonography training. The ultrasonography was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the ultrasonography also performed the needle aspiration to maintain spatial relationship. The landmark technique was performed using visual landmarks in a superior to inferior approach until pus was obtained or 3 sticks were performed. Topical anesthesia and antibiotics were standardized. The primary endpoint was successful aspiration of purulent material. Secondary endpoints were diagnostic accuracy based on final diagnosis on follow-up within 1 week, frequency of specialist consultation, and need for additional imaging studies. Frequency data were analyzed using the Fisher Exact method. Results: There were 23 patients enrolled, 12 of which had ultrasonography guidance performed. The median age was 25 with a range of 19 to 50. There were 6 abscesses and 6 cases of cellulitis in the US arm and 7 abscesses and 4 cases of cellulitis in the LM arm. The results showed:
S74 Annals of Emergency Medicine
Successful aspiration by emergency physician: US 100% (95% CI: 56% to 100%) versus LM 42% (16% to 75%) p ⫽ 0.05 Overall Successful diagnosis: US 100% (72% to 100%) versus LM 63% (35% to 85%) p ⫽ 0.04 ENT consult rate: US 8% (0% to 37.5%) versus LM 55% (28% to 79%) p⫽0.03 Additional imaging required (all were CT scans): US 0% (0% to 28%) versus LM 45% (21%-72%) p ⫽ 0.01 ED LOS (minutes): US 176 (112-256) versus LM 265(180-351) p⫽0.14 Conclusion: Ultrasonography guidance increases the rate of successful aspiration of peritonsillar abscesses by emergency physicians. It can also aid in the diagnosis of peritonsillar cellulitis, which was surprisingly high in this population, and thereby avoid unnecessary aspiration attempts. Ultrasonography also decreased the need for specialist consultation and additional imaging studies which may lead to improved ED throughput.
225
The Use of a Novel Device Improves Real-Time Ultrasonography-Guided IV Access
Ferre RM, Hunt P, Palma J, Smith J/Palmetto Health Richland, Columbia, SC
Study Objective: Real-time ultrasonography guided intravenous (USGIV) access improves success and decreases complications of central intravenous access. However, the ability to perform this procedure requires skill and practice. The purpose of this study was to determine if a novel ultrasonography device improved emergency medicine residents (EMR) first-pass success rate compared with the traditional technique. Methods: This prospective, randomized, crossover study was approved by our IRB. A novel ultrasonography probe (Soma Development, LLC, Greenville, SC) which uses a small phased array transducer with an integrated needle guide and Hall effect sensor to graphically represent projected needle path and real-time needle position, was demonstrated to residents 1-2 weeks before study enrollment. EMR used the Soma device and traditional technique 1-2 times on a peripheral vein phantom during the introductory demonstration. The number of USGIV access procedures performed prior to the study was obtained for each EMR, who were then block randomized to start with either the Soma device or with the traditional technique. The traditional technique involved a two-handed technique with a 10-5 MHz linear transducer of a SonoSite M-turbo (SonoSite Inc., Bothel, WA). Each EMR performed USGIV access on three different simulated veins (peripheral, internal jugular and subclavian) in both the long and short vessel axis using Blue Phantom ™ models. Successful needle placement was confirmed by fluid aspiration. Primary outcome was first pass success rate. Secondary outcomes included: total time to intravenous access, needle tip visualization at time of vessel puncture, posterior wall vessel puncture, number of forward needle passes, and number of attempts. Data was collected using a standardized form and entered into an 2007 Excel spreadsheet (Microsoft Corp., Redmond, WA) where statistical analysis was performed using Pearson’s chi-square for non-parametric data and Student’s t-test for parametric data. Results: Twenty-four EMR participated (7 PGY-1, 7 PGY-2, 10 PGY-3). The mean number of USGIV performed by all EMR before the study was 23.75 (range 6-57). A total of 288 USGIV attempts were analyzed. There were 4 failures to obtain USGIV access with the traditional technique and none with the Soma device. First pass success rate for all USGIV attempts was significantly better with the Soma device (99.3%) versus 37.1% for the traditional technique, x2⫽127, p⬍0.001. This statistical significance for first pass success rate remained true in subgroup analysis of all vessels: peripheral (Soma 100% versus traditional 36.2%, x2⫽45, p⬍0.001), subclavian (Soma 97.9% versus traditional 21.7%, x2⫽56, p⬍0.001), and internal jugular (Soma 100% versus traditional 53.2%, x2⫽30, p⬍0.001). Needle tip visualization at vessel entry was significantly better for the Soma device 100% versus 39.8% for the traditional technique, x2⫽125, p⬍0.001. Time to obtain USGIV access was also significantly better with the Soma device 15.1 seconds versus traditional 52.3 seconds, t⫽7.35, df⫽286, p⬍0.001. Conclusion: USGIV access performed by EMR with the Soma device significantly improves first-pass success rate for peripheral, subclavian, and internal jugular veins compared with the traditional two-hand technique in a phantom model.
Volume , . : September