- Email: [email protected]
246 Admissions Within Seven Days of an Emergency Department Discharge
Research Forum Abstracts Methods: Trained research assistants enrolled consecutive patients age 18-65 in a cross-sectional study at an urban, safety-net hospital from June 2013 to July 2013. Patients reported their primary language, ethnicity, insurance status, and immigration documentation status. Additionally, patients reported any care they received for their chief complaint prior to their emergency department visit. If a patient had seen a health care provider for the same problem, the health care visit was categorized by type of health care encounter. Patients also answered questions about why they came to the ED after receiving care elsewhere, and could choose more than one option. We presented the overall results descriptively. We performed a stratified analysis by language, insurance status, immigration documentation status and ethnicity to examine differences in motivation for “second visit” ED care using chi-squared tests. Results: Of the 1243 patients who participated in the survey, 346 patients (28%) had previously seen a health care provider for the same problem that brought them to the emergency department. A majority of patients (55%) had been seen at an urgent care or walk-in clinic prior to their ED visit, while 23% had been seen at a previously scheduled routine appointment, 13% had been seen at a different emergency department and 9% had been seen at a scheduled sameday appointment with their regular clinic. Of the 346 patients who sought care previously, 42% (146) reported they came to the ED because they needed tests or services not available in the location they where initially seen, 36% (126) reported that they were sent directly from the previous location, 34% reported they could not afford the medication or tests needed, 22% reported their medical condition had worsened since prior evaluation, and 10% reported they were not satisfied with the care they received at the previous health care encounter. When examining the impact of language, ethnicity, immigration status and insurance, we found that Spanish speakers were more likely to have been referred from a previous health care encounter (30% compared to 24%, P ¼ .04), and less likely to have come to the ED because they needed tests or services not available in their prior health care site (38% vs 50%, P ¼ .03). No other factors had an impact on patients’ prior care or motivations for coming to the emergency department. Conclusion: In our safety-net ED population, the most common reasons for a second visit after a prior encounter are that patients need services and tests not available in their prior sites and are directly being referred by these previous health care providers. Interventions to steer patients into appropriate care channels will require communication with outside clinics and emergency departments to coordinate care, share medical information appropriately and find the ideal care site for these patients.
246
Admissions Within Seven Days of an Emergency Department Discharge
Brennan JJ, Chan TC, Vilke GM, Killeen JP, Hsia RY, Tehaney K, Castillo EM/University of California, San Diego, San Diego, CA; University of California, San Francisco, San Francisco, CA
Study Objectives: Patients who are discharged from the emergency department (ED) and return and are admitted within a short period of time can be considered “high risk.” Either their condition progressed, or it may have been misdiagnosed during the initial ED encounter. The purpose of this study is to identify and describe patients discharged from an ED with who are admitted within seven days of the discharge. Methods: This was a multi-center retrospective longitudinal cohort study of all hospital ED visits in California in 2011 using non-public data from 324 licensed nonmilitary acute care hospitals in the state of California. Visits without a valid patient identifier and patients under the age of 18 years or who expired were excluded. The seven-day post ED discharge admission rates were calculated and the clinical classifications and admission primary diagnoses are reported. Logistic regression was used to assess independent associations between demographic characteristics (age, gender, race/ethnicity and payer) between those who were discharged from the ED and returned within seven days and those who did not return in that period. Results: During the 12-month study period, 3,750,420 patients with a total of 6,105,015 index ED discharges were identified. A total of 117,884 patients (3.1%) were admitted within the seven-day follow-up period. The majority of patients who returned were between 45 and 64 years of age (35.2%), female (54.0%), non-Hispanic white (55.9%) and had Medicare as their primary payer (42.4%). The top three clinical classifications at ED discharge preceding a 7-day hospital admission were abdominal pain (9.1%), skin and subcutaneous tissue
Volume 66, no. 4s : October 2015
infections (4.1%), and nonspecific chest pain (3.9%). The most common admitting primary diagnoses were septicemia (5.5%), other cellulitis and abscess (4.5%) and cholelithiasis (3.1%). In the logistic regression model, patients with Medicare (OR¼2.3, 95% CI¼2.2, 2.3) and Medi-Cal (OR¼2.0, 95% CI¼1.9, 2.0) were more likely to be admitted within seven days compared to private insurance. Conclusion: In this study of all 324 non-military licensed EDs in California, a substantial number of patients were discharged from an ED and then were admitted within seven days were identified. A large proportion of these patients had been admitted for potentially serious conditions.
247
Emergency Physician X-Ray Ordering as a Function of the Patient’s Primary Language
Bilal S, Kuo D, Peacock WF, Pillow MT/Baylor College of Medicine, Houston, TX
Study Objectives: To study the effects of the patient’s primary language on emergency physician x-ray ordering. Methods: This is a retrospective 15-month case control study performed at a Level 1 trauma center in Houston with an annual census of >100,000 patients. Using a convenience sample, patients’ were stratified by triage level (1¼high, 5¼low acuity) and language group divided into English and non-English speakers. Race was self-identified. The inclusion requirements were age>18, triage level and self-reported primary language recorded. X-ray ordering was defined as obtaining an ultrasound (US) and/or computed tomography (CT) imaging of any type while in the ED. Univariate analysis was performed and results presented with 95% confidence intervals. We do not report data on triage levels 1 and 5 (n¼80), as x-ray ordering is protocol driven (level 1), or extremely rare (level 5). Results: A total of 1692 patients met the entry criteria. Of these 1033 were female, 382 spoke English, 674 spoke Spanish, and 636 neither. 50.6% were Latino, 35% Asian/Pacific Islanders, 5.9% African-American, 2.4% Caucasian, and 6.1% other. The mean (SD) age of English speakers was 43.9 (16.4) vs 55.2 (13.9) for nonEnglish. Overall, there were no differences in x-ray ordering practices in the higher triage acuity cohorts; however, in the lower acuity cohort (triage 4) non-English speakers were nearly 500% more likely to receive imaging than English language speakers. Conclusion: Physicians are more likely to order imaging studies for non-English speaking lower triage acuity patients. Mitigating the consequences of limited English language fluency may benefit patient care and ED operational considerations.
Table. X-ray ordering by triage and language Triage level 2 3 4
248
X-ray English % (95% CI)
X-ray non-English % (95% CI)
26.3 (16.9-37.7) 24.2 (18.5-29.9) 2.9 (0.34-10.1)
24.6 (17.6-31.7) 32.0 (27.4-36.6) 18.2 (10.3-28.6)
Can Data From a Health Information Exchange Be Used to Describe Frequent Emergency Department Users Within a Region?
Saef SH, Carr CM, Bush JS, Bartman M, Sendor AB, Spearman JB, Zhao W, Su Z, Zhang J, Arnaud C, Obeid J/Medical University of South Carolina, Charleston, SC
Background: A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize frequent ED users in our region regardless of hospital visited or payor class. Study Objectives: Use data from an HIE to characterize patients who are frequent ED users (FEDUs). Methods: We constructed a database from a cohort of adult patients (18 years of age or greater) who had information in a regional HIE for a one-year period beginning March 2012. Patients were defined as FEDUs (those who made 4 or more visits during the study period) and Non-FEDUs (those who made <4 ED
Annals of Emergency Medicine S89
246
Admissions Within Seven Days of an Emergency Department Discharge
Brennan JJ, Chan TC, Vilke GM, Killeen JP, Hsia RY, Tehaney K, Castillo EM/University of California, San Diego, San Diego, CA; University of California, San Francisco, San Francisco, CA
Study Objectives: Patients who are discharged from the emergency department (ED) and return and are admitted within a short period of time can be considered “high risk.” Either their condition progressed, or it may have been misdiagnosed during the initial ED encounter. The purpose of this study is to identify and describe patients discharged from an ED with who are admitted within seven days of the discharge. Methods: This was a multi-center retrospective longitudinal cohort study of all hospital ED visits in California in 2011 using non-public data from 324 licensed nonmilitary acute care hospitals in the state of California. Visits without a valid patient identifier and patients under the age of 18 years or who expired were excluded. The seven-day post ED discharge admission rates were calculated and the clinical classifications and admission primary diagnoses are reported. Logistic regression was used to assess independent associations between demographic characteristics (age, gender, race/ethnicity and payer) between those who were discharged from the ED and returned within seven days and those who did not return in that period. Results: During the 12-month study period, 3,750,420 patients with a total of 6,105,015 index ED discharges were identified. A total of 117,884 patients (3.1%) were admitted within the seven-day follow-up period. The majority of patients who returned were between 45 and 64 years of age (35.2%), female (54.0%), non-Hispanic white (55.9%) and had Medicare as their primary payer (42.4%). The top three clinical classifications at ED discharge preceding a 7-day hospital admission were abdominal pain (9.1%), skin and subcutaneous tissue
Volume 66, no. 4s : October 2015
infections (4.1%), and nonspecific chest pain (3.9%). The most common admitting primary diagnoses were septicemia (5.5%), other cellulitis and abscess (4.5%) and cholelithiasis (3.1%). In the logistic regression model, patients with Medicare (OR¼2.3, 95% CI¼2.2, 2.3) and Medi-Cal (OR¼2.0, 95% CI¼1.9, 2.0) were more likely to be admitted within seven days compared to private insurance. Conclusion: In this study of all 324 non-military licensed EDs in California, a substantial number of patients were discharged from an ED and then were admitted within seven days were identified. A large proportion of these patients had been admitted for potentially serious conditions.
247
Emergency Physician X-Ray Ordering as a Function of the Patient’s Primary Language
Bilal S, Kuo D, Peacock WF, Pillow MT/Baylor College of Medicine, Houston, TX
Study Objectives: To study the effects of the patient’s primary language on emergency physician x-ray ordering. Methods: This is a retrospective 15-month case control study performed at a Level 1 trauma center in Houston with an annual census of >100,000 patients. Using a convenience sample, patients’ were stratified by triage level (1¼high, 5¼low acuity) and language group divided into English and non-English speakers. Race was self-identified. The inclusion requirements were age>18, triage level and self-reported primary language recorded. X-ray ordering was defined as obtaining an ultrasound (US) and/or computed tomography (CT) imaging of any type while in the ED. Univariate analysis was performed and results presented with 95% confidence intervals. We do not report data on triage levels 1 and 5 (n¼80), as x-ray ordering is protocol driven (level 1), or extremely rare (level 5). Results: A total of 1692 patients met the entry criteria. Of these 1033 were female, 382 spoke English, 674 spoke Spanish, and 636 neither. 50.6% were Latino, 35% Asian/Pacific Islanders, 5.9% African-American, 2.4% Caucasian, and 6.1% other. The mean (SD) age of English speakers was 43.9 (16.4) vs 55.2 (13.9) for nonEnglish. Overall, there were no differences in x-ray ordering practices in the higher triage acuity cohorts; however, in the lower acuity cohort (triage 4) non-English speakers were nearly 500% more likely to receive imaging than English language speakers. Conclusion: Physicians are more likely to order imaging studies for non-English speaking lower triage acuity patients. Mitigating the consequences of limited English language fluency may benefit patient care and ED operational considerations.
Table. X-ray ordering by triage and language Triage level 2 3 4
248
X-ray English % (95% CI)
X-ray non-English % (95% CI)
26.3 (16.9-37.7) 24.2 (18.5-29.9) 2.9 (0.34-10.1)
24.6 (17.6-31.7) 32.0 (27.4-36.6) 18.2 (10.3-28.6)
Can Data From a Health Information Exchange Be Used to Describe Frequent Emergency Department Users Within a Region?
Saef SH, Carr CM, Bush JS, Bartman M, Sendor AB, Spearman JB, Zhao W, Su Z, Zhang J, Arnaud C, Obeid J/Medical University of South Carolina, Charleston, SC
Background: A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize frequent ED users in our region regardless of hospital visited or payor class. Study Objectives: Use data from an HIE to characterize patients who are frequent ED users (FEDUs). Methods: We constructed a database from a cohort of adult patients (18 years of age or greater) who had information in a regional HIE for a one-year period beginning March 2012. Patients were defined as FEDUs (those who made 4 or more visits during the study period) and Non-FEDUs (those who made <4 ED
Annals of Emergency Medicine S89