- Email: [email protected]
4 The Impact of Emergency Medicine Residents on the Operational Efficiency in a Busy Level 1 Trauma Center Emergency Department
Research Forum Abstracts Care Sensitive Condition (ACSC) versus non-ACSC. Using national ED visit frequency data from NHAMCS and HCUP, we estimated the aggregate expenditures and proportional costs of NHE by each visit category. Results: Among all encounters involving ED-directed health care, the greatest mean per visit expenditures were attributable to hospital admissions from the ED, with mean payments of $12,817 and $9,708 for non-ACSC and ACSC admissions, respectively. Non-urgent outpatient ED visits generated the lowest mean per visit expenditure of $819, even compared to all other outpatient ED encounters. Table 1 describes the proportional cost of all ED-directed health care and proportional cost of NHE by visit category. ED-directed health care accounted for 11.2% of NHE, with 7.0% NHE from ED admissions and 4.2% NHE from outpatient ED visits. Potentially avoidable ED-directed encounters, including non-emergent visits, emergent but preventable visits, and ACSC admissions, together accounted for 1.8% NHE. Conclusions: With ED care and ED-directed health care comprising more than 11% of NHE, it is important for ED providers to work collaboratively with other parts of the health care system to safely reduce health care costs. Given the relative importance of ED admissions over outpatient encounters, making use of the emergency physician’s role as a gatekeeper to admission may be the most effective way to reduce costs. Table 1. Proportional Costs of Emergency Department Directed Health Care and National Health Expenditures by Visit Type. % Cost % Cost of Aggregate of ED National National Directed Expenditure % ED Health Visits* Health Care† (in billions) Expenditures‡ Outpatient ED Encounters 88.6 Unclassified 43.2 Injuries 21.4 Non-emergent Visit 16.4 Emergency Visit, 3.7 Not Preventable Or Avoidable Emergency Visit, 2.1 Preventable/Avoidable Mental Health 1.8 Admissions from the ED 11.4 Non-ACSC 9.4 ACSC 2.0 All ED Encounters 100.0
37.6 19.5 8.0 6.0 2.6
$109.5 $56.8 $23.3 $17.4 $7.6
4.22 2.19 0.90 0.67 0.29
0.8
$2.3
0.09
0.7 62.4 53.6 8.8 100.0
$2.1 S182.4 S156.6 $25.8 $291 9
0.08 7.01 6.02 0.99 11.23
Notes: ED ¼ Emergency Department, ACSC ¼ Ambulatory Care Sensitive Condition. *Based on estimate from the 2010 National Health Ambulatory Care Survey for annual nationwide Emergency Department visits, which is 129.8 million. † Based on the study’s estimate for annual national aggregate costs for Emergency Department directed health care, which is $300 billion. ‡ Based on National Health Expenditures from 2010, which was $2599 billion.
3
At Risk Alcohol Use Predicts Risk of Repeat Emergency Department Visit for Trauma
Baugher A, Haley L, Jr., Adedinsewo D, Kelley M, Hankin A/Grady Health System, Atlanta, GA; Emory University, Atlanta, GA
Study Objectives: Patients with recurrent emergency department (ED) visits for trauma represent an important target for injury prevention efforts, as each repeat visit contributes to potentially preventable morbidity/mortality. It is unknown if alcohol use history at the initial trauma-related visit predicts risk of recurrent injury. Methods: A retrospective chart review study of patients seen for traumatic injuries at a Southeastern Level 1 Trauma center. During the baseline visit, patients were screened for alcohol risk with the Alcohol, Smoking, and Substance Involvement Test (ASSIST) as part of an alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) program serving all patients seen in the ED. Patients were included in the analysis if they were 18 years, presented to the ED with a traumatic injury (identified by ICD-9 code) between April 2009 and September 2011 and had an ASSIST score recorded by a member of the SBIRT team during the initial visit. Chart review was conducted to identify subsequent visits for injury within a 24-month period. Analyses
S2 Annals of Emergency Medicine
were conducted using chi-square and t-tests; Logistic and Poisson regression models were constructed to evaluate the independent effect of the ASSIST score on repeat trauma-related ED visits. Results: Among 4,319 charts of patients with ASSIST screening, 661 patients had an initial visit for trauma and met inclusion criteria, of whom 104 patients (15.7%) had a return visit for injury within 24 months. High-risk drinkers (ASSIST score > 27) had a higher likelihood of a return visit for trauma (aOR¼2.45, 95% CI):[1.11, 5.38]) and a greater number of subsequent ED visits than low-risk drinkers (ASSIST score <10) (mean # visits 0.44 versus 0.15; moderate-risk drinkers (ASSIST score 11-26) were also more likely to return to the ED (aOR¼1.85, 95% CI:[1.08, 3.19]) and have more return visits to the ED than low-risk drinkers (mean # visits 0.43 versus 0.15). High-risk drinkers were also more likely to have a subsequent ED visit requiring hospital admission for management of a traumatic injury within 24 months when compared with low-risk drinkers (OR¼5.9, 95% CI:[1.16, 29.96]). Conclusion: Trauma patients with high-risk drinking behavior were more likely to return to the ED within 24 months of the initial visit, have a subsequent traumarelated hospital admission within 2 years, and have more trauma-related ED visits compared to patients with ASSIST scores at the low-risk level. These findings suggest that ASSIST screening of trauma patients may identify patients who would benefit from intervention to prevent subsequent trauma; further research might also focus on determining whether interventions that decrease alcohol use, such as brief interventions, might also result in a decreased risk of repeat ED visit for trauma.
4
The Impact of Emergency Medicine Residents on the Operational Efficiency in a Busy Level 1 Trauma Center Emergency Department
Trop AM, Robinson R/John Peter Smith Health Network, Fort Worth, TX
Study Objective: There is a widely held perception that the presence of residents negatively impacts throughput and quality of patient care in the emergency department (ED). At most academic institutions this is seen as an acceptable sacrifice to train the next generation of medical providers. However, there is still controversy over this topic. John Peter Smith Health Network (JPS) is at a pivotal point in the development of an emergency medicine residency program, which puts us in the unique position to assess the effects of new residents on an already established ED. The aim of this study is to assess the impact of the addition of a PGY 1-3 emergency medicine residency program on the efficiency of emergency department operations in a large and growing Level 1 trauma center. Methods: This is an observational cohort study. All patients who presented to the JPS ED during the study period were assessed. The study includes approximately 200,000 patients of all ages, sexes, ethnicities, and chief complaints. The data from the 2010 time period, before the institution of emergency medicine residents, served as the control group. The study reviewed the time period from July through December in calendar years 2010 through 2013. Operational variables were collected from the electronic medical record to assess the effect of emergency medicine residents on basic throughput measures, as the program grew from 0 residents in 2010 to a full complement of 37 in 2013. These variables included number of patients per month, admission rate, patient length of stay (LOS), number of patients that left without being seen (LWBS) or left against medical advice (AMA), number of hours of attending and resident coverage, and patient satisfaction evaluation scores. Analysis of variance with Bonferroni correction was used for data comparison among groups. Results: Over the 4 years of the study, the yearly census in the ED grew by a total of 28.2%. The average number of patients per month increased from 7651 249 in 2010 to 9486 467 in 2013 (P<0.001). When compared to the time period before the addition of emergency medicine residents (2010), the combined LWBS and AMA rate showed a steady decrease from 9.21% in 2010 to 7.18% in 2013 (P¼0.0567), despite large increases in patient volume and acuity. Over the study period, the admission rate remained constant between 18-20%. Average LOS of discharged patients decreased from 344.4 43.2 minutes in 2010 to 237.9 22.4 minutes in 2013 (P<0.001). Meanwhile, Press Ganey analysis has shown a steady increase in patient satisfaction over the study period from 73.1% positive patient reviews in 2010 to 77.1% in 2013. Conclusions: The data demonstrates a significant decrease in patient LOS as residents were added to the system, despite drastic increases in patient volume and acuity level. Additionally, there was a decrease in the rate of patients who LWBS or AMA. It seems that residents have a positive impact on patient care and satisfaction in our study.
Volume 64, no. 4s : October 2014
37.6 19.5 8.0 6.0 2.6
$109.5 $56.8 $23.3 $17.4 $7.6
4.22 2.19 0.90 0.67 0.29
0.8
$2.3
0.09
0.7 62.4 53.6 8.8 100.0
$2.1 S182.4 S156.6 $25.8 $291 9
0.08 7.01 6.02 0.99 11.23
Notes: ED ¼ Emergency Department, ACSC ¼ Ambulatory Care Sensitive Condition. *Based on estimate from the 2010 National Health Ambulatory Care Survey for annual nationwide Emergency Department visits, which is 129.8 million. † Based on the study’s estimate for annual national aggregate costs for Emergency Department directed health care, which is $300 billion. ‡ Based on National Health Expenditures from 2010, which was $2599 billion.
3
At Risk Alcohol Use Predicts Risk of Repeat Emergency Department Visit for Trauma
Baugher A, Haley L, Jr., Adedinsewo D, Kelley M, Hankin A/Grady Health System, Atlanta, GA; Emory University, Atlanta, GA
Study Objectives: Patients with recurrent emergency department (ED) visits for trauma represent an important target for injury prevention efforts, as each repeat visit contributes to potentially preventable morbidity/mortality. It is unknown if alcohol use history at the initial trauma-related visit predicts risk of recurrent injury. Methods: A retrospective chart review study of patients seen for traumatic injuries at a Southeastern Level 1 Trauma center. During the baseline visit, patients were screened for alcohol risk with the Alcohol, Smoking, and Substance Involvement Test (ASSIST) as part of an alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) program serving all patients seen in the ED. Patients were included in the analysis if they were 18 years, presented to the ED with a traumatic injury (identified by ICD-9 code) between April 2009 and September 2011 and had an ASSIST score recorded by a member of the SBIRT team during the initial visit. Chart review was conducted to identify subsequent visits for injury within a 24-month period. Analyses
S2 Annals of Emergency Medicine
were conducted using chi-square and t-tests; Logistic and Poisson regression models were constructed to evaluate the independent effect of the ASSIST score on repeat trauma-related ED visits. Results: Among 4,319 charts of patients with ASSIST screening, 661 patients had an initial visit for trauma and met inclusion criteria, of whom 104 patients (15.7%) had a return visit for injury within 24 months. High-risk drinkers (ASSIST score > 27) had a higher likelihood of a return visit for trauma (aOR¼2.45, 95% CI):[1.11, 5.38]) and a greater number of subsequent ED visits than low-risk drinkers (ASSIST score <10) (mean # visits 0.44 versus 0.15; moderate-risk drinkers (ASSIST score 11-26) were also more likely to return to the ED (aOR¼1.85, 95% CI:[1.08, 3.19]) and have more return visits to the ED than low-risk drinkers (mean # visits 0.43 versus 0.15). High-risk drinkers were also more likely to have a subsequent ED visit requiring hospital admission for management of a traumatic injury within 24 months when compared with low-risk drinkers (OR¼5.9, 95% CI:[1.16, 29.96]). Conclusion: Trauma patients with high-risk drinking behavior were more likely to return to the ED within 24 months of the initial visit, have a subsequent traumarelated hospital admission within 2 years, and have more trauma-related ED visits compared to patients with ASSIST scores at the low-risk level. These findings suggest that ASSIST screening of trauma patients may identify patients who would benefit from intervention to prevent subsequent trauma; further research might also focus on determining whether interventions that decrease alcohol use, such as brief interventions, might also result in a decreased risk of repeat ED visit for trauma.
4
The Impact of Emergency Medicine Residents on the Operational Efficiency in a Busy Level 1 Trauma Center Emergency Department
Trop AM, Robinson R/John Peter Smith Health Network, Fort Worth, TX
Study Objective: There is a widely held perception that the presence of residents negatively impacts throughput and quality of patient care in the emergency department (ED). At most academic institutions this is seen as an acceptable sacrifice to train the next generation of medical providers. However, there is still controversy over this topic. John Peter Smith Health Network (JPS) is at a pivotal point in the development of an emergency medicine residency program, which puts us in the unique position to assess the effects of new residents on an already established ED. The aim of this study is to assess the impact of the addition of a PGY 1-3 emergency medicine residency program on the efficiency of emergency department operations in a large and growing Level 1 trauma center. Methods: This is an observational cohort study. All patients who presented to the JPS ED during the study period were assessed. The study includes approximately 200,000 patients of all ages, sexes, ethnicities, and chief complaints. The data from the 2010 time period, before the institution of emergency medicine residents, served as the control group. The study reviewed the time period from July through December in calendar years 2010 through 2013. Operational variables were collected from the electronic medical record to assess the effect of emergency medicine residents on basic throughput measures, as the program grew from 0 residents in 2010 to a full complement of 37 in 2013. These variables included number of patients per month, admission rate, patient length of stay (LOS), number of patients that left without being seen (LWBS) or left against medical advice (AMA), number of hours of attending and resident coverage, and patient satisfaction evaluation scores. Analysis of variance with Bonferroni correction was used for data comparison among groups. Results: Over the 4 years of the study, the yearly census in the ED grew by a total of 28.2%. The average number of patients per month increased from 7651 249 in 2010 to 9486 467 in 2013 (P<0.001). When compared to the time period before the addition of emergency medicine residents (2010), the combined LWBS and AMA rate showed a steady decrease from 9.21% in 2010 to 7.18% in 2013 (P¼0.0567), despite large increases in patient volume and acuity. Over the study period, the admission rate remained constant between 18-20%. Average LOS of discharged patients decreased from 344.4 43.2 minutes in 2010 to 237.9 22.4 minutes in 2013 (P<0.001). Meanwhile, Press Ganey analysis has shown a steady increase in patient satisfaction over the study period from 73.1% positive patient reviews in 2010 to 77.1% in 2013. Conclusions: The data demonstrates a significant decrease in patient LOS as residents were added to the system, despite drastic increases in patient volume and acuity level. Additionally, there was a decrease in the rate of patients who LWBS or AMA. It seems that residents have a positive impact on patient care and satisfaction in our study.
Volume 64, no. 4s : October 2014