- Email: [email protected]
Association of Patient, Operational, and Care Factors With Emergency Department Satisfaction in Dental Pain, Back Pain, and Headache Patients
Research Forum Abstracts Conclusions: This study demonstrates that an email follow-up reminder was well received by all demographic groups of ED patients enrolled in this study including geriatric patients. The patients who received email follow-up reminders found them helpful and were more likely to want a similar follow-up reminder email in the future than those that did not receive reminder emails. With technology always advancing and potential for an EMR to automatically generate similar email reminders, this could serve as a minimally work intensive yet very promising source of increasing patient satisfaction.
135
Association of Patient, Operational, and Care Factors With Emergency Department Satisfaction in Dental Pain, Back Pain, and Headache Patients
Morgan M, Isenberger KM, Lefevere RC, Thomas AJ, Salzman JG/Regions Hospital, St. Paul, MN; HealthPartners Institute for Education and Research, Bloomington, MN
Study Objectives: Due to the limited treatment options available to emergency physicians to treat certain chief complaints, providers anecdotally report the perception that these patients may rate satisfaction with their care lower. This will be important as health care reform incorporates patient satisfaction into reimbursement models. This study aimed to determine which factors appear to influence patient satisfaction scores for three different chief complaints with treatment options that are limited to symptomatic care (dental pain, low back pain, and headache). Methods: This is a retrospective observational study of patient satisfaction data from patients seen at a single, urban, community-based Level 1 Adult and Pediatric Trauma Center with an emergency medicine residency program. As part of a performance improvement initiative, a 3rd party vendor specializing in emergency medicine patient satisfaction assessment made up to 3 telephone attempts to contact each English or Spanish-speaking patient discharged from the emergency department (ED) between September 1, 2011, and March 31st, 2012. Patients were administered a standardized survey assessing satisfaction with their overall ED experience. Multivariate ordinal logistic regression with forward selection was used to determine the impact of patient (sex, age group, primary language, race/ethnicity, insurance status, multiple visits within the study period), operational (day of week, time of day, treatment pod, wait time), and care (Emergency Severity Index score, number of lab tests, number of imaging tests, number of prescriptions written, number of prescriptions filled, self-assessed change in medical condition) variables on a five-level patient satisfaction score (5 ¼ Best; 1 ¼ Worst). Results: During the study period, 5,479 patients were discharged from our emergency department with a chief complaint of dental pain (37.1%), headache (28.5%), or back pain (44.4%), and 49.6% were reached by the survey vendor. Overall patient satisfaction was distributed as follows: 5 ¼ 60.3%; 4 ¼ 23.4%; 3 ¼ 9.5%; 2 ¼ 3.4%; 1 ¼ 3.5%. The odds of lower satisfaction for all conditions was associated with a longer wait time to be roomed and longer time from rooming to final disposition (OR ¼ 0.63; 95% CI 0.56-0.69; OR ¼ 0.83; 95% CI 0.77-0.89, respectively) and patient self-assessed condition remaining the same or worsening after discharge (OR ¼ 0.60; 95% CI 0.49-0.73; OR ¼ 0.37; 95% CI ¼ 0.27-0.51, respectively). Patients aged 0-7 years old had higher odds of having lower satisfaction than those > 18 years old (OR¼0.37; 95% CI 0.14-0.99). The odds of higher patient satisfaction were present for patients who received more imaging (OR ¼1.23; 1.11-1.37). Conclusions: In this urban community emergency department, patient satisfaction for conditions with limited emergency department treatment options does not appear to be linked to patient care interventions, with the exception of the number of imaging tests patients receive. Focusing on operational factors, such as reducing wait times, may result in higher satisfaction in this subset of patients. Addressing expectations about the likelihood of their condition improving in a short amount of time may also assist in improving patient satisfaction.
136
Pediatric Emergency Department Discharge Failure: A Systemic Review of Risk Factors and Interventions
Tran Q, Bayram J, Case M, Connor C, Doggett D, Fawole O, Ijagbemi M, Pham JC /Johns Hopkins University, Baltimore, MD; Johns Hopkins University, Baltimore, MD; Johns Hopkins Armstrong Institute for Patient Quality & Safety, Baltimore, MD; Johns Hopkins University, Baltimore, MD
Study Objective: Pediatric emergency department (ED) discharge failure, defined as ED return within 72 hours or more, poor compliance or comprehension, carries significant clinical implications such as unfinished treatments, progression
S52 Annals of Emergency Medicine
of illness. Therefore, identifying risk factors for pediatric ED discharge failure would serve to design better interventions to improve patient care. This systemic review aimed at identifying risk factors and interventions trying to reduce discharge failure. Methods: The investigators developed a comprehensive search strategy for PubMed, employing multiple different definitions for ED discharge failure described previously in emergency medicine literature. The search strategy was also applied to ACEP conference proceedings and clinicaltrials.gov database for any qualitative information from the “gray literature.” Studies, published in English, were included if they either identified risk factors for ED discharge failure among pediatric patients or interventions trying to reduce such failures. One author performed the search and multiple authors independently reviewed abstracts and titles for relevant studies which were retrieved and abstracted into a standard database. Result: Our search yielded 963 records and 18 studies met our primary inclusion criteria, four studies were further excluded for not reporting any measures for pediatric ED discharge failure. Most studies involved asthmatic patients. Among the risk factors, psychiatric illnesses, such as disruptive behavior, suicidality were associated with high risk of ED revisit, OR of 2.85 and 2.04 respectively. Young age less than 3 and high acuity of illness were also associated with high risk (OR of 2.3 for both) of ED return. Among the interventions, providing inhaled steroids for asthmatic patients in ED was associated with less ED returns and higher follow-up compliance (OR 2.9), having pediatricians as consultants in ED was also associated with lower risk (OR 0.64) of ED return. Providing disease-specific information significantly improved parental comprehension of discharge instructions (DCI). ED-made appointments with or without case management programs, combination of pager and telephone calls, monetary incentive were associated with higher follow-up compliance but not lower ED returns. Finally, email reminders and computerized DCIs did not improve followup nor reduce ED returns. Conclusions: Many risk factors for pediatric ED discharge failures had been identified. Overall, treating asthmatic patients appropriately with inhaled steroids was most effective intervention modality. Other interventions, while improving follow-up compliance or parental comprehension of DCIs, did not reduce ED returns. Studies for new interventional modalities are needed to identify more effective measures to prevent ED discharge failure in pediatric populations.
137
GEDI WISE: Initial Effects on Admissions and Emergency Department Revisits
Grudzen C, Chen A, Richardson LD, Winkel G, Baumlin K, Holder-Hayes E, Hwang U/ Icahn School of Medicine at Mount Sinai, New York, NY; Robert Wood Johnson Medical School, New Brunswick, NJ
Background: Inpatient stays represent the largest proportion of total costs to the Medicare program. While reducing readmissions is important for hospitals in light of new payment penalties, reducing admissions to begin with would have an even greater effect on total costs of care. Study Objectives: To evaluate whether Geriatric Emergency Department Innovations through Workforce, Informatics, and Structural Enhancements (GEDI WISE) was able to reduce the admission rate for ED patients 65 years and older (65þ) at the main study site without resulting in a significant increase in 72-hour ED revisits or 30-day readmissions. Methods: Monthly admission, 72-hour revisit, and 30-day readmission rates for patients 65þ were tracked from January 2011 (six months before the quality improvement team was formed) through December 2012. Admission rate was defined as the number of ED patients 65þ admitted to the hospital divided by all ED visitors 65þ during the same month who were admitted, observed, transferred, or discharged; a readmission was defined as an ED admission within 30 days of hospital discharge date, and a 72-hour revisit was any ED visit within 72 hours of ED discharge; patients who eloped, left against medical advice or died in the ED were excluded from the analysis. A times series analyses was performed to determine whether monthly ED admission, 72-hour revisit, or 30-day readmission rate changed over the 24 month study period. A second time series analysis adjusting for co-morbidities and demographics is forthcoming and will be completed before October 2013. Results: In January 2011, six months before the GEDI WISE quality improvement team was formed, the admission rate was 59.8%, and it dropped to 49.0% by December 2012 (beta ¼ -0.5, p<0.001). 72-hour ED revisit rate increased from 2.9% to 3.6%, and 30-day readmission rate went from 15.4% at the beginning of the study
Volume 62, no. 4s : October 2013
135
Association of Patient, Operational, and Care Factors With Emergency Department Satisfaction in Dental Pain, Back Pain, and Headache Patients
Morgan M, Isenberger KM, Lefevere RC, Thomas AJ, Salzman JG/Regions Hospital, St. Paul, MN; HealthPartners Institute for Education and Research, Bloomington, MN
Study Objectives: Due to the limited treatment options available to emergency physicians to treat certain chief complaints, providers anecdotally report the perception that these patients may rate satisfaction with their care lower. This will be important as health care reform incorporates patient satisfaction into reimbursement models. This study aimed to determine which factors appear to influence patient satisfaction scores for three different chief complaints with treatment options that are limited to symptomatic care (dental pain, low back pain, and headache). Methods: This is a retrospective observational study of patient satisfaction data from patients seen at a single, urban, community-based Level 1 Adult and Pediatric Trauma Center with an emergency medicine residency program. As part of a performance improvement initiative, a 3rd party vendor specializing in emergency medicine patient satisfaction assessment made up to 3 telephone attempts to contact each English or Spanish-speaking patient discharged from the emergency department (ED) between September 1, 2011, and March 31st, 2012. Patients were administered a standardized survey assessing satisfaction with their overall ED experience. Multivariate ordinal logistic regression with forward selection was used to determine the impact of patient (sex, age group, primary language, race/ethnicity, insurance status, multiple visits within the study period), operational (day of week, time of day, treatment pod, wait time), and care (Emergency Severity Index score, number of lab tests, number of imaging tests, number of prescriptions written, number of prescriptions filled, self-assessed change in medical condition) variables on a five-level patient satisfaction score (5 ¼ Best; 1 ¼ Worst). Results: During the study period, 5,479 patients were discharged from our emergency department with a chief complaint of dental pain (37.1%), headache (28.5%), or back pain (44.4%), and 49.6% were reached by the survey vendor. Overall patient satisfaction was distributed as follows: 5 ¼ 60.3%; 4 ¼ 23.4%; 3 ¼ 9.5%; 2 ¼ 3.4%; 1 ¼ 3.5%. The odds of lower satisfaction for all conditions was associated with a longer wait time to be roomed and longer time from rooming to final disposition (OR ¼ 0.63; 95% CI 0.56-0.69; OR ¼ 0.83; 95% CI 0.77-0.89, respectively) and patient self-assessed condition remaining the same or worsening after discharge (OR ¼ 0.60; 95% CI 0.49-0.73; OR ¼ 0.37; 95% CI ¼ 0.27-0.51, respectively). Patients aged 0-7 years old had higher odds of having lower satisfaction than those > 18 years old (OR¼0.37; 95% CI 0.14-0.99). The odds of higher patient satisfaction were present for patients who received more imaging (OR ¼1.23; 1.11-1.37). Conclusions: In this urban community emergency department, patient satisfaction for conditions with limited emergency department treatment options does not appear to be linked to patient care interventions, with the exception of the number of imaging tests patients receive. Focusing on operational factors, such as reducing wait times, may result in higher satisfaction in this subset of patients. Addressing expectations about the likelihood of their condition improving in a short amount of time may also assist in improving patient satisfaction.
136
Pediatric Emergency Department Discharge Failure: A Systemic Review of Risk Factors and Interventions
Tran Q, Bayram J, Case M, Connor C, Doggett D, Fawole O, Ijagbemi M, Pham JC /Johns Hopkins University, Baltimore, MD; Johns Hopkins University, Baltimore, MD; Johns Hopkins Armstrong Institute for Patient Quality & Safety, Baltimore, MD; Johns Hopkins University, Baltimore, MD
Study Objective: Pediatric emergency department (ED) discharge failure, defined as ED return within 72 hours or more, poor compliance or comprehension, carries significant clinical implications such as unfinished treatments, progression
S52 Annals of Emergency Medicine
of illness. Therefore, identifying risk factors for pediatric ED discharge failure would serve to design better interventions to improve patient care. This systemic review aimed at identifying risk factors and interventions trying to reduce discharge failure. Methods: The investigators developed a comprehensive search strategy for PubMed, employing multiple different definitions for ED discharge failure described previously in emergency medicine literature. The search strategy was also applied to ACEP conference proceedings and clinicaltrials.gov database for any qualitative information from the “gray literature.” Studies, published in English, were included if they either identified risk factors for ED discharge failure among pediatric patients or interventions trying to reduce such failures. One author performed the search and multiple authors independently reviewed abstracts and titles for relevant studies which were retrieved and abstracted into a standard database. Result: Our search yielded 963 records and 18 studies met our primary inclusion criteria, four studies were further excluded for not reporting any measures for pediatric ED discharge failure. Most studies involved asthmatic patients. Among the risk factors, psychiatric illnesses, such as disruptive behavior, suicidality were associated with high risk of ED revisit, OR of 2.85 and 2.04 respectively. Young age less than 3 and high acuity of illness were also associated with high risk (OR of 2.3 for both) of ED return. Among the interventions, providing inhaled steroids for asthmatic patients in ED was associated with less ED returns and higher follow-up compliance (OR 2.9), having pediatricians as consultants in ED was also associated with lower risk (OR 0.64) of ED return. Providing disease-specific information significantly improved parental comprehension of discharge instructions (DCI). ED-made appointments with or without case management programs, combination of pager and telephone calls, monetary incentive were associated with higher follow-up compliance but not lower ED returns. Finally, email reminders and computerized DCIs did not improve followup nor reduce ED returns. Conclusions: Many risk factors for pediatric ED discharge failures had been identified. Overall, treating asthmatic patients appropriately with inhaled steroids was most effective intervention modality. Other interventions, while improving follow-up compliance or parental comprehension of DCIs, did not reduce ED returns. Studies for new interventional modalities are needed to identify more effective measures to prevent ED discharge failure in pediatric populations.
137
GEDI WISE: Initial Effects on Admissions and Emergency Department Revisits
Grudzen C, Chen A, Richardson LD, Winkel G, Baumlin K, Holder-Hayes E, Hwang U/ Icahn School of Medicine at Mount Sinai, New York, NY; Robert Wood Johnson Medical School, New Brunswick, NJ
Background: Inpatient stays represent the largest proportion of total costs to the Medicare program. While reducing readmissions is important for hospitals in light of new payment penalties, reducing admissions to begin with would have an even greater effect on total costs of care. Study Objectives: To evaluate whether Geriatric Emergency Department Innovations through Workforce, Informatics, and Structural Enhancements (GEDI WISE) was able to reduce the admission rate for ED patients 65 years and older (65þ) at the main study site without resulting in a significant increase in 72-hour ED revisits or 30-day readmissions. Methods: Monthly admission, 72-hour revisit, and 30-day readmission rates for patients 65þ were tracked from January 2011 (six months before the quality improvement team was formed) through December 2012. Admission rate was defined as the number of ED patients 65þ admitted to the hospital divided by all ED visitors 65þ during the same month who were admitted, observed, transferred, or discharged; a readmission was defined as an ED admission within 30 days of hospital discharge date, and a 72-hour revisit was any ED visit within 72 hours of ED discharge; patients who eloped, left against medical advice or died in the ED were excluded from the analysis. A times series analyses was performed to determine whether monthly ED admission, 72-hour revisit, or 30-day readmission rate changed over the 24 month study period. A second time series analysis adjusting for co-morbidities and demographics is forthcoming and will be completed before October 2013. Results: In January 2011, six months before the GEDI WISE quality improvement team was formed, the admission rate was 59.8%, and it dropped to 49.0% by December 2012 (beta ¼ -0.5, p<0.001). 72-hour ED revisit rate increased from 2.9% to 3.6%, and 30-day readmission rate went from 15.4% at the beginning of the study
Volume 62, no. 4s : October 2013