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Scholarly Works (4 results)

  • Article
  • Peer Reviewed
Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 14, Issue 3 (2013)

Introduction:The purpose of this study was to determine if differences could be detected in the presentation patterns and admission rates among frequent emergency department users (FEDU) of an urban emergency department over a 10-year period.

Methods: This was an IRB approved, retrospective review of all patients who presented to the ED 5 or more times for 3 distinct time periods: “year 0” 11/98-10/99, “year 5” 11/03–10/04, and “year 10” 11/08–10/9. FEDU were grouped into those with 5–9, 10–14, 15–19, and ≥ 20 visits per year. Variables analyzed included number of visits, disposition, and insurance status. We performed comparisons using Kolmogorov-Smirnov and chi-square tests. A P < 0.05 was considered significant.

Results: We found a a 66% increase in FEDU patients over the decade studied, with a significant increase in both the number of FEDU in each visit frequency category over the 3 time periods (P < 0.0001), as well as the total number of visits by each group of FEDU (P < 0.0001). The proportion of FEDU visits for the 5–9 group resulting in admission increased from 25.9% to 29% from year 0 to year 10 (P < 0.001), but not for the other visit groups. In comparing admission rates between FEDU groups, the admission rate for the 5–9 group was significantly higher than the ≥ 20 group for the year 5 time period (P < 0.001) and the year 10 time period (P < 0.001) and showed a similar trend, but not significant, at year 0 (P = 0.052). The overall hospital admission rate for emergency patients over the same time span remained stable at 22-24%. The overall proportion of uninsured FEDU was stable over the decade studied, while the uninsured rate for the overall ED population for the same time periods increased.

Conclusion: The results demonstrate the FEDU population is not a homogeneous group of patients. Increased attention to differences among FEDU groups is necessary in order to plan more effective interventions. [West J Emerg Med. 2013;14(3):243–246.]

    Cover page: Ten Years of Frequent Users in an Inner City Emergency DepartmentCreative Commons 'BY-NC' version 4.0 license
    • Article
    • Peer Reviewed
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 11, Issue 4 (2010)

    Objective: To determine if the effective use of Health Information Technologies (HIT) and the Electronic Medical Record (EMR) affects emergency department (ED) usage in a complicated frequently presenting patient population.

    Methods: A retrospective, observational study of 45 patients enrolled in our Frequent User Program called Community Resources for Emergency Department Overuse (CREDO) between June 2005 and July 2007. The study was conducted at an urban hospital with greater than 95,000 annual visits. Patients served as their own historical controls. In this pre-post study, the pre-intervention control period was determined by the number of months the patient had been enrolled in the program. The pre- and post-intervention time periods were the same for each patient but varied between patients. The intervention included using HIT to identify the most frequently presenting patients and creating individualized care plans for those patients. The care plans were made available through the EMR to all healthcare providers. Study variables in this study intervention included ED charges, lab studies ordered, number of ED visits, length of stay (LOS), and Total Emergency Department Contact Time (TEDCT), which is the product of the number of visits and the LOS. We analyzed these variables using paired T-tests. This study was approved by the institutional review board.

    Results: Forty-five patients were enrolled, but nine were excluded for no post enrollment visits; thus, statistical analysis was conducted with n=36. The ED charges decreased by 24% from $64,721 to $49,208 (p=0.049). The number of lab studies ordered decreased by 28% from 1847 to 1328 (p=0.04). The average number of ED visits/patient decreased by 25% from 67.4 to 50.5 (p=0.046). The TEDCT decreased by 39% from 443.7 hours to 270.6 hours (p=0.003).

    Conclusion: In this pre-post analysis of an intervention targeting ED frequent users, the use of HIT and the EMR to identify patients and store easily accessible care plans significantly reduced ED charges, labs ordered, number of ED visits, and the TEDCT. [West J Emerg Med 2010; 11(4):348-353.]

    • 1 supplemental file
    Cover page: Use of Health Information Technology to Manage Frequently Presenting Emergency Department PatientsCreative Commons 'BY-NC' version 4.0 license
    • Article
    • Peer Reviewed
    UC Davis Previously Published Works (2015)
    BACKGROUND: As US health care increasingly focuses on outcomes as a means for quantifying quality, there is a growing demand for risk models that can account for the variability of patients treated at different hospitals so that equitable comparisons between institutions can be made. We sought to apply aspects of prior risk-standardization methodology to begin development of a risk-standardization tool for the National Cardiovascular Data Registry (NCDR) IMPACT (Improving Pediatric and Adult Congenital Treatment) Registry. METHODS AND RESULTS: Using IMPACT, we identified all patients undergoing diagnostic or interventional cardiac catheterization between January 2011 and March 2013. Multivariable hierarchical logistic regression was used to identify patient and procedural characteristics predictive of experiencing a major adverse event after cardiac catheterization. A total of 19,608 cardiac catheterizations were performed between January 2011 and March 2013. Among all cases, a major adverse event occurred in 378 of all cases (1.9%). After multivariable adjustment, 8 variables were identified as critical for risk standardization: patient age, renal insufficiency, single-ventricle physiology, procedure-type risk group, low systemic saturation, low mixed venous saturation, elevated systemic ventricular end-diastolic pressure, and elevated main pulmonary artery pressures. The model had good discrimination (C statistic, 0.70), confirmed by bootstrap validation (validation C statistic, 0.69). CONCLUSIONS: Using prior risk-standardization efforts as a foundation, we developed and internally validated a model to predict the occurrence of a major adverse event after cardiac catheterization for congenital heart disease. Future efforts should be directed toward further refinement of the model variables within this large, multicenter data set.
      Cover page: Adjusting for Risk Associated With Pediatric and Congenital Cardiac Catheterization: A Report From the NCDR IMPACT Registry.
      • Article
      • Peer Reviewed
      UCLA Previously Published Works (2024)

      Objective

      Our objective was to gauge adherence to nationally endorsed protocols in implementation of pulse oximetry (POx) screening for critical congenital heart disease (CCHD) in infants after mandate by all states and to assess associated characteristics.

      Study design

      Between March and October 2019, an online questionnaire was administered to nurse supervisors who oversee personnel conducting POx screening. The questionnaire used eight questions regarding performance and interpretation of screening protocols to measure policy consistency, which is adherence to nationally endorsed protocols for POx screening developed by professional medical societies. Multilevel linear regression models evaluated associations between policy consistency and characteristics of hospitals and individuals, state of hospital location, early versus late mandate adopters, and state reporting requirements.

      Results

      Responses from 189 nurse supervisors spanning 38 states were analyzed. Only 17% received maximum points indicating full policy consistency, and 24% selected all four options for potential hypoxia that require a repeat screen. Notably, 33% did not recognize ≤90% SpO2 as an immediate failed screen and 31% responded that an infant with SpO2 of 89% in one extremity will be rescreened by nurses in an hour rather than receiving an immediate physician referral. Lower policy consistency was associated with lack of state reporting mandates (beta = -1.23 p = 0.01) and early adoption by states (beta = -1.01, p < 0.01).

      Conclusion

      When presented with SpO2 screening values on a questionnaire, a low percentage of nurse supervisors selected responses that demonstrated adherence to nationally endorsed protocols for CCHD screening. Most notably, almost one-third of respondents did not recognize ≤90% SpO2 as a failed screen that requires immediate physician follow-up. In addition, states without reporting mandates and early adopter states were associated with low policy consistency. Implementing state reporting requirements might increase policy consistency, but some inconsistency may be the result of unique protocols in early adopter states that differ from nationally endorsed protocols.

      Key points

      · Low adherence to nationally endorsed protocols.. · Inconsistent physician follow-up to hypoxia.. · Reporting improved consistency with national policy..
        Cover page: Current Postlaunch Implementation of State Mandates of Newborn Screening for Critical Congenital Heart Disease by Pulse Oximetry in U.S. States and Hospitals
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