Health Outcomes

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois

Weygandt, MD, et al.

Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois.

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Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis

Miller, MD, et al.

This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit.

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Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions

Carmel, MD, et al.

Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center.

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Pain Perception in Latino vs. Caucasian and Male vs. Female Patients: Is There Really a Difference?

Molly Aufiero, DO, et al.

Pain is one of the most common complaints in emergency departments (ED) nationwide. The perception of pain in others is, therefore, an important component of patient assessment and treatment. There are difficulties in studying pain since it is subjective, which raises the question of what is a clinically significant change in pain.

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Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

Jessica R. Schumacher, PhD, et al.

Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions.

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Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment

Amy Stuck, PhD, RN, et al.

The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization.

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Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department

Shiloni Bhambani, MD, et al.

A dislodged gastrostomy tube (GT) is a common complaint that requires evaluation in the pediatric emergency department (ED) and, on occasion, will require stoma dilation to successfully replace the GT. The objective of this study was to describe the frequency that stoma dilation is required, the success rate of replacement, complications encountered, and the techniques used to confirm placement of the GT after dilation.

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A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department

Jason M. Mefford, MD, et al.

The evaluation of urolithiasis is largely influenced by the results of a urinalysis (UA). While the presence of microscopic hematuria favors a diagnosis of urolithiasis in a patient presenting with symptoms suggestive of ureteral colic, it is estimated that 10–20% of patients with urolithiasis can present without microscopic hematuria on UA.

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Management of Sickle Cell Disease Super Utilizers

Author Affiliation Gary A. Johnson, MD SUNY Upstate Medical University, Department of Emergency Medicine, Syracuse, New York   Much attention has been directed toward super utilizers of emergency department (ED) and hospital services. Often these patients have a chronic illness with significant potential for acute morbidity. In many settings, adults with sickle cell disease (SCD) […]

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Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits

Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits
Brian Sharp, MD, et al.

Nausea and vomiting in pregnancy (NVP) is a condition that commonly affects women in the first trimester of pregnancy. Despite frequently leading to emergency department (ED) visits, little evidence exists to characterize the nature of ED visits or to guide its treatment in the ED. Our objectives were to evaluate the treatment of NVP in the ED and to identify factors that predict return visits to the ED for NVP.

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Association of Age, Systolic Blood Pressure, and Heart Rate with Adult Morbidity and Mortality after Urgent Care Visits

Association of Age, Systolic Blood Pressure, and Heart Rate with Adult Morbidity and Mortality after Urgent Care Visits
James Hart, MD et al.

Little data exists to help urgent care (UC) clinicians predict morbidity and mortality risk. Age, systolic blood pressure (SBP), and heart rate (HR) are easily obtainable and have been used in other settings to predict short-term risk of deterioration. We hypothesized that there is a relationship between advancing age, SBP, HR, and short-term health outcomes in the UC setting.

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Contrast CT Scans in the Emergency Department Do Not Increase Risk of Adverse Renal Outcomes

Volume 17, Issue 4, July 2016
Michael Heller, MD et al.

It has long been accepted that intravenous contrast used in both computed tomography (CT) and plain imaging carries a risk of nephropathy and renal failure, particularly in subpopulations thought to be at highest risk.1-3 Although early studies used high osmolality contrast media that is not typical of emergency department (ED) use today, the issue of contrast-induced nephropathy (CIN) is still an area of active interest with many studies appearing each year from many different specialties, on its pathogenesis, incidence, prevention and treatment.4-7 The plethora of data has usually focused on the incidence of CIN, usually defined as a small (such as 25% or an absolute increase of 0.5mg/dL) increase in creatinine after receiving intravenous (IV) contrast for either a particular indication (such as cardiac catheterization) or in a particular patient group (diabetics); the meaning of a creatinine rise in this setting is not at all clear, however.8-10 Many regimens have been proposed to ameliorate this creatinine rise, but there is a scarcity of data on what actual adverse clinical events occur and whether these can truly be ascribed to the IV contrast itself rather than the events that might well occur in a (usually) hospitalized population that required imaging. A few authors have even expressed doubt as to whether modern iodinated contrast (which is iso-osmolal) is a nephrotoxin.11-13

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Trends in Hospital Admission and Surgical Procedures Following ED visits for Diverticulitis

Volume 17, Issue 4, July 2016
Margaret B. Greenwood-Ericksen, MD, MPH et al.

Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission.

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Undertriage of Trauma-Related Deaths in U.S. Emergency Departments

Volume 17, Issue 3, May 2016
Jenelle Holst, MD. et al.

Introduction: Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers.
Methods: This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression.
Results: We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]).
Conclusion: We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.

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Vital Signs Predict Rapid-Response Team Activation Within Twelve Hours of Emergency Department Admission

Volume 17, Issue 3, May 2016
James Walston, MD. et al.

Introduction: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients’ vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.
Methods: We conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.
Results: A total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25–3.27]), tachypneic (OR 2.92, 95% CI [1.73–4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42–3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65–4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08–2.72] for low BP and OR 1.82, 95% CI [1.19–2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44–7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43–3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03–77.87]), invasive interventions (OR 5.49, 95%CI [3.82–7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60–11.24]), and mortality at one month (OR 4.02, 95%CI [2.44–6.62]).
Conclusion: After matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: westjem@gmail.com

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WestJEM
ISSN: 1936-900X
e-ISSN: 1936-9018

CPC-EM
ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.