Healthcare Utilization

Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department

Michael M. Neeki, DO, MS et al.

Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient’s acuity level to determine the need to transport to an ED.

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Healthcare Utilization

Utility of Chest Radiography in Emergency Department Patients Presenting with Syncope

Matthew L. Wong, MD, MPH et al.

Syncope has myriad etiologies, ranging from benign to immediately life threatening. This frequently leads to over testing. Chest radiographs (CXR) are among these commonly performed tests despite their uncertain diagnostic yield. The objective is to study the distribution of normal and abnormal chest radiographs in patients presenting with syncope, stratified by those who did or did not have an adverse event at 30 days

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Healthcare Utilization

Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Volume 17, Issue 1, January 2016.
Niels Rathlev, MD, et al.

Introduction: There is a paucity of literature supporting the use of electronic alerts for patients
with high frequency emergency department (ED) use. We sought to measure changes in opioid
prescribing and administration practices, total charges and other resource utilization using electronic
alerts to notify providers of an opioid-use care plan for high frequency ED patients.
Methods: This was a randomized, non-blinded, two-group parallel design study of patients who
had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical
electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care
groups”. Between the years before and after randomization, we compared as primary outcomes
the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and
administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED
visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging
[MRI]) studies, and 5) inpatient admissions.
Results: A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the
proportion of morphine mg equivalents received in the post-period compared with the pre-period was
15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the
pre-period was 4.5% (ratio=0.29, 95% CI [0.07-1.12]; p=0.07). For discharged patients in the “Usual
Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with
the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period
compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional
change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01-0.092];
p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT
or MRI or inpatient admissions.
Conclusion: Electronic care plans were associated with an incremental decrease in opioids (in
morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED

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Healthcare Utilization

Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation

Volume 17, Issue 1, January 2016.
Michael Gottlieb, MD, et al.

Introduction: Most emergency physicians routinely obtain shoulder radiographs before and after
shoulder dislocations. However, currently there is limited literature demonstrating how frequently
new fractures are identified on post-reduction radiographs. The primary objective of this study
was to determine the frequency of new, clinically significant fractures identified on post-reduction
radiographs with a secondary outcome assessing total new fractures identified.
Methods: We conducted a retrospective chart review using appropriate International Classification
of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were
reduced in a single, urban, academic emergency department (ED) over a five-year period. We
excluded cases that required operative reduction, had associated proximal humeral head or shaft
fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted
separately by two study investigators with disagreements settled by consensus among three
investigators. Images from indeterminate cases were reviewed by a radiology attending physician
with musculoskeletal expertise. The primary outcome was the percentage of new, clinically
significant fractures defined as those altering acute ED management. Secondary outcomes included
percentage of new fractures of any type.
Results: We identified 185 total patients meeting our study criteria. There were no new,
clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI
[3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for
acute ED management.
Conclusion: Post-reduction radiographs do not appear to identify any new, clinically significant
fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED
setting for shoulder dislocations.

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Healthcare Utilization

Identifying Frequent Users of an Urban Emergency Medical Service Using Descriptive Statistics and Regression Analyses

Volume 17, Issue 1, January 2015.
Chenelle Norman, MPH, et al.

This retrospective cohort study provides a descriptive analysis of a population that frequently uses
an urban emergency medical service (EMS) and identifies factors that contribute to use among all
frequent users. For purposes of this study we divided frequent users into the following groups: lowfrequent
users (4 EMS transports in 2012), medium-frequent users (5 to 6 EMS transports in 2012),
high-frequent users (7 to 10 EMS transports in 2012) and super-frequent users (11 or more EMS
transports in 2012). Overall, we identified 539 individuals as frequent users.
For all groups of EMS frequent users (i.e. low, medium, high and super) one or more hospital
admissions, receiving a referral for follow-up care upon discharge, and having no insurance were
found to be statistically significant with frequent EMS use (P<0.05). Within the diagnostic categories,
41.61% of super-frequent users had a diagnosis of “primarily substance abuse/misuse” and among
low-frequent users a majority, 53.33%, were identified as having a “reoccurring (medical) diagnosis.”
Lastly, relative risk ratios for the highest group of users, super-frequent users, were 3.34 (95% CI
[1.90-5.87]) for obtaining at least one referral for follow-up care, 13.67 (95% CI [5.60-33.34]) for
having four or more hospital admissions and 5.95 (95% CI [1.80-19.63]) for having a diagnoses of
primarily substance abuse/misuse.
Findings from this study demonstrate that among low- and medium-frequent users a majority of
patients are using EMS for reoccurring medical conditions. This could potentially be avoided with
better care management. In addition, this study adds to the current literature that illustrates a strong
correlation between substance abuse/misuse and high/super-frequent EMS use. For the subgroup
analysis among individuals 65 years of age and older, we did not find any of the independent
variables included in our model to be statistically significant with frequent EMS use.

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Healthcare Utilization

Written Informed Consent for Computed Tomography of the Abdomen/Pelvis is Associated with Decreased CT Utilization in Low-Risk Emergency Department Patients

Volume 16, Issue 7, December 2015.
Lisa H. Merck, MD, MPH, et al.

Introduction: The increasing rate of patient exposure to radiation from computerized tomography
(CT) raises questions about appropriateness of utilization. There is no current standard to employ
informed consent for CT (ICCT). Our study assessed the relationship between informed consent and
CT utilization in emergency department (ED) patients.
Methods: An observational multiphase before-after cohort study was completed from 4/2010-5/2011.
We assessed CT utilization before and after (Time I/ Time II) the implementation of an informed
consent protocol. Adult patients were included if they presented with symptoms of abdominal/pelvic
pathology or completed ED CT. We excluded patients with pregnancy, trauma, or altered mental
status. Data on history, exam, diagnostics, and disposition were collected via standard abstraction
tool. We generated a multivariate logistic model via stepwise regression, to assess CT utilization
across risk groups. Logistic models, stratified by risk, were generated to include study phase and a
propensity score that controlled for potential confounders of CT utilization.
Results: 7,684 patients met inclusion criteria. In PHASE 2, there was a 24% (95% CI [10-36%])
reduction in CT utilization in the low-risk patient group (p<0.002). ICCT did not affect CT utilization in the
high-risk group (p=0.16). In low-risk patients, the propensity score was significant (p<0.001). There were
no adverse events reported during the study period.
Conclusion: The implementation of ICCT was associated with reduced CT utilization in low-risk ED
patients. ICCT has the potential to increase informed, shared decision making with patients, as well
as to reduce the risks and cost associated with CT.

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Healthcare Utilization

Inpatient Readmissions and Emergency Department Visits within 30 Days of a Hospital Admission

Volume 16, Issue 7, December 2015.
Jesse J. Brennan, MA, et al.

Introduction: Inpatient hospital readmissions have become a focus for healthcare reform and costcontainment
efforts. Initiatives targeting unanticipated readmissions have included care coordination
for specific high readmission diseases and patients and health coaching during the post-discharge
transition period. However, little research has focused on emergency department (ED) visits
following an inpatient admission. The objective of this study was to assess 30-day ED utilization and
all-cause readmissions following a hospital admission.
Methods: This was a retrospective study using inpatient and ED utilization data from two hospitals
with a shared patient population in 2011. We assessed the 30-day ED visit rate and 30-day
readmission rate and compared patient characteristics among individuals with 30-day inpatient
readmissions, 30-day ED discharges, and no 30-day visits.
Results: There were 13,449 patients who met the criteria of an index visit. Overall, 2,453 (18.2%)
patients had an ED visit within 30 days of an inpatient stay. However, only 55.6% (n=1,363) of these
patients were admitted at one of these 30-day visits, resulting in a 30-day all-cause readmission rate
of 10.1%.
Conclusion: Approximately one in five patients presented to the ED within 30 days of an inpatient
hospitalization and over half of these patients were readmitted. Readmission measures that
incorporate ED visits following an inpatient stay might better inform interventions to reduce avoidable

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Healthcare Utilization

Achieving the Triple Aim Through Informed Consent for Computed Tomography

Volume 16, Issue 7, December 2015.
Dylan Carney, MD, et al.

At the end of a particularly busy shift, you meet Mary,
a 24 year-old female with no past medical history, who
presents with six hours of crampy, intermittent, periumbilical
abdominal pain but no associated fever, nausea, vomiting,
diarrhea or anorexia. Her vital signs are normal and her
abdominal and gynecological exams are notable only for mild,
diffuse abdominal tenderness without rebound or guarding.
Her lab results and urinalysis are unremarkable, and her pain
improves somewhat with intravenous pain medications. You
explain to the patient that you have a low suspicion for an
intraabdominal emergency, but cannot be certain without
a computed tomography (CT) scan. “I’ll do whatever you
recommend,” she replies. The patient ultimately gets a CT,
which is normal, and she is discharged 30 minutes later with a
diagnosis of nonspecific abdominal pain.

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Healthcare Utilization

Invasive Mechanical Ventilation in California Over 2000–2009: Implications for Emergency Medicine

Volume 16, Issue 5, September 2015.
Seshadri C. Mudumbai, MD, MS, et al.

Introduction: Patients who require invasive mechanical ventilation (IMV) often represent a sequence
of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most
populous state, little information exists to define patterns of IMV use within the state of California.
Methods: We examined data from the masked Patient Discharge Database of California’s Office
of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV
during their stay were identified using the International Classification of Diseases 9th Revision
and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age
strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV
discharges during the study period, we quantified the number of ED vs. non-ED based admissions;
changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV;
determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and
projected the number of IMV discharges and ED-based admissions by year 2020.
Results: There were 696,634 IMV discharges available for analysis. From 2000–2009, IMV
discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868
(328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based
admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35–64
year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients
requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by
29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of
patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for
younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest
predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites;
and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to
n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.
Conclusion: Based on sustained growth over the past decade, by the year 2020, we project a further
increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed
capacities, ongoing increases in the number and type of IMV patients have the potential to adversely
affect California EDs that often admit patients to ICUs.

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Healthcare Utilization

Factors Associated with Decision to Hospitalize Emergency Department Patients with Skin and Soft Tissue Infection

Volume 16, Issue 1, January 2015
David A. Talan, MD et al.

Emergency department (ED) hospitalizations for skin and soft tissue infection (SSTI) have increased, while concern for costs has grown and outpatient parenteral antibiotic options have expanded. To identify opportunities to reduce admissions, we explored factors that influence the decision to hospitalize an ED patient with a SSTI.

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Healthcare Utilization

Trauma Center Staffing, Infrastructure, and Patient Characteristics that Influence Trauma Center Need

Volume 16, Issue 1, January 2015
Mark Faul, PhD, MA et al.

The most effective use of trauma center resources helps reduce morbidity and mortality, while saving costs. Identifying critical infrastructure characteristics, patient characteristics and staffing components of a trauma center associated with the proportion of patients needing major trauma care will help planners create better systems for patient care.

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Healthcare Utilization

American Academy of Pediatrics 2014 Bronchiolitis Guidelines: Bonfire of the Evidence

Volume 16, Issue 1, January 2015
Paul Walsh, MD, MSc et al.

The American Academy of Pediatrics (AAP) 2014 Bronchiolitis guidelines (the guidelines) were recently published in the official journal of the AAP, Pediatrics. The committee that wrote the guidelines anticipates that these will form the basis of bronchiolitis treatment throughout the house of medicine, not just in pediatricians’ offices.

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Healthcare Utilization

Depression is Associated with Repeat Emergency Department Visits in Patients with Non-specific Abdominal Pain

Volume 15, Issue 3, May 2014
Andrew Charles Meltzer, MD et al.

Patients with abdominal pain often return multiple times despite no definitive diagnosis. Our objective was to determine if repeat emergency department (ED) use among patients with non-specific abdominal pain might be associated with a diagnosis of moderate to severe depressive disorder.

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Emergency Department Access Healthcare Utilization

New Drugs and Devices from 2011 – 2012 That Might Change Your Practice

To be honest, I thought this would be a lost cause. Even after skipping a New Drugs and Devices essay in 2012, I figured that I would have to search long and hard to find 10 new things that emergency practitioners needed to know about. Although there were no true blockbuster medications for emergency physicians, I nonetheless found 10 medicines that we probably should know, along with a new device that may change the way we work up patients with palpitations, and a clever new delivery system for subcutaneous epinephrine.

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Healthcare Utilization

Financial Implications for Physicians Accepting Higher Level of Care Transfers

Introduction: The objective of this study is to describe the financial consequences to physicians who care for HLOC transfers across specialties and compare these with all patients from each specialty and specialty-specific national reimbursement benchmarks.
Conclusion: Average professional fee reimbursement for HLOC patients was higher for EM and neurosurgery than for all other patients in these specialties at this site, but lower for the rest of the specialties.

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Healthcare Utilization

Oral and Intravenous Acetylcysteine for Treatment of Acetaminophen Toxicity: A Systematic Review and Meta-analysis

Introduction: There are few reports summarizing the effectiveness of oral and intravenous (IV) acetylcysteine. We determined the proportion of acetaminophen poisoned patients who develop hepatotoxicity (serum transaminase > 1000 IU/L) when treated with oral and IV acetylcysteine.
Conclusion: Studies report similar rates of hepatotoxicity for oral and IV acetylcysteine, but direct comparisons are lacking.

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Healthcare Utilization

Abnormal Arterial Blood Gas and Serum Lactate Levels Do Not Alter Disposition in Adult Blunt Trauma Patients after Early Computed Tomography

Introduction: Arterial blood gas and serum lactate (ABG / SL) values have been shown to be markers for occult shock and poor outcome following blunt trauma. However, the utility of ABG / SL in blunt trauma patients who also receive computed tomographies (CT) of the chest, abdomen, and pelvis (CT C&A) remains unknown.
Conclusion: We found that abnormal ABG / SL results do not change management or discharge disposition in patients without clinical or radiographic evidence of traumatic injury on CT C&A. Among patients who receive CT C&A, the routine measurement of arterial blood gas and lactate may be an unnecessary source of additional cost, patient discomfort, and delay in care.

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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


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

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.