Couples Match in Emergency Medicine.

The Match is a daunting process for everyone, but it can be exceedingly more complicated for couples. Accordingly, the Couples Match was introduced by the National Residency Match Program in 1984 and has been witnessing a steady increase in the number of participating couples over the past 30 years. The highest number of couples participating in the match, and the highest match rate among them, was recorded in 2018. In this article, we provide couples considering the Couples Match, with one or both partners planning to apply to emergency medicine, with insights on this process. Although it may initially appear to be complicated, the Couples Match enables partners to obtain postgraduate training in geographic proximity to one another. With good communication between the partners and their advisors, an exciting joint venture can unfold that is fueled by the strength of the couple.

Emergency department transfers and transfer relationships in United States hospitals.

OBJECTIVES: The objective was to describe transfers out of hospital-based emergency departments (EDs) in the United States and to identify different characteristics of sending and receiving hospitals, travel distance during transfer, disposition on arrival to the second hospital, and median number of transfer partners among sending hospitals. METHODS: Emergency department records were linked at transferring hospitals to ED and inpatient records at receiving hospitals in nine U.S. states using the 2010 Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases and State Inpatient Databases, the American Hospital Association Annual Survey, and the Trauma Information Exchange Program. Using the Clinical Classification Software (CCS) to categorize conditions, the 50 disease categories with the highest transfer rates were studied, and these were then placed into nine clinical groups. Records were included where both sending and receiving records were available; these data were tabulated to describe ED transfer patterns, hospital-to-hospital distances, final patient disposition, and number of transfer partners. RESULTS: A total of 97,021 ED transfer encounters were included in the analysis from the 50 highest transfer rate disease categories. Among these, transfer rates ranged from 1% to 13%. Circulatory conditions made up about half of all transfers. Receiving hospitals were more likely to be nonprofit, teaching, trauma, and urban and have more beds with greater specialty coverage and more advanced diagnostic and therapeutic resources. The median transfer distance was 23 miles, with 25% traveling more than 40 to 50 miles. About 8% of transferred encounters were discharged from the second ED, but that varied from 0.6% to 53% across the 50 conditions. Sending hospitals had a median of seven transfer partners across all conditions and between one and four per clinical group. CONCLUSIONS: Among high-transfer conditions in U.S. EDs, patients are often transferred great distances, more commonly to large teaching hospitals with greater resources. The large number of transfer partners indicates a possible lack of stable transfer relationships between U.S. hospitals.

The transfer instability index: a novel metric of emergency department transfer relationships.

OBJECTIVES: In this study, the objective was to characterize emergency department (ED) transfer relationships and study the factors that predict the stability of those relationships. A metric is derived for ED transfer relationships that may be useful in assessing emergency care regionalization and as a resource for future emergency medicine research. METHODS: Emergency department records at transferring hospitals were linked to ED and inpatient records at receiving hospitals in nine U.S. states using the 2010 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases, the American Hospital Association Annual Survey, and the Trauma Information Exchange Program. Using the Clinical Classification Software to categorize conditions, high transfer rate conditions were placed into nine clinical groups. The authors created a new measure, the "transfer instability index," which estimates the effective number of "transfer partners" for each sending ED: this is designed to measure the stability of outgoing transfer relationships, where higher values of the index indicate less stable relationships. The index provides a measure of how many hospitals a transferring hospital sends its patients to (weighted by how often each transfer partner is used). Regression was used to analyze factors associated with higher values of the index. RESULTS: Sending hospitals had a median of 3.5 effective transfer partners across all conditions. The calculated transfer instability indices varied from 1 to 2.4 across disease categories. In general, higher index values were associated with treating a higher proportion of publicly insured patients: 10 and 12% increases in the Medicare and Medicaid share of ED encounters, respectively, were associated with 10 and 14% increases in the effective number of transfer partners. This public insurance effect held while studying all conditions together as well as within individual disease categories, such as cardiac, neurologic, and traumatic conditions. CONCLUSIONS: United States EDs that transfer patients to other hospitals often have multiple transfer partners. The stability of the transfer relationship, assessed by the transfer instability index, differs by condition. Less stable transfer relationships (i.e., hospitals with greater numbers of transfer partners) were more common in EDs with higher proportions of publicly insured patients.

Emergency department variation in utilization and diagnostic yield of advanced radiography in diagnosis of pulmonary embolus.

BACKGROUND: There is growing pressure to measure and reduce unnecessary imaging in the emergency department. OBJECTIVE: We study provider and hospital variation in utilization and diagnostic yield for advanced radiography in diagnosis of pulmonary embolism (PE) and to assess patient- and provider-level factors associated with diagnostic yield. METHODS: Retrospective chart review of all adult patients presenting to four hospitals from January 2006 through December 2009 who had a computed tomography or ventilation/perfusion scan to evaluate for PE. Demographic data on the providers ordering the scans were collected. Diagnostic yield (positive scans/total scans ordered) was calculated at the hospital and provider level. The study was not designed to assess appropriateness of imaging. RESULTS: There was significant variation in utilization and diagnostic yield at the hospital level (chi-squared, p < 0.05). Diagnostic yield ranged from 4.2% to 8.2%; after adjusting for patient- and provider-level factors; the two hospitals with an emergency medicine residency training program had higher diagnostic yields (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.5 and OR 1.9, 95% CI 1.5-2.4). There was no significant variation in diagnostic yield among the 90 providers after adjusting for patient, hospital, and provider characteristics. Providers with < 10 years of experience had lower odds of diagnosing a PE than more experienced graduates (OR 0.8, 95% CI 0.6-0.9). CONCLUSIONS: Although we found significant variation in utilization of advanced radiography for PE and diagnostic yield at the hospital level, there was no significant variation at the provider level after adjusting for patient-, hospital-, and provider-level factors.

Admit or transfer? The role of insurance in high-transfer-rate medical conditions in the emergency department.

STUDY OBJECTIVE: We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers. METHODS: This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs). RESULTS: Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28). CONCLUSION: Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

A case of Hickam's dictum: concurrent appendicitis and ectopic pregnancy.

BACKGROUND: Both ectopic pregnancy and appendicitis are surgical emergencies that should be considered in female patients who present with right lower-quadrant pain. Deciding on the appropriate imaging modality in the pregnant patient can be difficult. The challenge of diagnosis is compounded when one considers that both pathologies may be present simultaneously. OBJECTIVES: We present a case demonstrating co-occurrence of ectopic pregnancy and appendicitis and suggest an algorithm for evaluation and management of cases with this presentation. CASE REPORT: A 25-year-old woman presented to the Emergency Department complaining of 3 days of abdominal pain and a positive urine pregnancy test. After consultation with Obstetrics/Gynecology (OB/GYN) and General Surgery, a nondiagnostic pelvic ultrasound (US), and a magnetic resonance imaging (MRI) study consistent with appendiceal inflammation, the patient was taken to the operating room for a laparoscopic appendectomy. While removing the inflamed appendix, the general surgeon noted the right fallopian tube was enlarged, suggestive of an ectopic pregnancy. OB/GYN was consulted again intraoperatively and noted a right ectopic pregnancy. The surgical intervention was completed with a right salpingectomy. CONCLUSION: In a pregnant patient with right lower-quadrant pain, the differential diagnosis includes ectopic pregnancy, acute appendicitis, or in rare cases, both.

Ill, itinerant, and insured: the top 20 users of emergency departments in Baltimore city.

The purpose of this study was to document the clinical and demographic characteristics of the 20 most frequent users of emergency departments (EDs) in one urban area. We reviewed administrative records from three EDs and two agencies providing services to homeless people in Baltimore City. The top 20 users accounted for 2,079 visits at the three EDs. Their mean age was 48, and median age was 51. Nineteen patients visited at least 2 EDs, 18 were homeless, and 13 had some form of public insurance. The vast majority of visits (86%) were triaged as moderate or high acuity. The five most frequent diagnoses were limb pain (n = 9), lack of housing (n = 6), alteration of consciousness (n = 6), infection with human immunodeficiency virus (HIV) (n = 5), and nausea/vomiting (n = 5). Hypertension, HIV infection, diabetes, substance abuse, and alcohol abuse were the most common chronic illnesses. The most frequent ED users were relatively young, accounted for a high number of visits, used multiple EDs, and often received high triage scores. Homelessness was the most common characteristic of this patient group, suggesting a relationship between this social factor and frequent ED use.

School meals: a nutritional and environmental perspective.

In light of the rise in childhood obesity rates and the influence of the food system on fossil fuel use, this article analyzes current school meals in Baltimore and makes suggestions for school meal reform based on both childhood nutrition and environmental resource use. The nutrient content and estimated energy costs of a typical school lunch are compared with a proposed alternate meal. The study indicates that healthier meals can significantly limit fossil fuel energy inputs for harvesting, production, processing, packaging, and transportation. The authors also provide strategies for developing menus that are both more nutritious and more energy efficient.