Characteristics of Frequent Users of the Emergency Department with Psychiatric Conditions.

STUDY OBJECTIVE: The goal of this study was to evaluate demographic factors associated with increased emergency department use among people with psychiatric conditions. METHODS: This was a retrospective cohort study of all patients presenting to an urban, academic emergency department with a history of at least one mental health-related final diagnosis. RESULTS: A total of 569 people with psychiatric conditions were included in the study. Of this group, 22.1% had four or more visits within 2009. People with more than four annual visits were more likely to be over age 40, to have at least one chronic condition, to have Medicaid, and to be Black compared with those with fewer than four annual visits. DISCUSSION: The frequent-user group had fewer visits with a final psychiatric diagnosis, lower rate of psychiatric admissions, and higher rate of visits resulting in a medical admission than the infrequent-user group.

Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients.

STUDY OBJECTIVE: We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program. METHODS: We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS: During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION: The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.

Provider variation in fast track treatment time.

OBJECTIVE: To examine the degree to which fast track (FT) treatment time varies among providers. METHODS: A retrospective cohort study that included 105,783 FT visits at 3 emergency departments (EDs) during a 3-year period. We calculated the median treatment time for 80 primary providers (physicians and physician extenders) and 109 nurses (2 sites only). We used a hierarchical linear regression model that accounted for the clustering of patient visits to the same provider to estimate each provider's median treatment time controlling for patient, clinical, temporal, and ED demand (ie, number of arrivals) characteristics. RESULTS: Median FT treatment time across the 3 sites ranged from 48 to 134 minutes. Adjusted for other factors, the median FT treatment time of providers at the 90th versus 10th percentiles was 1.4 to 2.6 times longer across the 3 sites. The variation by FT nurses was also large. The median FT treatment time of nurses at the 90th versus 10th percentiles was 1.5 and 1.4 times longer at sites A and C, respectively. At all sites, provider and clinical factors explained more variation in FT treatment time than patient, ED demand, or temporal factors. CONCLUSIONS: There were clinically meaningful differences in FT treatment time among the providers at all sites. Given that the providers share the same environment and patient population, understanding why such large provider variation in FT treatment time exists warrants further investigation.

International perspectives on emergency department crowding.

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.