Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care.

BACKGROUND: Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations. OBJECTIVE: We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians. METHODS: This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering. RESULTS: Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a ß-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period. CONCLUSIONS: An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

Opioid overdoses involving xylazine in emergency department patients: a multicenter study.

INTRODUCTION: Illicit opioids, consisting largely of fentanyl, novel synthetic opioids, and adulterants, are the primary cause of drug overdose fatality in the United States. Xylazine, an alpha-2 adrenergic agonist and veterinary tranquilizer, is being increasingly detected among decedents following illicit opioid overdose. Clinical outcomes in non-fatal overdose involving xylazine are unexplored. Therefore, among emergency department patients with illicit opioid overdose, we evaluated clinical outcome differences for patients with and without xylazine exposures. METHODS: This multicenter, prospective cohort study enrolled adult patients with opioid overdose who presented to one of nine United States emergency departments between 21 September 2020, and 17 August 2021. Patients with opioid overdose were screened and included if they tested positive for an illicit opioid (heroin, fentanyl, fentanyl analog, or novel synthetic opioid) or xylazine. Patient serum was analyzed via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect current illicit opioids, novel synthetic opioids, xylazine and adulterants. Overdose severity surrogate outcomes were: (a) cardiac arrest requiring cardiopulmonary resuscitation (primary); and (b) coma within 4 h of arrival (secondary). RESULTS: Three hundred and twenty-one patients met inclusion criteria: 90 tested positive for xylazine and 231 were negative. The primary outcome occurred in 37 patients, and the secondary outcome occurred in 111 patients. Using multivariable regression analysis, patients positive for xylazine had significantly lower adjusted odds of cardiac arrest (adjusted OR 0.30, 95% CI 0.10-0.92) and coma (adjusted OR 0.52, 95% CI 0.29-0.94). CONCLUSIONS: In this large multicenter cohort, cardiac arrest and coma in emergency department patients with illicit opioid overdose were significantly less severe in those testing positive for xylazine.

Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care.

Importance: Postpartum emergency department (ED) visits may indicate poor access to care and risk for maternal morbidity. Objectives: To identify patient and hospital characteristics associated with postpartum ED visit rates. Design, Setting, and Participants: This retrospective cohort study used data from the 2014 to 2016 New York State Inpatient Database and State Emergency Department Database. All obstetric discharges from acute care hospitals in New York State from January 1, 2014, through November 15, 2016, were included. Obstetric discharges in the inpatient database were linked to subsequent ED visits by the same patient in the ED database. Data were analyzed from February 2020 to August 2022. Exposures: Patient characteristics assessed included age, race, insurance, home zip code income quartile, Charlson Comorbidity Index score, and obstetric risk factors. Hospital characteristics assessed included safety net status, teaching status, and status as a hospital disproportionally serving racial and ethnic minority populations. Main Outcomes and Measures: The primary outcome was any ED visit within 42 days of obstetric discharge. Multilevel logistic regression with 2-level nested mixed effects was used to account for patient and hospital characteristics and hospital-level clustering. Results: Of 608 559 obstetric discharges, 35 299 (5.8%) were associated with an ED visit within 42 days. The median (IQR) birth hospital postpartum ED visit rate was 6.3% (4.6%-8.7%). The mean (SD) age was 28.4 (9.1) years, 53 006 (8.7%) were Asian patients, 90 675 (14.9%) were Black patients, 101 812 (16.7%) were Hispanic patients, and 275 860 (45.3%) were White patients; 292 991 (48%) were insured by Medicaid, and 290 526 (47.7%) had private insurance. Asian patients had the lowest postpartum ED visit rates (2118 ED visits after 53 006 births by Asian patients [3.99%]), and Black patients had the highest postpartum ED visit rates (8306 ED visits after 90 675 births by Black patients [9.15%]). Odds of postpartum ED visits were greater for Black patients (odds ratio [OR], 1.31; 95% CI, 1.26-1.35; P < .001) and Hispanic patients (OR, 1.19; 95% CI, 1.15-1.24; P < .001) relative to White patients; those with Medicare (OR, 1.55; 95% CI, 1.39-1.72; P < .001), Medicaid (OR, 1.37; 95% CI, 1.34-1.41; P < .001), or self-pay insurance (OR, 1.50; 95% CI, 1.41-1.59; P < .001) relative to commercial insurance; births that occurred at safety net hospitals (OR, 1.43; 95% CI, 1.37-1.51; P < .001) and hospitals disproportionately serving racial and ethnic minority populations (OR, 1.14; 95% CI, 1.08-1.20; P < .001); and births that occurred at hospitals with fewer than 500 births per year (OR, 1.25; 95% CI, 1.14-1.39; P < .001) relative to those with more than 2000 annual births. Adjusted odds of postpartum ED visits were lower after birth at teaching hospitals (OR, 0.82; 95% CI, 0.74-0.91; P < .001) and metropolitan hospitals (OR, 0.74; 95% CI, 0.65-0.85; P < .001). Conclusions and Relevance: This cohort study found that Black and Hispanic patients experienced higher adjusted odds of postpartum ED visits across all hospital types, particularly at safety net hospitals and those disproportionately serving racial and ethnic minority populations . These findings support the urgent need to mitigate structural racism underlying maternal health disparities.

Predictors of outpatient follow-up care after adult emergency department asthma visits and association with 30-day outcomes.

Objective: Guidelines recommend outpatient follow-up after emergency department visits for asthma, but factors related to rates of follow-up among the adult population are understudied. We sought to describe patient and community-level predictors of outpatient follow-up after an index ED visit for asthma and evaluate the association between outpatient follow-up visits and subsequent ED revisits.Methods: We conducted a retrospective observational cohort study of adult patients with emergency departments visits for asthma. The primary predictor was time to outpatient follow-up visit within 30 days of the index ED visit. The primary outcome was all-cause ED revisit within 30 days of the index ED visit. Cox proportional hazards regression was utilized to test the association between time to outpatient follow-up and hazard of ED revisit within 30 days.Results: Time to outpatient follow-up visit within 30 days was not significantly associated with hazard of 30-day ED revisit for asthma (HR 1.05; 95% CI 0.69-1.61). However, male patients (HR 1.45; 95% C 1.11-1.89) and smokers (HR 1.67; 95% CI 1.22-2.29) were significantly more likely to have an ED revisit.Conclusion: Younger, Black patients with Medicaid were less likely to receive follow-up care relative to older patients insured by Medicare. While follow-up visits were not associated with 30-day revisit rates, differences by age, race, and insurance status suggest disproportionate barriers to accessing care. Future research may target these subgroups to improve transitions of care after an ED visit for asthma.

Racial and Ethnic Disparities in Hospitalization and Clinical Outcomes Among Patients with COVID-19.

INTRODUCTION: The recent spread of coronavirus disease 2019 (COVID-19) has disproportionately impacted racial and ethnic minority groups; however, the impact of healthcare utilization on outcome disparities remains unexplored. Our study examines racial and ethnic disparities in hospitalization, medication usage, intensive care unit (ICU) admission and in-hospital mortality for COVID-19 patients. METHODS: In this retrospective cohort study, we analyzed data for adult patients within an integrated healthcare system in New York City between February 28-August 28, 2020, who had a lab-confirmed COVID-19 diagnosis. Primary outcome was likelihood of inpatient admission. Secondary outcomes were differences in medication administration, ICU admission, and in-hospital mortality. RESULTS: Of 4717 adult patients evaluated in the emergency department (ED), 3219 (68.2%) were admitted to an inpatient setting. Black patients were the largest group (29.1%), followed by Hispanic/Latinx (29.0%), White (22.9%), Asian (3.86%), and patients who reported "other" race-ethnicity (19.0%). After adjusting for demographic, clinical factors, time, and hospital site, Hispanic/Latinx patients had a significantly lower adjusted rate of admission compared to White patients (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.34-0.76). Black (OR 0.60; 95% CI 0.43-0.84) and Asian patients (OR 0.47; 95% CI 0.25 - 0.89) were less likely to be admitted to the ICU. We observed higher rates of ICU admission (OR 2.96; 95% CI 1.43-6.15, and OR 1.83; 95% CI 1.26-2.65) and in-hospital mortality (OR 4.38; 95% CI 2.66-7.24; and OR 2.96; 95% CI 2.12-4.14) at two community-based academic affiliate sites relative to the primary academic site. CONCLUSION: Non-White patients accounted for a disproportionate share of COVID-19 patients seeking care in the ED but were less likely to be admitted. Hospitals serving the highest proportion of minority patients experienced the worst outcomes, even within an integrated health system with shared resources. Limited capacity during the COVID-19 pandemic likely exacerbated pre-existing health disparities across racial and ethnic minority groups.

Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019.

BACKGROUND: Drug shortages contribute to avoidable medication error and patient harm; these shortages are exacerbated in the Emergency Department due to the time-sensitive nature of acute care. METHODS: We performed a cross-sectional study to describe the frequency and duration of drug shortages associated with the most frequent medications administered in the ED. We identified the most frequently used ED medications and calculated number of visits associated with these medications using the 2006-2019 National Hospital Ambulatory Medical Care Survey. We obtained the frequency and duration of shortages associated with these medications from the University of Utah Drug Information System. We calculated duration and total ED visits associated with shortages of the most frequently used ED medications. RESULTS: From 2006 through 2019, the most frequently used drugs were ondansetron (255.1 million ED visits), 0.9% normal saline (251.3 million ED visits), and ibuprofen (188.5 million ED visits). All but two of the top thirty most frequently used medications experienced a shortage. The median shortage duration was 425 days, while the longest were for injectable morphine (3,202 days). The number of ED visits associated with drugs experiencing shortages increased from 2,564,425 (2.2% of U.S. ED visits) in 2006 to 67,221,968 (60.4%) in 2019. The most common reasons for shortage include manufacturing delays and increased demand. CONCLUSIONS AND RELEVANCE: Drug shortages were more frequent and persistent from 2006 through 2019. Further studies on the clinical impact of these shortages are needed, in addition to policy interventions to mitigate shortages.

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality.

PURPOSE: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. METHODS: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. RESULTS: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. CONCLUSIONS: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Changes in alcohol-related hospital visits during COVID-19 in New York City.

BACKGROUND AND AIMS: Increased alcohol consumption has been proposed as a potential consequence of the coronavirus disease 2019 (COVID-19) pandemic. There has been little scrutiny of alcohol use behaviors resulting in hospital visits, which is essential to guide pandemic public policy. We aimed to determine whether COVID-19 peak restrictions were associated with increased hospital visits for alcohol use or withdrawal. Secondary objectives were to describe differences based on age, sex and race, and to examine alcohol-related complication incidence. DESIGN: Multi-center, retrospective, pre-post study. SETTING: New York City health system with five participating hospitals. PARTICIPANTS: Adult emergency department encounters for alcohol use, alcoholic gastritis or pancreatitis or hepatitis, alcohol withdrawal syndrome, withdrawal seizure or delirium tremens. MEASUREMENTS: Age, sex, race, site and encounter diagnosis. Encounters were compared between 2019 and 2020 for 1 March to 31 May. FINDINGS: There were 2790 alcohol-related visits during the 2019 study period and 1793 in 2020, with a decrease in total hospital visits. Of 4583 alcohol-related visits, median age was 47 years, with 22.3% females. In 2020 there was an increase in percentage of visits for alcohol withdrawal [adjusted odds ratio (aOR) = 1.34, 95% confidence interval (CI) = 1.07-1.67] and withdrawal with complications (aOR = 1.40, 95% CI = 1.14-1.72), and a decline in percentage of hospital visits for alcohol use (aOR = 0.70, 95% CI = 0.59-0.85) and use with complications (aOR = 0.71, 95% CI = 0.58-0.88). It is unknown whether use visit changes mirror declines in other chief complaints. The age groups 18-29 and 60-69 years were associated with increased visits for use and decreased visits for withdrawal, as were non-white race groups. Sex was not associated with alcohol-related visit changes despite male predominance. CONCLUSIONS: In New York City during the initial COVID-19 peak (1 March to 31 May 2020), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.

Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries.

Importance: There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. Objective: To evaluate the association of GED programs with Medicare costs per beneficiary. Design, Setting, and Participants: This cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups. Interventions: Treatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period. Main Outcomes and Measures: The main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter. Results: Of the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED. Conclusions and Relevance: Among Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study.

OBJECTIVE: To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults. METHODS: A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits. RESULTS: Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity. CONCLUSIONS: Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

Biomarkers of endothelial dysfunction in cocaine overdose and overdose-related cardiovascular events.

Overdose of stimulant drugs has been associated with increased risk of adverse cardiovascular events (ACVE), some of which may be ascribed to endothelial dysfunction. The aims of this study were to evaluate biomarkers of endothelial dysfunction in emergency department (ED) patients with acute cocaine overdose and to assess the association between in-hospital ACVE in ED patients with any acute drug overdose. This was a prospective consecutive cohort study over 9 months (2015-2016) at two urban, tertiary-care hospital EDs. Consecutive adults (≥18 years) presenting with suspected acute drug overdose were eligible and separated into three groups: cocaine (n = 47), other drugs (n = 128), and controls (n = 11). Data were obtained from medical records and linked to waste serum specimens, sent as part of routine clinical care, for biomarker analysis. Serum specimens were collected and analyzed using enzyme-linked immunosorbent assay kit for three biomarkers of endothelial dysfunction: (a) endothelin-1 (ET-1), (b) regulated upon activation normal T cell expressed and secreted (RANTES), and (c) soluble intercellular adhesion molecule-1 (siCAM-1). Mean siCAM was elevated for cocaine compared with controls and other drugs (p < .01); however, mean RANTES and ET-1 levels were not significantly different for any drug exposure groups. Receiver operating characteristics curve analysis for prediction of in-hospital ACVE revealed excellent performance of siCAM-1 (area under curve, 0.86; p < .001) but lack of predictive utility for either RANTES or ET-1. These results suggest that serum siCAM-1 is a viable biomarker for acute cocaine overdose and that endothelial dysfunction may be an important surrogate for adverse cardiovascular events following any drug overdose.

A Cross-sectional Study of Hospital Performance on ICU Utilization Practices for Patients with Chronic Obstructive Pulmonary Disease.

PURPOSE: Intensive care unit (ICU) resources are a costly but effective commodity used in the management of critically ill patients with chronic obstructive pulmonary disease (COPD). ICU admission decisions are determined by patient diagnosis and severity of illness, but also may be affected by hospital differences in quality and performance. We investigate the variability in ICU utilization for patients with COPD and its association with hospital characteristics. METHODS: Using a 3M administrative dataset spanning 2008-2013, we conducted a retrospective cohort study of adult patients discharged with COPD at hospitals in three state to determine variability in ICU utilization. Quality metrics were calculated for each hospital using observed-to-expected (O/E) ratios for overall mortality and length of stay. Logistic and multilevel multivariate regression models were constructed, estimating the association between hospital quality metrics on ICU utilization, after adjustment for available clinical factors and hospital characteristics. RESULTS: In 434 hospitals with 570,517 COPD patient visits, overall ICU admission rate was 33.1% [range 0-89%; median (IQR) 24% (8, 54)]. The addition of patient, hospital, and quality characteristics decreased the overall variability attributable to individual hospital differences seen within our cohort from 40.9 to 33%. Odds of ICU utilization were increased for larger hospitals and those seeing lower pulmonary case volume. Hospitals with better overall O/E ratios for length of stay or mortality had lower ICU utilization. CONCLUSIONS: Hospital characteristics, including quality metrics, are associated with variability in ICU utilization for COPD patients, with higher ICU utilization seen for lower performing hospitals.

Trends and predictors of hospitalization after emergency department asthma visits among U.S. Adults, 2006-2014.

Background: Asthma hospitalizations are an ambulatory care-sensitive condition; a majority originate in emergency departments (EDs).Objective: Describe trends and predictors of adult asthma hospitalizations originating in EDs.Methods: Observational study of ED visits resulting in hospitalization using a nationally representative sample. We tested trend in hospitalization rates from 2006 to 2014 using logistic regression, then assessed the association between hospitalization rates and patient and hospital characteristics using hierarchical multivariable regression accounting for hospital-level clustering.Results: Total ED asthma visits increased 15% from 2006 to 2014, from 1.06 to 1.22 million, while the likelihood of hospitalization decreased (20.9-18.2%, p < 0.01). Adjusting for increased asthma prevalence, ED visit rates and hospitalization rates decreased by 10 and 21%, respectively. Hospitalization was independently associated with older age, female gender (OR = 1.23, 95% CI 1.20-1.26), higher Charlson score (OR = 1.99, 95% CI 1.97-2.01), Medicaid (OR = 1.05, 95% CI 1.01-1.08) and Medicare (OR = 1.26, 95% CI 1.22-1.31) insurance, and trauma centers (OR = 1.34, 95% CI 1.12-1.60). Hospitalization was less likely for uninsured visits (OR = 0.7, 95% CI 0.67-0.73), lower income areas (OR = 0.89, 95% CI 0.85-0.93), non-metropolitan teaching hospitals (OR = 0.83, 95% CI 0.71-0.96), Midwestern (OR = 0.84, 95% CI 0.69-1.01) or Western regions (OR 0.69, 95% CI 0.56-0.83). Unmeasured hospital-specific effects account for 15.8% of variability in hospital admission rates after adjusting for patient and hospital factors.Conclusions: Total asthma ED visits increased, but prevalence-adjusted ED visits, and ED hospitalization rates have declined. Uninsured patients have disproportionately more ED visits but 30% lower odds of hospitalization. Substantial variation implies unmeasured clinical, social and environmental factors accounting for hospital-specific differences in hospitalization.

Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults.

OBJECTIVES: Transitional care nurse (TCN) care has been associated with decreased hospitalizations for older adults in the emergency department (ED). The objective of this study was to evaluate the association between TCN care and readmission for geriatric patients who visit the ED within 30 days of a prior hospital discharge. METHODS: We studied a prospective cohort of ED patients aged 65 and older with an ED visit within 30 days of inpatient discharge. Patients with an Emergency Severity Index of 1 or prior TCN contact were excluded. Entropy balancing and logistic regression were used to estimate the average incremental effect of the TCN intervention on risk of admission during the index ED visit and within 30 days of prior discharge. RESULTS: Of 6,838 visits, 608 included TCN care. TCN patients had lower risk of readmission during the index ED visit at Mount Sinai Medical Center (MSMC), -10.1 percentage points (95% confidence interval [CI] = -18.5 to -2.7), and Northwestern Memorial Hospital (NMH), -17.3 percentage points (95% CI = -23.1 to -11.5), but not St. Joseph's Regional Medical Center (SJRMC), -2.5 percentage points (95% CI = -10.5 to 5.5). TCN patients had fewer readmissions within 30 days of prior hospital discharge at NMH, -16.2 percentage points (95% CI = -22.0 to -10.3), but not at MSMC, -5.6 percentage points (95% CI = -13.1 to 1.8), or at SJRMC, 0.5 percentage points (95% CI = -7.2 to 8.2). CONCLUSIONS: Transitional care nurse care in the ED after a prior hospitalization was associated with decreased readmission of older adults during the index ED visit at two of three hospitals, with sustained reduction for the entire 30-day readmission window at one hospital. TCN interventions in the ED may decrease readmissions for geriatric patients in the ED; however, these results may be dependent on implementation of the program and availability of ED, hospital, and local resources for older adults.

Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients.

OBJECTIVES: ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality. DESIGN: A retrospective cohort study. SETTING: Single academic tertiary care hospital. PATIENTS: Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase). CONCLUSIONS: ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use.

OBJECTIVES: To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use. DESIGN: Prospective observational cohort. SETTING: Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015. PARTICIPANTS: Individuals aged 65 and older in the ED (N = 57,287). INTERVENTION: The intervention was first TCN contact. Controls never saw a TCN during the study period. MEASUREMENTS: We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits. RESULTS: A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%). CONCLUSION: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.