The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults

BACKGROUND: There is little consensus as to the effects of insurance expansion on emergency department (ED) utilization for mental health purposes. We aimed to study the race specific association between the dependent coverage provision of the Affordable Care Act (ACA) and changes in young adults' usage of emergency department services for psychiatric diagnoses.     

Impact of the Affordable Care Act Medicaid expansion on emergency department high utilizers with ambulatory care sensitive conditions: A cross-sectional study

Objectives

The effect of the Affordable Care Act on emergency department (ED) high utilizers has not yet been thoroughly studied. We sought to determine the impact of changes in insurance eligibility following the 2014 Medicaid expansion on ED utilization for ambulatory care sensitive conditions (ACSC) by high ED utilizers in an urban safety net hospital.

The impact of the Affordable Care Act on hospital‐led community health evaluation in the U.S. Appalachian Ohio region

In recent years, policy developments in the United States have dramatically changed how nonprofit hospitals interact with surrounding communities. However, despite the importance of these changes encoded in Internal Revenue Service regulations, little is known about how these requirements have affected how nonprofit hospitals are approaching community health evaluation. We present qualitative findings from interviews with hospital employees and consultants overseeing preliminary rounds of community health needs assessments, as required by the Affordable Care Act. The sample comes from the Appalachian region of Ohio, an area targeted because of significant health challenges. Our findings suggest that the Affordable Care Act has led hospitals to formalize their processes, focus on developing an evidence base, cultivate local partnerships, and reflect on the role of the hospital in public health.     

Shift in U.S. payer responsibility for the acute care of violent injuries after the Affordable Care Act: Implications for prevention

Background

Investment in violence prevention programs is hampered by lack of clearly identifiable stakeholders with a financial stake in prevention. We determined the total annual charges for the acute care of injuries from interpersonal violence and the shift in financial responsibility for these charges after the Medicaid expansion from the Affordable Care Act in 2014.

Impact of scribes on emergency department patient throughput one year after implementation

Objectives

Assess the impact of scribes on an academic emergency department's (ED) throughput one year after implementation.

Predicting hospital admission at the emergency department triage: A novel prediction model

BackgroundEmergency department (ED) overcrowding is a growing international patient safety issue. A major contributor to overcrowding is long wait times for inpatient hospital admission. The objective of this study is to create a model that can predict a patient's need for hospital admission at the time of triage.MethodsRetrospective observational study of electronic clinical records of all ED visits over ten years to a large urban hospital in Singapore. The data was randomly divided into a derivation set and a validation set. We used the derivation set to develop a logistic regression model that predicts probability of hospital admission for patients presenting to the ED. We tested the model on the validation set and evaluated the performance with receiver operating characteristic (ROC) curve analysis.ResultsA total of 1,232,016 visits were included for final analysis, of which 38.7% were admitted. Eight variables were included in the final model: age group, race, postal code, day of week, time of day, triage category, mode of arrival, and fever status. The model performed well on the validation set with an area under the curve of 0.825 (95% CI 0.824–0.827). Increasing age, increasing triage acuity, and mode of arrival via private patient transport were most predictive of the need for admission.ConclusionsWe developed a model that accurately predicts admission for patients presenting to the ED using demographic, administrative, and clinical data routinely collected at triage. Implementation of the model into the electronic health record could help reduce the burden of overcrowding.     

Lessons learnt from the implementation of same-day discharge after percutaneous coronary intervention

BackgroundChange in healthcare organisations is constant and requires adequate resources for effective implementation. Same-day discharge after percutaneous coronary intervention has been found to be no different from the patients who stayed overnight after procedure; however, its uptake remains low.ObjectivesThe aim of the study was to identify what factors helped or hindered the implementation of same-day discharge.MethodsThis interpretive study was conducted in a cardiac catheterisation suite of an Australian tertiary hospital between June and December 2016. Semistructured individual interviews with 26 healthcare professionals were conducted to explore the factors that influenced the implementation. A deductive approach to content analysis was guided by the theoretical domains framework.FindingsFive domains, including beliefs about consequences, professional role and identity, resources, behaviour regulation, and optimism, were identified which were strongly related to the factors that impacted the implementation. The findings showed that participants believed same-day discharge benefits while also concerning about its safety and holding different opinions on eligibility criteria. The findings also showed that participants’ involvement in the change process varied with no clear roles and responsibilities and that their understanding about same-day discharge evidence and the guideline also differed. Lack of dedicated resources was also identified as the hindrance to the implementation. Behaviour regulation domain depicted how communication was managed and how the care for same-day discharge patients was improved. Despite several issues identified, participants were optimistic with achievement.Discussion and conclusionThis study has provided valuable insight into the factors that influenced the implementation, which will inform policymakers when designing interventions for future improvement. Plan for change and involvement of all stakeholders along with dedicated resources including time, people, and change management expertise are essential if hospitals want to see the success of change.     

Characterizing the impact of snowfall on patient attendance at an urban emergency department in Toronto,Canada

ObjectivesWe sought to determine whether addition of a snowfall variable improves emergency department (ED) patient volume forecasting. Our secondary objective was to characterize the magnitude of effect of snowfall on ED volume.MethodsWe used daily historical patient volume data and local snowfall records from April 1st, 2011 to March 31st, 2018 (2542 days) to fit a series of four generalized linear models: a baseline model which included calendar variables and three different snowfall models with an indicator variable for either any snowfall (>0 cm), moderate snowfall (≥1 cm), or large snowfall (≥5 cm). To evaluate model fit, we examined the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). Incident rate ratios were calculated to determine the effect of snowfall in each model.ResultsAll three snowfall models demonstrated improved model fit compared to the model without snowfall. The best fitting model included a binary variable for snowfall (<1 cm vs. ≥1 cm). This model showed a statistically significant decrease in daily ED volume of 2.65% (95% CI: 1.23%–4.00%) on snowfall days.DiscussionThe addition of a snowfall variable results in improved model performance in short-term ED volume forecasting. Snowfall is associated with a modest, but statistically significant reduction in ED volume.     

思政元素融入《急危重症护理学》教学模式的构建与实施效果分析

目的构建思政元素融入《急危重症护理学》教学模式并探讨其应用效果。 方法选取广东药科大学四年制三年级2018级204名护生为试验组，实施急危重症护理学思政教学模式，同时以2017级245名三年级护生为对照组（实施一般护理教学模式）。比较两组学生急危重症护理学期末成绩、护生的人文关怀能力量表得分和师生及督导组成员对思政教学模式的主观评价。 结果试验组护生急危重症护理学期末成绩与人文关怀能力得分高于对照组学生（均P<0.05），师生对思政教学模式的满意度均在90%以上，督导组对思政教学模式的满意度在80%以上。结论思政元素融入《急危重症护理学》教学模式有助于提高护生的学习成绩及人文关怀能力，师生及督导组成员对思政教学模式的满意度均较高，值得推广。     

The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data

Background

In March 2002 the Australian Industrial Relations Commission ordered the introduction of a new staffing method - nursing hours per patient day (NHPPD) - for implementation in Western Australia public hospitals. This method used a “bottom up” approach to classify each hospital ward into one of seven categories using characteristics such as patient complexity, intervention levels, the presence of high dependency beds, the emergency/elective patient mix and patient turnover. Once classified, NHPPD were allocated for each ward.

Objectives

The objective of this study was to determine the impact of implementing the NHPPD staffing method on 14 nursing-sensitive outcomes: central nervous system complications, wound infections, pulmonary failure, urinary tract infection, pressure ulcer, pneumonia, deep vein thrombosis, ulcer/gastritis/upper gastrointestinal bleed, sepsis, physiologic/metabolic derangement, shock/cardiac arrest, mortality, failure to rescue and length of stay.

Design and setting

The research design was an interrupted time series using retrospective analysis of patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over a 4-year period.

Sample

All patient records (N = 236,454) and nurse staffing records (N = 150,925) from NHPPD wards were included.

Results

The study found significant decreases in the rates of nine nursing-sensitive outcomes when examining hospital-level data following implementation of NHPPD; mortality, central nervous system complications, pressure ulcers, deep vein thrombosis, sepsis, ulcer/gastritis/upper gastrointestinal bleed shock/cardiac arrest, pneumonia and average length of stay. At the ward level, significant decreases in the rates of five nursing-sensitive outcomes; mortality, shock/cardiac arrest, ulcer/gastritis/upper gastrointestinal bleed, length of stay and urinary tract infections occurred.

Conclusions

The findings provide evidence to support the continuation of the NHPPD staffing method. They also add to evidence about the importance of nurse staffing to patient safety; evidence that must influence policy. This study is one of the first to empirically review a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a “one-size-fits-all” approach.     

Emergency department electric scooter injuries after the introduction of shared e-scooter services: A retrospective review of 3,331 cases

BACKGROUND: To determine the frequency, characteristics, and use of resources related to electric scooter(e-scooter) injuries in the emergency department(ED) of a major metropolitan area hospital.METHODS: We performed a retrospective review of all ED presentations related to e-scooter injuries at a level I trauma center between May 2017 and February 2020. We identified ED presentation data, injury-related data, patients’ clinical course after evaluation, injury diagnosis, surgical procedures, and ED readmissions.RESULTS: A total of 3,331 patients with e-scooter injuries presented to the ED over a 34-month period. There was a 6-fold increase in e-scooter-related injuries presenting to the ED, from an average of 26.9 injuries per month before the introduction of shared e-scooter services in August 2018 to an average of 152.6 injuries per month after its introduction. The average injury rate during weekdays was 3.27 per day, with the majority of injuries occurring in the afternoon. The most common mechanism of injury was rider fall(79.1%). There were a total of 2,637 orthopedic injuries, of which 599(22.7%) were fractures. A total of 296(8.9%) patients were hospitalized following the initial ED admission, and 462 surgeries were performed within 7 days of ED arrival.CONCLUSIONS: The introduction of the shared e-scooter services is associated with a dramatic increase in e-scooter injuries presenting to the ED. E-scooter use carries considerably underestimated injury risks of high-energy trauma and misunderstood mechanisms of injuries. These injuries challenge the healthcare system, with a major impact on both EDs and surgical departments.     

Optimizing the month of the year backwards test for delirium screening of older patients in the emergency department

IntroductionDifferent scoring methods exist for the Month of the Year Backward Test (MBT), which is designed to detect inattention, the core feature of delirium. When used as a part of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED), each error in the MBT scores one point. Because this scoring procedure is complex, we aimed to simplify the scoring method of the MBT.MethodsThis is a secondary analysis of a single center prospective validation study of the mCAM-ED comprising a sample of Emergency Department (ED) patients aged 65 or older presenting to our ED.Data collectionResearch assistants (RAs) who were trained nurses conducted the MBT. Geriatricians conducted the reference standard delirium assessment within 1 h of the RA.ResultsFor the scoring method “number of errors”, optimal performance according the Youden index was achieved when 8 or more errors were reached resulting in an overall sensitivity of 0.95 and overall specificity of 0.94. The scoring method “number of errors in combination with time needed” resulted in a comparable result with minimally lower positive likelihood ratios. For the scoring method “last month in correct order”, optimal performance according the Youden index was achieved with the month of September resulting in an overall sensitivity of 0.90 and an overall specificity of 0.89.DiscussionWe suggest omitting the factor time and using a more practical scoring method with good performance: “last month in correct order” with the requirement to reach September to rule out delirium.     

Prognosis of cirrhotic patients admitted to Emergency Departments: A multicenter study

ObjectivesLife threatening complications can occur at any stage of cirrhosis progression. There are few studies on the prognosis of cirrhotic patients managed in an Emergency Department (ED) although management of patients will occur in the ED. The objective of our study was to determine the risk factors for mortality in cirrhotic patients who visited to the ED.MethodsAll cirrhotic patients attending ED in three different university hospitals of Assistance Publique - Hôpitaux de Paris between January 2014 and June 2015 were identified by a retrospective analysis of digital records and included in the study. The primary end-point was 30-day mortality in all cirrhotic patients who visited the ED.ResultsA total of 609 ED visits were analyzed among 224 patients: 115 (51%) presented a cirrhosis of alcoholic origin, 43 (19%) were caused by Hepatitis C, 28 (13%) of mixed origin (viral and alcoholic), 17 (8%) were caused by Hepatitis B and 21 (9%) of other origins. Fifty-five (25%) of these patients died within 30 days of their initial presentation to the ED. In multivariate analysis, the age (Odds Ratio: 1.04 [1.01–1.07]), cirrhosis associated with hepatocellular carcinoma (OR: 3.07 [1.37–6.91]), serum creatinine at admission (OR: 1.01 [1.01–1.02]), serum bilirubin at admission (OR: 1.01 [1.01–1.02]) and health impairment (OR: 2.57 [1.28–5.16]) were associated with mortality.ConclusionsThe mortality rate of cirrhotic patients attending an ED was high. The prognosis of cirrhotic patients admitted to the ED depended on the severity of the liver and other organ dysfunction. The presence of a hepatocellular carcinoma on admission was also a risk factor for death.     

Workplace Violence and Bullying Faced by Health Care Personnel at the Emergency Department of a Tertiary Care Hospital of Karachi,Pakistan: A Cross-Sectional Study

IntroductionThe emergency department is the most affected by physical and verbal abuse and bullying in health care. Violence against health care workers not only affects their safety, but also their performance and motivation. This study aimed to determine the prevalence and associated determinants of violence against health care personnel.MethodsA cross-sectional study design was used with 182 health care personnel at the emergency department tertiary care hospital of Karachi, Pakistan. Data were collected through a questionnaire comprised of 2 sections: (1) demographic questions and (2) statements to identify the prevalence of workplace violence and bullying among health care personnel. Nonprobability purposive sampling was used for recruitment. Binary logistic regression was used to identify the prevalence and determinants of violence and bullying.ResultsMost participants were younger than 40 years of age (n = 106, 58.2%). Participants were mainly nurses (n = 105, 57.7%) and physicians (n = 31, 17.0%). Participants reported experiencing sexual abuse (n = 5, 2.7%), physical violence (n = 30, 16.50%), verbal abuse (n = 107, 58.8%), and bullying (n = 49, 26.9%). The odds of experiencing physical violence were 3.7 times greater (confidence interval = 1.6-9.2) when there was not a procedure for reporting workplace violence compared to when there was a procedure.DiscussionAttention is required to identify the prevalence of workplace violence. Creating effective policies and procedures for a reporting system would potentially lead to lowering violence rates and positively impacting health care workers’ well-being.     

A National Dataset Analysis of older adults in emergency department observation units

BackgroundEmergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age.DesignThis is an analysis of 2010–2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation.ResultsThe number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5–1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18–64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279).ConclusionsOlder adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.