George T. Loo

Patient Perspectives on EMS Alternate Destination Models

Abstract Introduction: Studies have shown that a large number of ambulance transports to emergency departments (ED) could have been safely treated in an alternative environment, prompting interest in the development of more patient-centered models for prehospital care. We examined patient attitudes, perspectives, and agreement/comfort with alternate destinations and other proposed innovations in Emergency Medical Services (EMS) care delivery and determined whether demographic, socioeconomic, acuity, and EMS utilization history factors impact levels of agreement. Methods: We conducted a cross-sectional study on a convenience sample of patients and caregivers presenting to an urban academic ED between July 2012 and May 2013. Respondents were surveyed on levels of agreement with 13 statements corresponding to various aspects of a proposed patient-centered emergency response system including increased EMS access to healthcare records, shared decision making with the patient and/or primary care physician, transport to alternative destinations, and relative importance of EMS assessment versus transportation. Information on demographic and socioeconomic factors, level of acuity, and EMS utilization history were also determined via survey and chart review. Responses were analyzed descriptively and compared across patient characteristics using chi-square and regression analyses. Results: A total of 621 patients were enrolled. The percentage of patients who agreed or strongly agreed with each of the 13 statements ranged from 48.2 to 93.8%. About 86% agreed with increased EMS access to healthcare records; approximately 72% agreed with coordinating disposition decisions with a primary physician; and about 58% supported transport to alternative destinations for low acuity conditions. No association was found between levels of agreement and the patients level of acuity or EMS utilization history. Only Black or Hispanic race showed isolated associations with lower rates of agreement with some aspects of an innovative EMS care delivery model. Conclusion: A substantial proportion of patients surveyed in this cross sectional study agreed with a more patient-centered approach to prehospital care where a 9-1-1 call could be met with a variety of treatment and transportation options. Agreement was relatively consistent among a diverse group of patients with varying demographics, levels of acuity and EMS utilization history. MeSH Key words: emergency medical services; triage; telemedicine; surveys and questionnaires; transportation of patients

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

To examine the effect of an emergency department (ED)‐based transitional care nurse (TCN) on hospital use.

Coping behavior and risk of post-traumatic stress disorder among federal disaster responders

BACKGROUND Our knowledge about the impact of coping behavior styles in people exposed to stressful disaster events is limited. Effective coping behavior has been shown to be a psychosocial stress modifier in both occupational and nonoccupational settings. METHODS Data were collected by using a web-based survey that administered the Post-Traumatic Stress Disorder (PTSD) Checklist-Civilian, General Coping Questionnaire-30, and a supplementary questionnaire assessing various risk factors. Logistic regression models were used to test for the association of the 3 coping styles with probable PTSD following disaster exposure among federal disaster responders. RESULTS In this sample of 549 study subjects, avoidant coping behavior was most associated with probable PTSD. In tested regression models, the odds ratios ranged from 1.19 to 1.26 and 95% confidence intervals ranged from 1.08 to 1.35. With control for various predictors, emotion-based coping behavior was also found to be associated with probable PTSD (odds ratio=1.11; 95% confidence interval: 1.01-1.22). CONCLUSION This study found that in disaster responders exposed to traumatic disaster events, the likelihood of probable PTSD can be influenced by individual coping behavior style and other covariates. The continued probability of disasters underscores the critical importance of these findings both in terms of guiding mental health practitioners in treating exposed disaster responders and in stimulating future research.

National Assessment of Quality Programs in Emergency Medical Services

Abstract Objective: This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS. Methods: A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©. Results: A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 −0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%). Conclusions: EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.

Bouncing Back Elsewhere: Multilevel Analysis of Return Visits to the Same or a Different Hospital After Initial Emergency Department Presentation

Study objective Analyses of 72‐hour emergency department (ED) return visits are frequently used for quality assurance purposes and have been proposed as a means of measuring provider performance. These analyses have traditionally examined only patients returning to the same hospital as the initial visit. We use a health information exchange network to describe differences between ED visits resulting in 72‐hour revisits to the same hospital and those resulting in revisits to a different site. Methods We examined data from a 31‐hospital health information exchange of all ED visits during a 5‐year period to identify 72‐hour return visits and collected available encounter, patient, and hospital variables. Next, we used multilevel analysis of encounter‐level, patient‐level, and hospital‐level data to describe differences between initial ED visits resulting in different‐site and same‐site return visits. Results We identified 12,621,159 patient visits to the 31 study EDs, including 841,259 same‐site and 107,713 different‐site return visits within 72 hours of initial ED presentation. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the initial‐visit characteristics’ predictive relationship that any return visit would be at a different site: daytime visit (OR 1.10; 95% CI 1.07 to 1.12), patient‐hospital county concordance (OR 1.40; 95% CI 1.36 to 1.44), male sex (OR 1.27; 95% CI 1.24 to 1.30), aged 65 years or older (OR 0.55; 95% CI 0.53 to 0.57), sites with an ED residency (OR 0.41; 95% CI 0.40 to 0.43), sites at an academic hospital (OR 1.12; 95% CI 1.08 to 1.15), sites with high density of surrounding EDs (OR 1.73; 95% CI 1.68 to 1.77), and sites with a high frequency of same‐site return visits (OR 0.10; 95% CI 0.10 to 0.11). Conclusion This analysis describes how ED encounters with early revisits to the same hospital differ from those with revisits to a second hospital. These findings challenge the use of single‐site return‐visit frequency as a quality measure, and, more constructively, describe how hospitals can use health information exchange to more accurately identify early ED return visits and to support programs related to these revisits.

Expanding Health Information Exchange Improves Identification of Frequent Emergency Department Users

Study objective Frequent emergency department (ED) users are of interest to policymakers and hospitals. The objective of this study is to examine the effect of health information exchange size on the identification of frequent ED users. Methods We retrospectively analyzed data from Healthix, a health information exchange in New York that previously included 10 hospitals and then grew to 31 hospitals. We divided patients into 3 cohorts: high‐frequency ED users with 4 or more visits in any 30‐day period, medium‐frequency ED users with 4 or more visits in any year, and infrequent ED users with fewer than 4 visits in any year. For both the smaller (10‐hospital) and larger (31‐hospital) health information exchanges, we compared the identification rate of frequent ED users that was based on hospital‐specific data with the corresponding rates that were based on health information exchange data. Results The smaller health information exchange (n=1,696,279 unique ED patients) identified 11.4% more high‐frequency users (33,467 versus 30,057) and 9.5% more medium‐frequency users (109,497 versus 100,014) than the hospital‐specific data. The larger health information exchange (n=3,684,999) identified 19.6% more high‐frequency patients (52,727 versus 44,079) and 18.2% more medium‐frequency patients (222,574 versus 192,541) than the hospital‐specific data. Expanding from the smaller health information exchange to the larger one, we found an absolute increase of 8.2% and 8.7% identified high‐ and medium‐frequency users, respectively. Conclusion Increasing health information exchange size more accurately reflects how patients access EDs and ultimately improves not only the total number of identified frequent ED users but also their identification rate.

The role of reduced heart rate volatility in predicting disposition from the emergency department

Objective Heart rate volatility (HRVO) is a physiological parameter that is believed to reflect the sympathetic activity of the autonomic nervous system. We explored the utility of HRVO as a predictive tool for declining physiological states, hypothesising that patients admitted from the resuscitation area of the ED to a high-dependency unit (HDU) experience low HRVO compared with patients who did not. Methods We retrospectively reviewed HR data recordings, medical charts and disposition decisions from the ED of patients who were admitted to the five resuscitation beds in our adult ED between 29 April 2014 and 30 May 2015. HRVO was calculated for each 5 min interval; it was measured as the SD of all HRs within that interval. Logistic regression was used to model the odds of admission to a HDU given low HRVO during ED stay. Results HR data from 2051 patients was collected and approximately 7 million HR data points were analysed. 402 patients experienced low HRVO. Patients who experienced low HRVO during their ED stay were twice as likely to be admitted to a HDU from the ED (OR=2.07, 95% CI 1.64 to 2.60; p<0.001). Conclusions Our result provides additional evidence supporting previously published data indicating that autonomic nervous system measures such as HRVO could serve as important and useful clinical tools in the early triage of critically ill patients in the ED.