Mark G. Moseley

Emergency Department Observation Units and the Older Patient

An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.

Effect of advanced age and vital signs on admission from an ED observation unit.

OBJECTIVES The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. METHODS We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. RESULTS Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). CONCLUSIONS Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.

The Influence of Emergency Medical Services Transport on Emergency Severity Index Triage Level for Patients With Abdominal Pain

OBJECTIVES The Emergency Severity Index (ESI) is a prospectively validated, five-level emergency department (ED) triage system designed to match triage acuity to both patient acuity and appropriate resource allocation. The study hypothesis was that, in practice, there exists an inappropriate bias toward triaging patients with abdominal pain to a higher ESI level based solely upon their mode of arrival to the ED. METHODS The authors performed a retrospective case-control study of patients presenting with abdominal pain. Patients were matched on sex, age (± 5 years), and date of arrival. Cases were those patients triaged to a Level 2, and controls were those triaged as Level 3. Conditional multiple variable logistic regression was used to evaluate the effect of the following variables on the odds of being triaged as Level 2: mode of arrival, systolic blood pressure (<90 mm Hg; normal, >140 mm Hg), heart rate, severe pain score (≥ 8 of 10), fever, race, history of cancer, and previous abdominal surgery. Age was also included in the regression modeling to confirm that matching was adequate. One-hundred cases and 100 controls were necessary to provide adequate sample size. A backward modeling technique was used, requiring a p < 0.05 for retention. RESULTS Of the 200 subjects, 52 arrived by emergency medical services (EMS) and 148 walked in. After matching for sex, age, and date of arrival, and after adjusting for heart rate, cancer diagnosis, and severe pain, the odds ratio (OR) for being triaged ESI Level 2 was 7.19 (95% confidence interval [CI] = 2.75 to 18.8, p < 0.0001) for EMS patients compared to walk-in patients. The admission rate for Level 2 patients was not different from that of Level 3 patients (49% vs. 35% of Level 3 patients, p = 0.06), but EMS patients were more likely to be admitted, regardless of ESI level assignment (65% vs. 34%, p < 0.001). CONCLUSIONS After adjusting for covariates, EMS patients with abdominal pain were more likely to be triaged to a higher acuity level. Triage level was not associated with admission, but patients arriving by EMS were more likely to be admitted. This may indicate that the effect of EMS arrival on triage level assignment is actually appropriate. Further research is necessary to validate whether mode of arrival should be incorporated in the initial ESI triage acuity assignment.

The Impact of Medical Student Participation in Emergency Medicine Patient Care on Departmental Press Ganey Scores

Introduction Press Ganey (PG) scores are used by public entities to gauge the quality of patient care from medical facilities in the United States. Academic health centers (AHCs) are charged with educating the new generation of doctors, but rely heavily on PG scores for their business operation. AHCs need to know what impact medical student involvement has on patient care and their PG scores. Purpose We sought to identify the impact students have on emergency department (ED) PG scores related to overall visit and the treating physician’s performance. Methods This was a retrospective, observational cohort study of discharged ED patients who completed PG satisfaction surveys at one academic, and one community-based ED. Outcomes were responses to questions about the overall visit assessment and doctor’s care, measured on a five-point scale. We compared the distribution of responses for each question through proportions with 95% confidence intervals (CIs) stratified by medical student participation. For each question, we constructed a multivariable ordinal logistic regression model including medical student involvement and other independent variables known to affect PG scores. Results We analyzed 2,753 encounters, of which 259 (9.4%) had medical student involvement. For all questions, there were no appreciable differences in patient responses when stratifying by medical student involvement. In regression models, medical student involvement was not associated with PG score for any outcome, including overall rating of care (odds ratio [OR] 1.10, 95% CI [0.90–1.34]) or likelihood of recommending our EDs (OR 1.07, 95% CI [0.86–1.32]). Findings were similar when each ED was analyzed individually. Conclusion We found that medical student involvement in patient care did not adversely impact ED PG scores in discharged patients. Neither overall scores nor physician-specific scores were impacted. Results were similar at both the academic medical center and the community teaching hospital at our institution.

Observation Unit Economics

With an aging population, the United States health care delivery system is struggling to handle an onslaught of chronic disease burden. The current process of regulatory oversight and pay-for-performance reimbursement is a reality in todays health care delivery system. To maintain profitability, facilities must be willing to implement new strategies that marry operational redesign, quality care, and cost-effective treatment. As payers increasingly favor outpatient strategies for patient management, inpatient facilities must develop effective strategies to shift inpatient care into ambulatory settings. This article presents a model, based on acute heart failure, that offers a solution that is fixed on process improvement techniques that levy positive economic impact.

Massive Pulmonary Embolism Algorithm

ince September 11, 2001, many terrorist threats and ttacks have occurred in the United States as well as lobally that may affect individuals’ perceptions of terorism and the need to protect against it when the means xist. The ability to protect ourselves against a terrorist ttack is especially relevant if smallpox were the agent. mallpox vaccination is currently available, and production as been increased so that enough is available to vaccinate he nation if needed. Presumably, the public’s anxiety over errorism peaked after September 11, and health care workrs may have been more likely to get vaccinated in the onths after the World Trade Center attacks than in the ears following, based on perception of risk. In an initial study that we conducted after the Sepember 11 terrorist attacks, emergency physicians (EPs) ho perceived a significant risk of a bioterrorist attack were .7 times more likely to volunteer for smallpox vaccination ompared with those who thought the risk was minimal (1). hen we conducted the survey again on a sample of 20 mergency Medicine programs from the original sample of 5 programs, our present study showed that EPs’ percepions toward smallpox vaccination are likely a dynamic ssue. EPs were less willing to get vaccinated in 2005 than 003. Although there was no difference in the perception of mallpox vaccine risk, fewer EPs felt that the benefits of the accine outweighed the risk in 2005 than 2003. In addition, Ps felt that a bioterrorist attack using smallpox in 2005 as less likely than in 2003 (Table 1). The results from this study suggest that factors such as erception of the risk of a bioterrorist attack on the