Mark S. Zocchi

Variation in Emergency Department Admission Rates Across the United States

There were more than 19 million hospitalizations in 2008 from hospital-based emergency departments (EDs), representing nearly 50% of all U.S. admissions. Factors related to variation in hospital-level ED admission rates are unknown. Generalized linear models were used to assess patient-, hospital-, and community-level factors associated with ED admission rates across a sample of U.S. hospitals using Healthcare Cost and Utilization Project data. In 1,376 EDs, the mean ED admission rate, when defined as direct admissions and also transfers from one ED to another hospital, was 17.5% and varied from 9.8% to 25.8% at the 10th and 90th percentiles. Higher proportions of Medicare and uninsured patients, more inpatient beds, lower ED volumes, for-profit ownership, trauma center status, and higher hospital occupancy rates were associated with higher ED admission rates. Also, hospitals in counties with fewer primary care physicians per capita and higher county-level ED admission rates had higher ED admission rates.

Antibacterial Drug Shortages From 2001 to 2013: Implications for Clinical Practice

BACKGROUND Previous studies have described drug shortages; however, there has been no comprehensive evaluation focusing on US antibacterial shortages. METHODS Drug shortage data from the University of Utah Drug Information Service database were analyzed, with a focus on antibacterial agents from 2001 to 2013. We used descriptive statistics to describe trends in drug shortages, analyze drug classes commonly affected, and investigate whether drugs experienced multiple periods of shortages. RESULTS One hundred forty-eight antibacterial drugs were on shortage over the 13-year study period, with 26 drugs still active on shortage as of December 2013. The median number of new shortages per year was 10 (interquartile range [IQR], 7). The number of drugs on shortage increased at a rate of 0.35 additional drugs every month (95% confidence interval, .22-.49) from July 2007 to December 2013 (P < .001). The median shortage duration was 188 days (IQR, 366.5). Twenty-two percent of drugs experienced multiple shortage periods. CONCLUSIONS There were a substantial number of drug shortages from 2001 to 2013, with a dramatic rise in shortages since 2007. Shortages of agents used to treat multidrug-resistant infections are of concern due to continued transmission and limited treatment options.

Longitudinal Trends in U.S. Drug Shortages for Medications Used in Emergency Departments (2001-2014).

OBJECTIVES This was a study of longitudinal trends in U.S. drug shortages within the scope of emergency medicine (EM) practice from 2001 to 2014. METHODS Drug shortage data from the University of Utah Drug Information Service were analyzed from January 2001 to March 2014. Two board-certified emergency physicians classified drug shortages based on whether they were within the scope of EM practice, whether they are used for lifesaving interventions or high-acuity conditions, and whether a substitute for the drug exists for its routine use in emergency care. Trends in the length of shortages for drugs used in EM practice were described using standard descriptive statistics and regression analyses. RESULTS Of the 1,798 drug shortages over the approximately 13-year period (159 months), 610 shortages (33.9%) were classified as within the scope of EM practice. Of those, 321 (52.6%) were for drugs used as lifesaving interventions or for high-acuity conditions, and of those, 32 (10.0%) were for drugs with no available substitute. The prevalence of EM drug shortages fell from 2002 to 2007; however, between January 2008 and March 2014, the number of EM drug shortages sharply increased by 435% from 23 to 123. From January 2008 to March 2014 shortages in drugs used as a direct lifesaving intervention or for high-acuity conditions increased 393% from 14 to 69, and shortages for drugs with no available substitute grew 125% from four to nine. Almost half (46.6%) of all EM drug shortages were caused by unknown reasons (the manufacturer did not cite a specific reason when contacted). Infectious disease drugs were the most common EM drugs on shortage, with 148 drug shortages totaling 2,213 months during the study period. CONCLUSIONS Drug shortages impacting emergency care have grown dramatically since 2008. The majority of shortages are for drugs used for lifesaving interventions or high-acuity conditions. For some, no substitute is available.

Drug shortages: Implications for medical toxicology

Abstract Context. Drug shortages have significantly increased over the past decade. There are limited data describing how shortages impact medical toxicology of drugs. Objective. To characterize drug shortages affecting the management of poisoned patients. Materials and Methods. Drug shortage data from January 2001 to December 2013 were obtained from the University of Utah Drug Information Service. Shortage data for agents used to treat poisonings were analyzed. Information on drug type, formulation, reason for shortage, shortage duration, marketing, and whether the drug was available from a single source was collected. The availability of a substitute therapy and whether substitutes were in shortage during the study period were also investigated. Results. Of 1,751 shortages, 141 (8.1%) impacted drugs used to treat poisoned patients, and as of December 2013, 21 (14.9%) remained unresolved. New toxicology shortages increased steadily from the mid-2000s, reaching a high of 26 in 2011. Median shortage duration was 164 days (interquartile range: 76–434). Generic drugs were involved in 85.1% of shortages and 41.1% were single-source products. Parenteral formulations were often involved in shortages (89.4%). The most common medications in shortage were sedative/hypnotics (15.6%). An alternative agent was available for 121 (85.8%) drugs; however, 88 (72.7%) alternatives were also affected by shortages at some point during the study period. When present, the most common reasons reported were manufacturing delays (22.0%) and supply/demand issues (17.0%). Shortage reason was not reported for 48.2% of drugs. Discussion. Toxicology drug shortages are becoming increasingly prevalent, which can result in both suboptimal treatment and medication errors from using less familiar alternatives. Conclusion. Drug shortages affected a substantial number of critical agents used in the management of poisoned patients. Shortages were often of long duration and for drugs without alternatives. Providers caring for poisoned patients should be aware of current shortages and implement mitigation strategies to safeguard patient care.

Comparison of mortality and costs at trauma and nontrauma centers for minor and moderately severe injuries in california

STUDY OBJECTIVE We examine differences in inpatient mortality and hospitalization costs at trauma and nontrauma centers for injuries of minor and moderate severity. METHODS Inpatient data sets from the California Office of Statewide Health Planning and Development were analyzed for 2009 to 2011. The study population included patients younger than 85 years and admitted to general, acute care hospitals with a primary diagnosis of a minor or moderate injury. Minor injuries were defined as having a New Injury Severity Score less than 5 and moderate injuries as having a score of 5 to 15. Multivariate logistic regression and generalized linear model with log-link and γ distribution were used to estimate differences in adjusted inpatient mortality and costs. RESULTS A total of 126,103 admissions with minor or moderate injury were included in the study population. The unadjusted mortality rate was 6.4 per 1,000 admissions (95% confidence interval [CI] 5.9 to 6.8). There was no significant difference found in mortality between trauma and nontrauma centers in unadjusted (odds ratio 1.2; 95% CI 0.97 to 1.48) or adjusted models (odds ratio 1.1; 95% CI 0.79 to 1.57). The average cost of a hospitalization was

Comparison of antibiotic susceptibility of Escherichia coli in urinary isolates from an emergency department with other institutional susceptibility data.

13,465 (95% CI

Increasing Throughput: Results from a 42-Hospital Collaborative to Improve Emergency Department Flow

12,733 to

U.S. Drug Shortages for Medications Used in Adult Critical Care (2001-2016).

14,198) and, after adjustment, was 33.1% higher at trauma centers compared with nontrauma centers (95% CI 16.9% to 51.6%). CONCLUSION For patients admitted to hospitals for minor and moderate injuries, hospitalization costs in this study population were higher at trauma centers than nontrauma centers, after adjustments for patient clinical-, demographic-, and hospital-level characteristics. Mortality was a rare event in the study population and did not significantly differ between trauma and nontrauma centers.

Treatment Failure Outcomes for Emergency Department Patients with Skin and Soft Tissue Infections

PURPOSE The antibiotic susceptibility of Escherichia coli in isolates from patients with uncomplicated urinary tract infection (UTI) in an emergency department (ED) was compared with susceptibility data from the associated hospital. METHODS Patients eligible for study participation included women age 18-65 years with one or more symptoms consistent with a UTI for whom a urine dipstick, urinalysis, or urine culture was ordered. Clinical decision-making, including the decision to order a urine culture, was at the discretion of the individual healthcare provider; however, a deidentified urine culture and antimicrobial susceptibility testing were performed for those study participants for whom a urine culture was not ordered. We compared the E. coli-specific antibiogram for uncomplicated UTI to the antibiogram based on all urine cultures in the ED regardless of patient disposition, non-intensive care unit (ICU) hospital inpatients, and the hospitalwide antibiogram. RESULTS Of the 578 ED patients screened for study eligibility, 119 met the inclusion criteria. E. coli, detected in 53 (74%) of the 72 pathogen-positive cultures, was the most common pathogen isolated. For E. coli, ciprofloxacin nonsusceptibility was significantly less common in isolates from ED patients with uncomplicated cystitis and pyelonephritis than in isolates from non-ICU inpatients or from the hospitalwide population. E. coli nonsusceptibility to ciprofloxacin was significantly less common in ED isolates from patients with uncomplicated UTI than in isolates from all ED patients with clinician-ordered urine cultures. CONCLUSION Antibiotic susceptibility of E. coli in an ED and its associated hospital depended on factors such as whether patients were hospitalized and whether ED isolates were from patients with uncomplicated UTI.

A Randomized Clinical Trial Comparing Use of Rapid Molecular Testing for Staphylococcus aureus for Patients With Cutaneous Abscesses in the Emergency Department With Standard of Care

BACKGROUND An 18-month collaborative in 42 hospitals across 16 communities in the United States to improve emergency department (ED) flow was conducted from October 2010 through March 2012. METHODS Hospitals were invited to participate through the Aligning Forces for Quality (AF4Q) program. Each participating hospital identified one or more interventions to improve ED flow and submitted data on four measures of ED flow: discharged length of stay (LOS), admitted LOS, boarding time, and left without being seen (LWBS) rates. Participating hospitals also provided quarterly progress reports on challenges encountered and lessons learned. Univariate linear regression was used to assess the effectiveness of interventions at the hospital level, where an improvement was defined as a negative slope in one or more of the throughput indicators. Challenges and lessons learned were tabulated and described. RESULTS A total of 172 interventions were implemented across the 42 hospitals. Two thirds (n = 28) demonstrated improvement on at least one measure of ED flow. Among hospitals demonstrating improvement, the average reduction in discharged LOS was 26 minutes (95% confidence interval [CI] 11 to 41); admitted LOS, 36.5 minutes (95% CI 20 to 53), boarding time, 20.9 minutes (95% CI 12 to 30), and LWBS seen rates decreased by 1.4 absolute percentage points (95% CI 0.2 to 2.7). Teams were frequently challenged by issues related to leadership, staff buy-in, and resource constraints. CONCLUSION The majority of hospitals in this collaborative improved on one or more ED flow measures. Many challenges were shared across hospitals, demonstrating that successful approaches to ED flow improvement require certain fundamental elements, including engaged leadership and staff, and sufficient resources.