S. Terp

Improving attendance at post-emergency department follow-up via automated text message appointment reminders: a randomized controlled trial.

OBJECTIVES Patients discharged from the emergency department (ED) are often referred for primary care, specialty, or other disease-specific follow-up appointments. Attendance at these scheduled follow-up appointments has been found to improve patient outcomes, decrease ED bounce-backs, and reduce malpractice risk. Reasons for missing follow-up visits are complex, but the most commonly reason cited by patients is simply forgetting. In this study the authors evaluated the ability of an automated text message reminder system to increase attendance at post-ED discharge follow-up appointments in a predominantly Hispanic safety-net population. METHODS This was a randomized controlled trial of ED patients with outpatient follow-up visits scheduled at the time of ED discharge. A total of 374 English- and Spanish-speaking patients with text-capable mobile phones were enrolled. Patients in the intervention arm received automated, personalized text message appointment reminders including date, time, and clinic location at 7, 3, and 1 day before scheduled visits. A t-test of proportions was used to compare outcomes between intervention and control groups. Both an intention-to-treat (ITT) and a per-protocol analysis of the data were performed. The ITT more accurately reflects real-world conditions where errors such as number entry errors are bound to occur. The per-protocol analysis adds value by isolating the effect of the intervention by comparing patients who actually received it compared with those who did not. RESULTS In the per-protocol analysis of the primary outcome, the overall appointment adherence rate was 72.6% in the intervention group compared with 62.1% in the control group (difference between groups = 10.5%, 95% confidence interval [CI] = 0.3% to 20.8%; p = 0.045; number needed to treat = 9.5). In the ITT analysis, the overall appointment attendance rate 70.2% in the intervention group compared with 62.1% in the control group (difference between groups = 8.2%; 95% CI = -1.6% to 17.7%; p = 0.100). In a secondary largely exploratory analysis, the intervention was found to have the most benefit in patients with the lowest baseline follow-up rate (English speakers with specialty care appointments). CONCLUSIONS Automated text message appointment reminders resulted in improvement in attendance at scheduled post-ED discharge outpatient follow-up visits and represent a low-cost and highly scalable solution to increase attendance at post-ED follow-up appointments, which should be further explored in larger sample sizes and diverse patient populations.

Describing the evolution of mobile technology usage for Latino patients and comparing findings to national mHealth estimates

OBJECTIVES Describe the change in mobile technology used by an urban Latino population between 2011 and 2014, and compare findings with national estimates. MATERIALS AND METHODS Patients were surveyed on medical history and mobile technology use. We analyzed specific areas of mobile health capacity stratified by chronic disease, age, language preference, and educational attainment. RESULTS Of 2144 Latino patients, the percentage that owned a cell phone and texted were in-line with Pew estimates, but app usage was not. Patients with chronic disease had reduced access to mobile devices (P < .001) and lower use of mobile phone functionalities. DISCUSSION Prior research suggests that Latinos can access mHealth; however, we observed lower rates among Latino patients actively seeking heath care. CONCLUSION Published national estimates do not accurately reflect the mobile technology use of Latino patients served by our public safety-net facility. The difference is greater for older, less educated patients with chronic disease.

Routine Capnographic Monitoring is Not Indicated for All Patients Undergoing Emergency Department Procedural Sedation

These studies, performed in academic centers with multiple bedside providers, may be poorly representative of sedation in nonacademic clinical practice. When one emergency physician is performing both procedural sedation and a procedure, the safety afforded by continuous ETCO2 monitoring is likely magnified. Prolonged apnea, clinically significant hypoxemia, and unanticipated admissions are “never events.” Even a single death or ICU admission because of complications from ED procedural sedation is unacceptable. It is true that evidence in support of capnography is limited. Procedural sedation studies have not been adequately powered to detect these very rare complications. Evidence showing that pulse oximetry or continuous noninvasive blood pressure prevents adverse events is similarly lacking, yet common sense has led to the universal adoption of these monitoring modalities as procedural sedation standards. The inexpensiveness of capnography (about

Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014

10 to

Racial And Ethnic Differences In The Frequency Of Workplace Injuries And Prevalence Of Work-Related Disability

15 per-patient cost after purchase of the monitor) is eclipsed by the unacceptable cost of even a single serious sedation-related complication. As our patients age, become more obese, and have more comorbidities, hypoxemia is a relevant risk for severe complications. Capnography is a noninvasive, easily interpretable, and simple monitoring strategy that can prevent hypoxemia among sedated patients. With human life hanging in the balance, the infrequency with which catastrophic complications occur is no excuse for failing to adopt a proven prevention strategy, especially when state-of-the-art prevention is noninvasive and readily available. Capnography should be the monitoring modality of choice for all procedural sedations in the ED.

Exposure to and Use of Electronic Cigarettes: Does Language Matter?

Study objective We determine the incidence of and trends in enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) during the past decade. Methods We obtained a comprehensive list of all EMTALA investigations conducted between 2005 and 2014 directly from the Centers for Medicare & Medicaid Services (CMS) through a Freedom of Information Act request. Characteristics of EMTALA investigations and resulting citation for violations during the study period are described. Results Between 2005 and 2014, there were 4,772 investigations, of which 2,118 (44%) resulted in citations for EMTALA deficiencies at 1,498 (62%) of 2,417 hospitals investigated. Investigations were conducted at 43% of hospitals with CMS provider agreements, and citations issued at 27%. On average, 9% of hospitals were investigated and 4.3% were cited for EMTALA violation annually. The proportion of hospitals subject to EMTALA investigation decreased from 10.8% to 7.2%, and citations from 5.3% to 3.2%, between 2005 and 2014. There were 3.9 EMTALA investigations and 1.7 citations per million emergency department (ED) visits during the study period. Conclusion We report the first national estimates of EMTALA enforcement activities in more than a decade. Although EMTALA investigations and citations were common at the hospital level, they were rare at the ED‐visit level. CMS actively pursued EMTALA investigations and issued citations throughout the study period, with half of hospitals subject to EMTALA investigations and a quarter receiving a citation for EMTALA violation, although there was a declining trend in enforcement. Further investigation is needed to determine the effect of EMTALA on access to or quality of emergency care.

The Effect of Utilization Review on Emergency Department Operations

Occupational injuries and illnesses lead to significant health care costs and productivity losses for millions of workers each year. This study used national survey data to test for differences between members of minority groups and non-Hispanic white workers in the risk of workplace injuries and the prevalence of work-related disabilities. Non-Hispanic black workers and foreign-born Hispanic workers worked in jobs with the highest injury risk, on average, even after adjustment for education and sex. These elevated levels of workplace injury risk led to a significant increase in the prevalence of work-related disabilities for non-Hispanic black and foreign-born Hispanic workers. These findings suggest that disparities in economic opportunities expose members of minority groups to increased risk of workplace injury and disability.

Individual Physician Penalties Resulting From Violation of Emergency Medical Treatment and Labor Act: A Review of Office of the Inspector General Patient Dumping Settlements, 2002–2015

OBJECTIVES To determine whether patients who are English proficient become aware of e-cigarettes through different marketing tactics and have dissimilar patterns of use than patients who are non-English speaking. DESIGN This was a cross-sectional study surveying adult English- and Spanish-speaking patients. ANOVA and chi-squared tests were used to examine differences between groups. SETTING A large public, safety-net hospital in Los Angeles County, California. RESULTS Respondents (N=1899) were predominately Hispanic (78%), foreign-born (68%), and reported Spanish as a primary language (64%). Native English speakers reported the highest use of e-cigarettes (26%), followed by non-native (13%) and non-English speakers (2%) (P<.001). In terms of marketing, native and non-native English speakers were more likely to have friends and family as sources of e-cigarette information (P<.001). Native speakers were more likely to see advertisements for e-cigarettes on storefronts (P=.004) and on billboards (P<.001). Non-English speakers were most likely to learn about e-cigarettes on the news (P<.001) and in advertisements on the television and radio (P=.002). Differences in reasons for use were not significant between the three groups. CONCLUSIONS Native and non-native English speakers become aware of e-cigarettes through different mechanisms and use e-cigarettes at a significantly higher rate than non-English speakers. These results highlight an opportunity for public health programs to concentrate on specific channels of communication that introduce patient populations to e-cigarettes to slow the spread of e-cigarette usage.

1688Diagnosis of Pulmonary Tuberculosis among Admitted Patients at a Large, Urban Safety-net Facility — Los Angeles, 2010–2013

Study objective: Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety‐net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. Methods: In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis‐based criteria) or secondary review (medical necessity as determined by an on‐site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30‐day ED revisits, and 30‐day admission rates. Excluding a 6‐month implementation period, monthly summary metrics were compared pre‐ and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30‐day ED revisits, 30‐day admission rate among return visitors to the ED, and estimated cost. Results: Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty‐day revisits increased (20.4% to 24.4%), although the 30‐day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled

43 Describing the Evolution of Mobile Technology Usage for Latino Patients and Comparing Findings to National Mobile Health Estimates

193.17 per ED visit. Conclusion: The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30‐day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings.