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Emergency Department (ED, emergency room, ER)

Epidemiology: - return visits [3] - 3-day revisit rate ~8% - 30 day revisit rate ~20% - ~1/3 of revisits were to different hospitals - most common index diagnoses resulting in revisit - skin infections & soft tissue infections (23%) - abdominal pain (10%) - headache (9%) - elderly choose the emergency department (ED) for convenient, comprehensive, high-quality care - ~1/3 of elderly are referred to the ED by a provider - ~1/3 arrive by ambulance - common reasons for presentation of elderly to the ED - fall-related injuries - other acute injuries - pain Complications: - 0.12% of Medicare patients discharged from the ED die within 7 days [6] - 7 day mortality 0.27% among hospitals in the lowest 1/5 of inpatient admissions from the emergency department [6] - ED crowding & boarding harms critically-ill patients [7] - combined outcome of in-hospital mortality, persistent organ dysfunction (vasopressors, mechanical ventilation, dialysis) or death at 28 days increases from ~25% at hour 0 to 40% at hour 12 for critically-ill patients boarded in the ED - 47% of ICU admission requests from the ED are declined [7] - 10-day mortality 50% higher when EDs most crowded [13] - incorrect diagnosis ~5.7%, adverse event in ~2.0% due to incorrect diagnosis, ~0.3% of adverse events serious, translating to ~1 in 18 patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, & 1 in 350 suffering permanent disability or death [15] - 5 conditions (stroke, myocardial infarction, aortic aneurysm or dissection, spinal cord compression or injury, venous thromboembolism) account for ~40% of serious misdiagnosis-related harms [15] - American College of Emergency Physicians & 8 other emergency medicine organizations issued a letter expressing concern about the report [15] Management: Choosing Wisely recommendations: - avoid head CT in patients with minor head injury who are at low risk based on validated decision rules [2] - avoid head CT in asymptomatic adult patients with syncope, insignificant trauma & a normal neurological evaluation [2] - avoid placing indwelling urinary catheters for either urine output monitoring in stable patients who can void, or for patient or staff convenience [2] - do not delay engaging available palliative & hospice care services for patients likely to benefit [2] - avoid antibiotics & wound cultures in patients with uncomplicated skin & soft tissue abscesses after successful incision & drainage & with adequate medical follow-up [2] - avoid IV fluids before a trial of oral rehydration in uncomplicated cases of mild to moderate dehydration in children [2] - avoid CT pulmonary angiography in patients with a low- pretest probability of pulmonary embolism & a negative plasma D-dimer [2] - avoid lumbar spine imaging for adults with non-traumatic [2] back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equine syndrome, or cancer with bony metastasis [2] - avoid prescribing antibiotics for uncomplicated sinusitis [2] - avoid ordering CT of the abdomen & pelvis in young otherwise healthy patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic [2] other - 5 elements of a nursing home to emergency department transfer form [14] - emergency contact/health care proxy - current medication list - reason for emergency department transfer - baseline neurological state - relevant diagnoses/medical history - emergency department crowding negatively impacts care [1] - triage seems to identify patients who need hospitalization but not those that need ICU or surgery vs outpatient care [5] - telephone calls after emergency department visits of seniors does not reduce return visits, hospitalization, or death [8] - evaluation of elderly in the emergency department by a transitional care nurse for functional status resulted in a 10% reduction in hospital admission, a decreased 30-day risk for hospital readmission, but ~1.5% increase in rate of 72-hour ED revisits at 2 of 3 sites [9] - cross-checking diagnostic & treatment plans with a colleague resulted in a 40% reduction in a preventable adverse event or near miss* [10] (mostly near misses) * a near miss = a medical error that has the potential to cause an adverse event, but did not, either by chance or after an intervention [10]

General

health care setting

References

  1. Singer AJ et al. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011 Dec; 18:1324. PMID: 22168198 - Sills MR et al. Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures. Acad Emerg Med 2011 Dec; 18:1330. PMID: 22168199 - Liu SW et al. An empirical assessment of boarding and quality of care: Delays in care among chest pain, pneumonia, and cellulitis patients. Acad Emerg Med 2011 Dec; 18:1339. PMID: 22168198 - Kennebeck SS et al. The association of emergency department crowding and time to antibiotics in febrile neonates. Acad Emerg Med 2011 Dec; 18:1380. PMID: 22168202
  2. American College of Emergency Physicians. Ten Things Physicians and Patients Should Question Choosing Wisely. October 14, 2014 http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/
  3. Duseja R, Bardach NS, Lin GA et al Revisit Rates and Associated Costs After an Emergency Department Encounter: A Multistate Analysis. Ann Intern Med. 2015;162(11):750-756. PMID: 26030633 http://annals.org/article.aspx?articleid=2299853 - Dharmarajan K, Krumholz HM Opportunities and Challenges for Reducing Hospital Revisits. Ann Intern Med. 2015;162(11):793-794. PMID: 26030636 http://annals.org/article.aspx?articleid=2299861
  4. Ioannides KL et al Medical Students in the Emergency Department and Patient Length of Stay. JAMA. 2015;314(22):2411-2413 PMID: 26647265 http://jama.jamanetwork.com/article.aspx?articleid=2474418
  5. Hsia RY et al. Urgent care needs among nonurgent visits to the emergency department. JAMA Intern Med 2016 Apr 18 PMID: 27089549
  6. Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017 Feb 1;356:j239. PMID: 28148486 Free Article
  7. Mathews KS, Durst, MS. Vargas-Torres C et al. Effect of emergency department and ICU occupancy on admission decisions and outcomes for critically ill patients. Crit Care Med 2018 Jan 30; PMID: 29384780 https://journals.lww.com/ccmjournal/Abstract/publishahead/Effect_of_Emergency_Department_and_ICU_Occupancy.96357.aspx
  8. Biese KJ, Busby-Whitehead J, Cai J et al. Telephone follow-up for older adults discharged to home from the emergency department: A pragmatic randomized controlled trial. J Am Geriatr Soc 2018 Mar; 66:452. PMID: 29272029 https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15142
  9. Hwang U et al. Geriatric emergency department innovations: Transitional care nurses and hospital use. J Am Geriatr Soc 2018 Mar; 66:459-466 PMID: 29318583
  10. Freund Y, Goulet H, Leblanc J, et al. Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial. JAMA Intern Med. 2018 Apr 23; PMID: 29710111 https://psnet.ahrq.gov/resources/resource/32100
  11. Goodridge D, Stempien J. Understanding why older adults choose to seek non-urgent care in the emergency department: The patient's perspective. CJEM 2018 May 30; PMID: 29843840 https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/understanding-why-older-adults-choose-to-seek-nonurgent-care-in-the-emergency-department-the-patients-perspective/E27962277A37F229630353B2C2490ED7
  12. Mercer MP, Singh MK, Kanzaria HK Reducing Emergency Department Length of Stay. JAMA. Published online March 19, 2019. PMID: 30888416 https://jamanetwork.com/journals/jama/fullarticle/2729032
  13. Berg LM, Ehrenberg A, Florin J et al. Associations between crowding and ten-day mortality among patients allocated lower triage acuity levels without need of acute hospital care on departure from the emergency department. Ann Emerg Med 2019 Jun 19 PMID: 31229391
  14. Tumolo J Automated Transfer Form May Improve Emergency Care for Nursing Home Residents. Annals of Long-term Care. May 11, 2021 https://www.managedhealthcareconnect.com/annals-long-term-care/automated-transfer-form-may-improve-emergency-care-nursing-home-residents - Vest JR, Unruh MA, Hilts KE, et al. End user information needs for a SMART on FHIR-based automated transfer form to support the care of nursing home patients during emergency department visits. AMIA Annu Symp Proc. 2021;2020:1239-1248. Published 2021 Jan 25
  15. Agency for Healthcare Research & Quality. Dec 15, 2022 Diagnostic Errors in the Emergency Department: A Systematic Review. https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research - Faust J The 'Fatal Flaw' in a Government Report on ER Misdiagnoses. Peer reviewers and technical experts worried about flimsy methods prior to publication. MedPage Today. Dec 19, 2022 https://www.medpagetoday.com/opinion/faustfiles/102307