This review synthesizes the existing literature to provide evidence-based predictions for the future of emergency care in the United States as a result of the Patient Protection and Affordable Care ...Act, with a focus on emergency department (ED) visit volume, acuity, and reimbursement. Patient behavior will likely be quite different for patients gaining Medicaid than for those gaining private insurance through the Marketplaces. Despite the threat of the individual mandate, not all uninsured patients will enroll, and those who choose to enroll will likely be a different population from those who remain uninsured. New Medicaid enrollees will be a sicker population and will likely increase their number of ED visits substantially. Their acuity will be higher at first but will then revert to the traditionally high number of low-acuity visits made by Medicaid patients. Most patients enrolling through the Marketplace are choosing high-deductible health plans, and they will initially avoid the ED because of high out-of-pocket costs but may present later and sicker after self-rationing their care. Most patients gaining health coverage through the Affordable Care Act will be shifting from uninsured to either Medicaid or private insurance, both of which reimburse more than self-pay, so ED collections should increase. Because of the differences between Medicaid and Marketplace plans, there will be a difference in ED volume, acuity, and financial outcomes, depending on states’ current demographics, whether states expand Medicaid, and how aggressively states advertise new options for coverage in Medicaid or state health insurance Marketplaces.
Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic ...populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations.
This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them.
Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks "all of the time" and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%).
Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
We conducted in-depth interviews to characterize reasons for COVID-19 vaccine hesitancy in emergency department (ED) patients and developed messaging platforms that may address their concerns. In ...this trial, we seek to determine whether provision of these COVID-19 vaccine messaging platforms in EDs will be associated with greater COVID-19 vaccine acceptance and uptake in unvaccinated ED patients.
This is a cluster-randomized controlled trial (RCT) evaluating our COVID-19 vaccine messaging platforms in seven hospital EDs (mix of academic, community, and safety-net EDs) in four US cities. Within each study site, we randomized 30 1-week periods to the intervention and 30 1-week periods to the control. Adult patients who have not received a COVID-19 vaccine are eligible with these exclusions: (1) major trauma, intoxication, altered mental status, or critical illness; (2) incarceration; (3) psychiatric chief complaint; and (4) suspicion of acute COVID-19 illness. Participants receive an orally administered Intake survey. During intervention weeks, participants then receive three COVID-19 vaccine messaging platforms (4-min video, one-page informational flyer and a brief, scripted face-to-face message delivered by an ED physician or nurse); patients enrolled during non-intervention weeks do not receive these platforms. Approximately, an hour after intake surveys, participants receive a Vaccine Acceptance survey during which the primary outcome of acceptance of the COVID-19 vaccine in the ED is ascertained. The other primary outcome of receipt of a COVID-19 vaccine within 32 days is ascertained by electronic health record review and phone follow-up. To determine whether provision of vaccine messaging platforms is associated with a 7% increase in vaccine acceptance and uptake, we will need to enroll 1290 patients.
Highlighting the difficulties of trial implementation during the COVID-19 pandemic in acute care settings, our novel trial will lay the groundwork for delivery of public health interventions to vulnerable populations whose only health care access occurs in EDs.
Toward addressing vaccine hesitancy in vulnerable populations who seek care in EDs, our cluster-RCT will determine whether implementation of vaccine messaging platforms is associated with greater COVID-19 vaccine acceptance and uptake in unvaccinated ED patients.
We began enrollment in December 2021 and expect to continue through 2022.
ClinicalTrials.gov NCT05142332 . Registered 02 December 2021.
Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such ...interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown.
Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies.
Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability.
Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.
IMPORTANCE: Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are ...based at a single site or health care system, limiting their generalizability. OBJECTIVE: To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds. DATA SOURCES: A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022. STUDY SELECTION: Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable. DATA EXTRACTION AND SYNTHESIS: Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022. MAIN OUTCOME(S) AND MEASURE(S): Risk of physical restraint use in adult ED patients by racial and ethnic background. RESULTS: The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89). CONCLUSIONS AND RELEVANCE: Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.
A total of 203 surveys were completed, with a 25% response rate overall. ...our study demonstrates gaps in healthcare coordination. Declaration of competing interest None. n = 195 Staff role APP 13 ...(7%) Attending 47 (24%) Resident 32 (16%) Nurse 77 (39%) Not specified 26 (13%) Years working at current site in current role 0–5 years 91 (47%) 6–10 years 23 (12%) 11–15 years 22 (11%) 16–20 years 13 (7%) >20 years 21 (11%) Not specified 25 (13%) Site Ben Taub Hospital 51 (26%) Cook County Hospital 47 (24%) San Francisco General Hospital 72 (37%) Not specified 25 (13%) Age <31 32 (16%) 31–40 70 (36%) 41–50 30 (15%) >50 34 (17%) Not specified 29 (15%) Gender Cis Men 57 (29%) Cis Women 101 (52%) Other 3 (2%) Not specified 34 (17%) Race Asian 26 (13%) Black 22 (11%) Mixed 16 (8%) Other 13 (7%) White 88 (45%) Not specified 30 (15%) Ethnicity Hispanic 21 (11%) Non-Hispanic 142 (73%) Not specified 32 (16%) Table 1 Characteristics of Survey Responders.
Background
Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ...ED‐based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration.
Methods
We conducted a retrospective cross‐sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018–2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters.
Results
The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval CI = 1.94–2.35) for infrequent use, OR = 4.98 (95% CI = 4.43–5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59–15.86) for those with super‐frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super‐frequent ED use remained elevated at 2.57 (95% CI = 1.94–3.41). Of those with super‐frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest.
Conclusions
Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.
•Overall, 9% of patients reported delays in accessing care.•Patients reporting delays were less likely to need further acute care or evaluation.•Men, White patients, and those without private ...insurance were less likely to delay.•The percentage reporting delays dropped throughout the study period (13.4% to7%).
Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular ...source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites and willingness to get the vaccine as part of ED care.
Cross sectional survey conducted from 12/10/2020 to 3/7/21 at 15 safety net United States EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt.
Of 2575 patients approached, 2301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of healthcare. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28 to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47 vs 38%, 9% difference, 95% CI 4 – 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female gender, African American race, Latinx ethnicity, and not having received an influenza vaccine in the past five years. Of the 61% COVID-19 vaccine acceptors, 21% stated that they lacked a primary doctor or clinic to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED.
ED patients who lack a regular source of medical care are particularly hesitant to COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may have pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.
Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ...ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing “take-home naloxone” programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a “C-suite” champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.
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