Study objective We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid ...expansion state. Methods Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. Results Average monthly ED visit volume increased by 14,080 visits (95% confidence interval CI 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI −27,037 to −21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI −11.1 to −6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. Conclusion ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation.
For early detection of sepsis, automated systems within the electronic health record have evolved to alert emergency department (ED) personnel to the possibility of sepsis, and in some cases link ...them to suggested care pathways. We conducted a systematic review of automated sepsis-alert detection systems in the ED.
We searched multiple health literature databases from the earliest available dates to August 2018. Articles were screened based on abstract, again via manuscript, and further narrowed with set inclusion criteria: 1) adult patients in the ED diagnosed with sepsis, severe sepsis, or septic shock; 2) an electronic system that alerts a healthcare provider of sepsis in real or near-real time; and 3) measures of diagnostic accuracy or quality of sepsis alerts. The final, detailed review was guided by QUADAS-2 and GRADE criteria. We tracked all articles using an online tool (Covidence), and the review was registered with PROSPERO registry of reviews. A two-author consensus was reached at the article choice stage and final review stage. Due to the variation in alert criteria and methods of sepsis diagnosis confirmation, the data were not combined for meta-analysis.
We screened 693 articles by title and abstract and 20 by full text; we then selected 10 for the study. The articles were published between 2009-2018. Two studies had algorithm-based alert systems, while eight had rule-based alert systems. All systems used different criteria based on systemic inflammatory response syndrome (SIRS) to define sepsis. Sensitivities ranged from 10-100%, specificities from 78-99%, and positive predictive value from 5.8-54%. Negative predictive value was consistently high at 99-100%. Studies showed some evidence for improved process-of-care markers, including improved time to antibiotics. Length of stay improved in two studies. One low quality study showed improved mortality.
The limited evidence available suggests that sepsis alerts in the ED setting can be set to high sensitivity. No high-quality studies showed a difference in mortality, but evidence exists for improvements in process of care. Significant further work is needed to understand the consequences of alert fatigue and sensitivity set points.
Study objective We evaluate a computer simulation model designed to assess the effect on emergency department (ED) length of stay of varying the number of ED beds or altering the interval of admitted ...patient departure from the ED. Methods We created a computer simulation model (Med Model) based on institutional data and augmented by expert estimates and assumptions. We evaluated simulations of increasing the number of ED beds, increasing the admitted patient departure and increasing ED census, analyzing potential effects on overall ED length of stay. Multiple sensitivity analyses tested the robustness of the results to changes in model assumptions and institutional data. Results With a constant ED departure rate at the base case and increasing ED beds, there is an increase in mean length of stay from 240 to 247 minutes (95% confidence interval CI 0.8 to 12.6 minutes). When keeping the number of beds constant at the base case and increasing the rate at which admitted patients depart the ED to their inpatient bed, the mean overall ED length of stay decreases from 240 to 218 minutes (95% CI 16.8 to 26.2 minutes). With a 15% increase in daily census, the trends are similar to the base case results. The sensitivity analyses reveal that despite a wide range of inputs, there are no differences from the base case. Conclusion Our computer simulation modeled that improving the rate at which admitted patients depart the ED produced an improvement in overall ED length of stay, whereas increasing the number of ED beds did not.
Abstract Background Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could ...positively affect ED boarding, and this hypothesis can be tested with computer modeling. Study Objective Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m. Methods A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies. Results A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4 h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0. Conclusion Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.
Abstract Background Prolonged emergency department (ED) wait times could potentially lead to increased mortality. Studies have demonstrated that black patients waited significantly longer for ED care ...than nonblack patients. However, the disparity in wait times need not necessarily manifest across all illness severities. We hypothesize that, on average, black patients wait longer than nonblack patients and that the disparity is more pronounced as illness severity decreases. Methods We studied 34 143 patient visits in 353 hospital EDs in the National Hospital Ambulatory Medical Care Survey in 2008. In a 2-model approach, we regressed natural logarithmically transformed wait time on the race variable, other patient-level variables, and hospital-level variables for 5 individually stratified illness severity categories. We reported results as percent difference in wait times, with 95% confidence intervals. We used P < .05 for significance level. Results On average, black patients experienced significantly longer mean ED wait times than white patients (69.2 vs 53.3 minutes; P < .001). In the multivariate model, black patients did not experience significant different wait times for the 2 most urgent severity categories; black patients experienced increasingly longer waits vs nonblack patients for the 3 least urgent severity categories (14.7%, P < .05; 15.9%, P < .05; 29.9%, P < .001, respectively). Conclusion Racial disparity in ED wait times between black and nonblack patients exists, and the size of the disparity is more pronounced as illness severity decreases. We do not find a racial disparity in wait times for critically ill patients.
The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with ...severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality.
This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality.
The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons.
We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.
Emergency department resuscitation plays a significant role in sepsis care, and it is unknown if patient outcomes vary by institution based on the level of sepsis experience of the emergency ...department. This study examines whether there is an association between the annual volume of patients admitted via the emergency department with sepsis and inpatient mortality.
Cross-sectional analysis of the 2007 Nationwide Inpatient Sample.
We included 87,166 adult emergency department sepsis admissions from 551 hospitals.
Hospitals were categorized into quartiles by 2007 emergency department sepsis volume. Univariate associations of patient characteristics, hospital characteristics, and inpatient mortality with sepsis volume level were evaluated by chi-square test. A population-averaged logistic regression model of inpatient mortality was used to estimate the effects of age, gender, comorbid conditions, payer status, median zip code income, hospital bed size, teaching status, and emergency department sepsis volume.
Overall inpatient sepsis mortality was 18.0% and early mortality (2 days after admission) was 6.9%. The risk-adjusted odds ratios of mortality were 0.73 (95% confidence interval, 0.64-0.83; p < .001) in quartile 4 (highest volume), 0.83 in quartile 3 (95% confidence interval, 0.74-0.93; p = .001), and 0.90 in quartile 2 (95% confidence interval, 0.82-0.99; p < .05) when compared to quartile 1 (lowest volume). Adjusted results were similar for early mortality: 0.69 (95% confidence interval, 0.61-0.76; p < .001) in quartile 4, 0.83 in quartile 3 (95% confidence interval, 0.74-0.93; p < .05), and 0.85 in quartile 2 (95% confidence interval, 0.77-0.94; p < .05) when compared to quartile 1.
After adjustment for comorbidity and hospital-level factors, there was a significant relationship between emergency department sepsis case volume and overall and early inpatient mortality among patients admitted through the emergency department with sepsis. Patients admitted to hospitals in the highest-volume quartile had 27% lower odds of inpatient mortality in this large heterogeneous sample.
Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion ...on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois.
We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression.
There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval CI 0.93-1.17). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI 1.14-1.88).
While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma.
Abstract Background Mortality differences in weekend and weekday admissions have been observed for a variety of conditions that require aggressive early intervention. It is unknown if there is a ...mortality difference that exists for patients presenting to the Emergency Department (ED) with sepsis on the weekend. Study Objectives We hypothesized that there is an increase in early inpatient mortality (death on day 1 or day 2 of hospitalization) among patients with sepsis who present to the ED on the weekend vs. weekdays. Methods We performed a cross-sectional analysis of 114,611 ED admissions with a principal diagnosis consistent with sepsis from 576 hospitals in the 2008 Nationwide Inpatient Sample. Adjusted analyses controlled for patient and hospital characteristics, and examined the likelihood of either early (day 1 or day 2 of hospitalization) or overall inpatient mortality. Results A greater proportion of patients admitted on the weekend died on day 1 and day 2 of hospitalization (5.4% vs. 4.0%, p < 0.001; and 7.5% vs. 6.9%, p = 0.001), the difference for overall inpatient mortality was not significant (17.9% vs. 17.5%, p = 0.08). The risk-adjusted odds ratio (OR) of day 1 and day 2 early inpatient mortality of weekend vs. weekday admissions was 1.10 (95% confidence interval CI 1.04–1.17) and 1.08 (95% CI 1.03–1.14), respectively; the association with overall inpatient mortality was not significant (OR 1.03, 95% CI 1.00–1.07). Conclusions Patients admitted through the ED with sepsis on the weekend had a greater likelihood of early mortality, but not overall mortality, when compared to patients admitted on weekdays.
Study objective The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment ...elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure. Methods We conducted a 2-part study: FMECA of the door-to-balloon time system and process of care, and evaluation of a single institution's door-to-balloon time operational data using a retrospective observational cohort design. A multidisciplinary group of FMECA participants described the door-to-balloon time process to then create a comprehensive map and table listing all process steps and identified process failures, including their frequency, consequence, and causes. Door-to-balloon time operational data were assessed by “on” versus “off” hours. Results Fifty-one failure points were identified across 4 door-to-balloon time phases. Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. Total door-to-balloon time during on hours had a median time of 55 minutes (95% confidence interval 46 to 60 minutes) compared with 77 minutes (95% confidence interval 68 to 83 minutes) during off hours. Conclusion The FMECA revealed clear areas of potential delay and vulnerability that can be addressed to decrease door-to-balloon time from 90 to 60 minutes. FMECAs can provide a robust assessment of potential risks and can serve as the platform for significant process improvement and system redesign for door-to-balloon time.
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