Canadian ERs Use Less Pediatric Diagnostic Imaging Than US Interview with:

Eyal Cohen, MD, M.Sc, FRCP(C)Professor, PediatricsUniversity of TorontoCo-Founder, Complex Care ProgramThe Hospital for Sick Children

Dr. Cohen

Eyal Cohen, MD, M.Sc, FRCP(C)
Professor, Pediatrics
University of Toronto
Co-Founder, Complex Care Program
The Hospital for Sick Children What is the background for this study?

Response: Minimizing care that provides little benefit to patients has become an important focus to decrease health care costs and improve the quality of care delivery.  Diagnostic imaging in children is a common focus for campaigns designed to reduce overuse both in Canada and the US. There are some suggestions that there may be more overuse of care in the United States than Canada, but there has been little study in children.

We compared the use of low-value diagnostic imaging rates from four pediatric emergency departments in Ontario to 26 in the United States from 2006 to 2016.  We defined low-value imaging as situations where children are discharged from an emergency department with a diagnosis for which routine use of diagnostic imaging may not be necessary, like asthma or constipation.  Continue reading

What Kinds of Errors Are Made in Emergency Rooms? Who is Most Vulnerable? Interview with:

Benjamin H. Schnapp, MD BerBee Walsh Department of Emergency Medicine Assistant Professor (CHS) Assistant Emergency Medicine Residency Program Director University of Wisconsin

Dr. Schnapp

Benjamin H. Schnapp, MD
BerBee Walsh Department of Emergency Medicine
Assistant Professor (CHS)
Assistant Emergency Medicine Residency Program Director
University of Wisconsin What is the background for this study? What are the main findings?

Response: Medical errors harm thousands of patients per year.  There’s already a lot we know about systems errors – the ways that care delivery can go wrong.  We know less about cognitive errors, or the ways in which doctors think that can lead to bad outcomes.  An Emergency Department can feel particularly vulnerable to this type of errors – it’s a chaotic environment with patients in various states of illness, many unaccompanied, without records, or too ill to communicate well.

An Emergency Department with trainee physicians can feel even more chaotic – even though they are supervised by staff physicians, resident physicians in their first few months to years of training have not yet accumulated the same level of knowledge and experience as longer-tenured doctors.  Errors that get made on the hospital floor are errors of information processing – physicians have the right information, they just don’t always do the right thing with it.  We wanted to know what kinds of errors get made in an Emergency Department with trainees.  Are the errors related to the chaos and an inability to obtain reliable information from patients?  Are they related to the trainees not having enough knowledge and experience?  Or are they like the errors that get made on an inpatient floor?

Our study found that the most frequent type of errors were errors of information processing – just like on the hospital floors.  The most common types of errors we saw were physicians settling on a diagnosis prematurely and weighing the importance of findings incorrectly. Patients with abdominal problems had the highest number of errors in our study.  Patients with certain risk factors, such as psychiatric disease or substance abuse, seemed to be particularly prone to errors.

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Teaching Hospitals See Largest Number of Homeless Emergency Room Patients Interview with:

Ruirui Sun, Ph.D. AHRQ

Dr. Sun

Ruirui Sun, Ph.D.
AHRQ What is the background for this study?

Response: Homeless people are more likely than the members of the general public to use emergency department (ED) services, and it is usually at teaching hospitals when they seek medical care (Kushel et al., 2001; Bowdler and Barrell, 1987). This Healthcare Cost and Utilization Project (HCUP) Statistical Brief studies patient characteristics, insurance coverage and clinical profile of the ED visits among homeless individuals by hospital teaching status, during 2014 from eight States (AZ, FL, GA, MA, MD, MO, NY, and WI).

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Over One Million Stair-Related Injuries Treated in ERs Each Year Interview with:

Gary Smith, MD, DrPH Director, Center for Injury Research and Policy Nationwide Children’s Hospital Columbus, OH

Dr. Smith

Gary Smith, MD, DrPH
Director, Center for Injury Research and Policy
Nationwide Children’s Hospital
Columbus, OH What is the background for this study?

Response: Previous studies have documented the frequency and characteristics of stair-related injuries among children and older adults. Numerous studies have examined gait characteristics of different age groups and their relationship to falls. In addition, it is estimated that the direct medical and indirect costs of non-fatal stair-related injuries are $92 billion annually in the US.

The current study investigates the epidemiological characteristics of stair-related injuries among all ages using a nationally representative sample over a multi-year period. Our study also expands upon prior research on this topic to investigate the mechanisms of stair-related injuries and examine trends.

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Youth With Autism Use Emergency Rooms At Markedly Increased Rate Interview with:

Guodong Liu, PhD  Assistant Professor Division of Health Services and Behavioral Research Department of Public Health Sciences, A210 Penn State University College of Medicine Hershey, PA 17033

Dr. Guodong Liu

Guodong Liu, PhD 
Assistant Professor
Division of Health Services and Behavioral Research
Department of Public Health Sciences, A210
Penn State University College of Medicine
Hershey, PA 17033 What is the background for this study? What are the main findings?

Response: Adolescents with autism spectrum disorder (ASD) use emergency department services four times as often as their peers without autism, according to Penn State College of Medicine researchers. The findings suggest that youth with autism may need better access to primary care and specialist services. What should readers take away from your report?

Response: Although there was no significant increase in autism rates among adolescents in the study over the nine-year period, emergency department use in adolescents with autism increased five-fold, from 3 percent in 2005 to 16 percent in 2013. During the same time period, emergency department use in adolescents without an autism diagnosis remained steady at around 3 percent.  there could be a link between this underutilization of preventive care services and overuse of emergency department services.

On average, adolescents with autism had a four-time higher risk of visiting the emergency department than adolescents without ASD.  Older adolescents with autism also visited the emergency department more often than their younger counterparts. A third of middle and late adolescents in this group had medical emergencies, compared to just one-tenth of early adolescents.  Females and individuals living in rural areas were more likely to visit the emergency room than males and those living in urban areas. What recommendations do you have for future research as a result of this study?

Response: We want to see more data on adolescents with ASD to confirm his findings. We are planning a similar study of emergency department use in adolescent Medicaid patients with autism. Our goal is to plot an unbiased nationally representative picture of how this special population fares in terms of their emergency department usage and, in related work, hospitalizations.

We are also searching for modifiable factors that could be addressed to reduce emergency visits and resulting hospitalizations in adolescents with autism. Is there anything else you would like to add?

Response: These Young ASD patients need to be actively taken care of and monitored. There should be better communication between these adolescents and their caregivers and with their regular pediatricians and specialists. If we can do those kinds of things we may help them have less frequent emergencies. This study was published by the Journal of Autism and Developmental Disorders.

I have no disclosures.

Lead author: Dr. Guodong Liu, assistant professor of public health sciences, Penn State University College of Medicine.

Other researchers on this study were Amanda M. Pearl, PhD and Michael J. Murray, MD, Department of Psychiatry; Lan Kong, PhD, Division of Biostatistics and Bioinformatics, Department of Public Health Sciences; and Douglas L. Leslie, PhD, Division of Health Services and Behavioral Research, Department of Public Health Sciences, all at Penn State College of Medicine.

Penn State College of Medicine Junior Faculty Development Program funded this research. Thank you for your contribution to the community.


Guodong Liu, Amanda M. Pearl, Lan Kong, Douglas L. Leslie, Michael J. Murray. A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 2016; 47 (2): 347 DOI: 10.1007/s10803-016-2953-8

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Uninsured Kids More Likely To Be Transferred From Emergency Departments Interview with:

Yunru Huang Ph.D. Candidate in epidemiology Department of Pediatrics University of California Davis, Sacramento, CA

Yunru Huang and Dr. James Marcin (left)

Yunru Huang
Ph.D. Candidate in epidemiology
Department of Pediatrics
University of California
Davis, Sacramento, CA What is the background for this study?

Response: Each year, more than 27 million children seek care in emergency departments (EDs) in the United States. Many EDs, however, are not fully equipped with the recommended pediatric supplies and may not have access to the pediatric specialists and resources needed to provide definitive care. As a result, many children receiving treatment in EDs of hospitals with limited pediatric resources are transferred to another hospital’s ED or inpatient unit for admission.

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to make decisions on patient transfer and admission independent of insurance status. That is, the decision to transfer a patient to another hospital for admission should only depend upon clinical factors or the need for specialty services. However, patterns observed in the medical literatures have suggested that a child’s insurance status could be associated with transfer and admission decisions. These studies have been limited to single institutions and/or have been limited to specific conditions._ENREF_14 Whether or not transfer decisions among pediatric patients are related to insurance status has yet to be studied on a national level and across a variety of diagnoses.

We used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample data and sought to investigate the relationships between insurance status and odds of transfer relative to local admission among pediatric patients receiving care in the ED.

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Nurse-Initiated Protocols Can Improve Timeliness of Care in an Urban Emergency Department Interview with
Mathew Douma, RN BSN ENC(C) CNCC(C)
Emergency Department, Royal Alexandra Hospital
Edmonton, Alberta, Canada; Masters of Nursing Student
University of Toronto, Toronto What is the background for this study?

Response: Many emergency departments experience crowding, which is typically defined as a situation where demands for service exceed the ability of the emergency department to provide quality care in a timely fashion. Typically when patients are waiting in a waiting room they do not undergo diagnostics or treatments. In an effort to speed the process up and reduce the amount of time the patient spends in the emergency department, some facilities have created protocols for diagnostics or treatments typically outside the traditional scope of practice of nursing staff.

Our emergency department had protocols like this for almost 15 years, though we had never evaluated their effectiveness. So an interdisciplinary group in our emergency department updated them and then we set out to evaluate them.

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ER Visits For Hypertension Common and Increasing

Candace D. McNaughton,

Dr. McNaughton Interview with:
Candace D. McNaughton, MD MPH FACEP
Assistant Professor
Emergency Medicine Research
Department of Emergency Medicine, Research Division
Vanderbilt University Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. McNaughton: Hypertension, or high blood pressure, affects 1/3rd of adults in the United States and more than 1 billion people worldwide.  It is also the #1 risk factor for cardiovascular disease such as heart attack and stroke, so it is very important to treat.

The burden of hypertension in the emergency department is not well understood.  The ER is not usually thought of as a place where perhaps we could or should be addressing hypertension; that has traditionally be left up to primary care providers. Through this study, our goals were to gain a better understanding of how many ER visits were either related to hypertension or were solely because of hypertension, and to determine whether this changed from 2006 to 2012.

We found that emergency room visits related to or solely for hypertension were common and that they both rose more than 20% from 2006 to 2012. Visits to the emergency department specifically for hypertension were more common among patients who were younger, healthier, and less likely to have health insurance. Despite increases in the number of ER visits related to hypertension, the proportion of patients who were hospitalized did not increase; this suggests that doctors in emergency departments may be more aware of hypertension and/or may be managing it without having to hospitalize patients.
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ACA May Result In More Patients Using Emergency Rooms For Primary Care Interview with:
Alexander Janke BS

School of Medicine at Wayne State University

Medical Research: What is the background for this study? What are the main findings?

Response: Health insurance by itself does not guarantee quality healthcare; patients need accessible primary care options. Without them, patients newly-enrolled in health insurance may not be able to enjoy the benefits of preventive care and chronic disease management that primary care can provide.

In a new study, Wayne State University School of Medicine researchers have found that patients newly-enrolled in health insurance may not be able to access primary care, and may instead rely on the emergency department (ED) for care

Alexander T. Janke, lead author on a new study, said, “Increasing insurance enrollment under the Affordable Care Act is likely to draw attention to problems with patients’ access to primary care providers. Patients may be diverted to our nations emergency departments. This will likely contribute to a pattern of inefficient healthcare spending, as most emergency department s are not currently well-equipped to provide for patients’ full range of healthcare needs. At the same time, this provides an opportunity to rethink the role of acute care in the United States.”

This is the first population-level study to demonstrate newly-enrolled patients’ propensity for lack of access-based ED utilization. In the wake of the Affordable Care Act, emergency departments will need to evolve into outlets that service a wider range of healthcare needs rather than function in their current capacity, which is largely to address acute issues in isolation.


Access to Care Issues and the Role of Emergency Departments in the wake of the Affordable Care Act

Alexander T. Janke | Aaron M. Brody | Daniel L. Overbeek | Justin C. Bedford | Robert D. Welch | Phillip D. Levy
The American Journal of Emergency Medicine
Published Online: November 13, 2014



Emergency Room Prescriptions for Opioid Pain Medications Markedly Increase

Maryann Mazer-Amirshahi PharmD, Interview with:
Maryann Mazer-Amirshahi PharmD, MD
The Department of Emergency Medicine, The George Washington University
The Department of Clinical Pharmacology, Children’s National Medical Center, Washington, DC What are the main findings of the study?

Answer: We found a significant increase in the prescribing of opioid pain medications in the emergency department. At the same time, this was not accounted for by a similar increase in pain-related visits and prescribing patterns of non-opioid analgesics did not change.

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Emergency Room Visits for Insulin-Related Hypoglycemia

Andrew I. Geller, MD Medical Officer in the Division of Healthcare Quality Promotion at Interview with:
Andrew I. Geller, MD
Medical Officer in the Division of Healthcare Quality Promotion at CDC. What are the main findings of the study?

Dr. Geller: Using CDC’s national medication safety monitoring system, we estimated that, each year, there were about 100,000 visits made to U.S. emergency departments (EDs) for insulin-related hypoglycemia and errors during 2007-2011, or about half a million ED visits over the 5-year study period.  This is important because many of these ED visits for insulin-related hypoglycemia may be preventable.

We also found these ED visits were more common with increasing age:  every year, 1 in 49 insulin-treated seniors (aged 65 years or older) visited the ED because of hypoglycemia while on insulin or because of a medication error related to insulin. Among the very elderly (aged 80 years or older), this number was 1 in 8 annually.
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ER Visits, EMS Calls Fell with Paramedics Visits to Senior Centers

Dr. Gina Agarwal Assistant Professor Department of Family Medicine McMaster Family Practice 690 Main Street West Hamilton , Ontario L8S Interview with:
Dr. Gina Agarwal
Assistant Professor Department of Family Medicine
McMaster Family Practice
690 Main Street West
Hamilton , Ontario L8S 1A4 What are the main findings of the study?

Dr. Agarwal: The study findings are just preliminary as of yet, but suggest that the CHAP-EMS program is potentially a feasible and effective health program for seniors housing buildings in urban areas. The program delivered tailored health risk assesments to seniors living in subsidized city housing, also assessing their risk of cardiovascular disease, diabetes and falls using validated tools. Paramedics were trained in how to assess, and deliver risk assessment results and then provide community resource information. Seniors attending the program could drop in any time and were encouraged to come back for follow up sessions. Results of each attendance were forwarded to family doctors to close the loop.

At the 5th month of implementation, we have recorded 241 participant visits by 40 unique participants; 37 had 2 or more visits; 70% had elevated BPs initially; 77.8% of those previously diagnosed hypertensive and 55.8% of those undiagnosed hypertensive had elevated BP; 82.5% had moderate to high CANRISK scores. Preliminary data shows a 32% reduction in EMS calls.

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Patterns of Emergency Medical Services Use and Its Association With Timely Stroke Treatment: Findings From Get With the Guidelines-Stroke eInterview with with Dr. O. James Ekundayo, MD, DrPH

Assistant Professor
Department of Family & Community Medicine
Meharry Medical College 1005 Dr. D.B. Todd Jr. Blvd.
Nashville, TN 37208

Written Interview conducted with author by Editor Marie Benz, MD What are the main findings of the study?

Answer: The key findings are:

·         One third of stroke patients did not activate Emergency Medical Services (EMS).

·         Subgroups of patients who were less likely to use EMS include younger patients, patients of minority race or ethnicity, and those living in rural communities.

·         Prior history of stroke /TIA does not confer greater likelihood of EMS activation during subsequent stroke.

·         Patients who used EMS had shorter pre-hospital and in-hospital delay. They arrived early, had prompter evaluation, and received more rapid treatment.

·         More patients, who were eligible for clot-busting drug, received them.

These happened because EMS gives the receiving hospital pre-notification about the arrival of the patient and the ER staff is ready to act as soon as the patient arrives.
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Effects of obesity on patient experience in the emergency department eInterview with Professor David McDonald Taylor
Emergency Department, Austin Health
PO Box 5555, Heidelberg, Vic. 3084, Australia What are the main findings of the study?

Answer: Overall, obese and non-obese patients have similar experiences during their ED stay. However, while obese patients tend to be younger and less sick, their more frequent presentation with potentially cardiac-related disease is reflected in their management. The excess of liver function tests and abdominal xrays performed on obese patients is likely to reflect examination difficulties and over investigation. Obese patients do experience more attempts at IV cannulation.
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