Outcomes in Vaso-Occlusive Crisis Treatment in the Emergency Department Vs. Acute Care Observation Center

I NTRODUCTION: Acute painful vaso-occlusive crises (VOC) are the leading cause of emergency department (ED) encounters and hospital admissions for those with sickle cell disease (SCD). For SCD patients, the goal of the sickle cell acute care observation unit (ACOU) at University of Illinois Health (UIH) is to improve patient outcomes by providing immediate care for an uncomplicated VOC. At our urban hospital which cares for more than 500 adult SCD patients, a considerable portion of SCD patients, despite having access to the ACOU, continue to present to the ED for treatment of an uncomplicated VOC. In order to help improve our current system, this study investigated outcomes in SCD patients who receive care for an uncomplicated VOC in the ACOU versus the ED at UIH. METHODS: By querying the electronic medical record, a retrospective study was conducted to analyze outcomes of encounters from the ACOU and ED at UIH between October 2019 and December 2019, specifically including SCD patients ≥18 years old who received morphine for treatment of an uncomplicated VOC. Encounters for complicated VOCs such as acute chest syndrome and stroke were excluded. Endpoints collected include time to first dose of morphine, total milligrams (mg) of IV morphine equivalents given, number of total morphine doses, admission rates, subsequent hospital length of stay, and 30-day inpatient admission rates. Time to the first dose (log transformed) and total dose in mg were analyzed by linear mixed effects models. The number of doses and hospitalization days were analyzed by negative binomial mixed effects model. Admissions and 30-day admissions were analyzed by logistic mixed effects models. These models adjusted for age, gender, and severe Hb genotype (HbSS or HbS beta0-thalassemia) and treated patient identity as random effect. P values were obtained from Wald- test. RESULTS: The ACOU data set contains 394 patient encounters for 79 patients with a median age of 33 years (interquartile range [IQR], 28-40), 71% female, and 73% with severe sickle genotypes. The ED data set contains 391 patient encounters for 128 patients with a median age of 30 years (IQR, 26-41), 53% female, and 74% with severe sickle genotypes. In the ACOU, the median time to first dose of morphine was 49 minutes (IQR, 39-60) compared to 107 minutes (IQR, 71-194) in the ED. The time to first dose was significantly longer in the ED compared to the ACOU (eβ=2.5, p <2×10-16). There was no significant difference in the total number of morphine doses received nor the total mg of morphine received between the two locations. Admission rate from ACOU was 6.6% compared to 53% from ED (OR=0.019, p=2x10-16). Of those admitted, the median number of hospitalization days from the ACOU was 4 days (IQR, 2.3-5.8) and 4 days (IQR, 2.0-6.5) from the ED. There was no significant difference in hospitalization days (p=0.6). The 30-day admission rate was 55% from the ACOU compared to 58% from the ED. 30-day admission rate however had strong intra-patient correlation (i.e., a patient was likely re-admitted multiple times): 44% of patients from the ACOU had admissions within 30 days of their ACOU visit compared to 32% from the ED. Controlling for the intra-patient correlation, ACOU visits had a higher 30-day admission rate than ED visit (OR=2.8, p=0.0015). DISCUSSION: SCD patients treated for an uncomplicated VOC at the sickle ACOU at UIH had a significantly shorter time to initial dose of IV pain medication. The wait time in the ED before first dose of IV pain medication received was more than double than those treated in the ACOU. Patients treated for an uncomplicated VOC in ACOU and ED had similar hospitalization days without a statistically significant difference. The 30-day admission rate to the inpatient setting was comparable for those treated in the ED versus the ACOU. However, given that only 6.6% of patients from the ACOU were admitted during the study period, this suggests that most patients who use both the ED and ACOU tend to be subsequently admitted from the ED. SCD patients may be presenting to the ED for treatment of VOC if capacity in the ACOU is exceeded or are presenting outside of hours of operation (currently 2 shifts Monday through Saturday). Therefore, improving access to our ACOU by increasing capacity and hours of operation may subsequently also lead to a decrease in time to first dose of medication and decrease in the overall 30-day admission rate. Disclosures Gordeuk: Imara: Research Funding; CSL Behring: Consultancy, Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; Novartis: Consultancy; Ironwood: Research Funding.

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Implementation of a Standard Order Set at a Sickle Cell Acute Care Observation Unit

Blood ◽

10.1182/blood-2019-130877 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3396-3396

Author(s):

Renee Cheng ◽

Rishi Patel ◽

Sandra Kang ◽

Frances Tian ◽

Xu Zhang ◽

...

Keyword(s):

Pain Management ◽

Sickle Cell Disease ◽

Length Of Stay ◽

Acute Care ◽

Sickle Cell ◽

Research Funding ◽

Mixed Effects ◽

Data Sets ◽

Cell Disease ◽

Data Set

I NTRODUCTION: Acute painful vaso-occlusive crises (VOC) in sickle cell disease (SCD) are the leading cause of emergency department (ED) encounters and frequent hospital admissions. For patients presenting with an uncomplicated VOC, acute care observation units (ACOU) have previously been shown to reduce admission rates and length of stay. We wished to evaluate if implementing a standardized acute care order set (ACOS) at the University of Illinois Hospital Sickle Cell ACOU would decrease the time to first dose of analgesic medication, inpatient hospital stays, and subsequent admissions to the ACOU. METHODS: The ACOS includes standard orders for laboratory tests to monitor severity of sickle cell hemolysis, intravenous fluids, and analgesic medications including opioids. We conducted a retrospective analysis to evaluate if the ACOS enhanced workflow and improved the timeliness of treatment in patients experiencing a VOC. The ACOS was created in April 2017 and we compiled data from the three months before (January-March 2017) and after (May-July 2017) ACOS creation. We collected data on the time it took to administer the first opioid dose, admission rate, length of stay, number of acute care visits, ED visits, and inpatient hospitalizations in a three-month span, and demographics including variations in age, gender, and sickle cell disease genotype. Patient data was collected from a pharmacy-generated list of patients who received narcotics in the ACOU during the aforementioned time period. We analyzed the effect of the ACOS on the aforementioned variables. A mixed effects linear model was used to compare time to first dose of opioids and length of stay between data sets. A mixed effects logistic model was used for binary outcomes. Covariates of age (years), gender, and severity of sickle cell hemoglobin genotype (severe: HbSS, HbS beta0 thalassemia; mild: HbSC, HbS beta+ thalassemia) were included in the models. Statistical analyses were carried out in R version 3.4.3. DISCUSSION: The pre-ACOS data set contains 291 patient encounters for 76 patients with a median age of 37 years (interquartile range [IQR], 30-47 years), 66% female, and 71% with severe genotypes. The post-ACOS data set contained 289 patient encounters for 80 patients with a median age of 32 years (IQR, 27-45 years), 80% female, and 73% with severe genotypes. Implementation of an ACOS was associated with decreased time to pain management by 3.7 minutes (p=0.077) in patients presenting with uncomplicated VOC and with fewer repeat visits to the ACOU in the studied 3-month period [OR 0.35 (95% CI 0.13-1.00), p=0.049]. The median number of opiate doses received by patients in both data sets was 3. Using 3 as a cutoff, the implementation of the ACOS was also associated with more patients receiving >3 doses of opiates [OR=1.84 (95% CI 1.05-3.19), p = 0.033]. We demonstrate that in SCD patients experiencing VOC, a standardized ACOS was associated with a trend to reducing time to receiving pain management, with increased total opioid doses during the ACOU admission (suggesting better pain control), and subsequently with a statistically significant reduction in the number of repeat ACOU visits in the studied 3-month period. We have shown that a standardized ACOS that streamlines workflow in an ACOU may play an important role in delivering timely and quality care to patients with SCD. Disclosures Gordeuk: Pfizer: Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Global Blood Therapeutics: Consultancy, Honoraria, Research Funding; Modus Therapeutics: Consultancy, Honoraria; Ironwood: Research Funding; CSL Behring: Consultancy, Honoraria, Research Funding; Imara: Research Funding; Inctye: Research Funding; Inctye: Research Funding; Pfizer: Research Funding; Emmaus: Consultancy, Honoraria; CSL Behring: Consultancy, Honoraria, Research Funding; Ironwood: Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Imara: Research Funding; Modus Therapeutics: Consultancy, Honoraria.

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Individual emergency physician admission rates: predictably unpredictable

CJEM ◽

10.1017/s1481803500011118 ◽

2009 ◽

Vol 11 (02) ◽

pp. 149-155 ◽

Cited By ~ 9

Author(s):

David Mutrie ◽

S. Kathleen Bailey ◽

Saleem Malik

Keyword(s):

Emergency Department ◽

Hospital Admissions ◽

Admission Rate ◽

Categorical Variables ◽

Full Time ◽

Emergency Physicians ◽

Data Set ◽

Admission Rates ◽

Normal Distribution Curve ◽

Time Part

ABSTRACTObjective:We sought to determine the degree and possible causes of variability in admission practices among individual emergency physicians (EPs) at 1 emergency department (ED) using a Canadian Emergency Department Triage Acuity Scale (CTAS)–matched ED patient population.Methods:We distributed a survey measuring attitudes and demographics to all EPs (n= 30) at a large regional hospital. Hospital admissions data from 1 calendar year were matched to individual EP survey results. Emergency physicians were ranked as “lower,” “average” or “higher” admitters and, using these categorical variables, the data set was analyzed for correlations and trends.Results:Overall, 97.0% of the EPs responded to the survey. Admissions by EPs ranged from 8.7% to 17.0%, (mean 12.52, standard deviation [SD] 2.21) of all patients seen. CTAS category–specific admission data demonstrated variability in the admission ranking of individual EPs. No EPs consistently performed at any 1 admission ranking across all CTAS categories. More years of emergency medicine experience was significantly correlated with higher admissions in the CTAS-2 ranking (r= 0.4,p< 0.05). Whether a physician worked full-time, part-time or as a locum was not associated with patterns of admission, nor was any particular postgraduate certification (e.g., CCFP, CCFP EM, FRCPC) or any of the surveyed attitudinal traits.Conclusion:Individual EPs' overall and CTAS-specific admissions varied substantially, and followed an approximately normal distribution curve. Emergency physicians with more years of experience had a statistically higher CTAS-2 admission rate; however, other variables, including postgraduate certification status, decision-related attitudes toward admission, and reported practices were not associated with admission proportions. Emergency physicians tend to have uniquely individual admission ranking profiles across all the CTAS categories.

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304 ED-FASU: A Novel ‘Front Door’ Multidisciplinary Service Assessing Patients with Falls and Syncope in the Emergency Department

Age and Ageing ◽

10.1093/ageing/afz103.195 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Robbie Bourke ◽

Ciara Rice ◽

Geraldine McMahon ◽

Conal Cunningham ◽

Rose Anne Kenny ◽

...

Keyword(s):

Emergency Department ◽

Pilot Study ◽

Geriatric Medicine ◽

Admission Rate ◽

Direct Access ◽

Nurse Specialist ◽

Similar Data ◽

Ambulatory Care Setting ◽

Specialist Registrar ◽

Admission Rates

Abstract Background Patients with falls/syncope/presyncope frequently present to the emergency department (ED) and many that could be managed safely in an ambulatory care setting are admitted for extensive diagnostic work-up. A pilot intervention commenced in March 2019, with direct access to specialist assessment in the ED for patients presenting with falls/syncope/presyncope, aiming to provide appropriate testing and early diagnosis to reduce unnecessary hospitalizations. This pilot study assessed the feasibility of embedding this service within the ED, as well as the effectiveness of the intervention in terms of admission avoidance. Methods The study was conducted between 25th March and 19th April 2019 in a large urban teaching hospital with a dedicated Falls & Syncope Unit and compared to similar data from March/April 2018. The core ED-FASU team comprised a consultant geriatrician, specialist registrar in geriatric medicine and clinical nurse specialist. Inclusion criteria were those of all ages, presenting with falls/syncope/presyncope/dizziness between 0800-1800 Monday-Friday. Patients were reviewed directly from triage or after referral from the ED team. Results In total, 203 patients were assessed during the pilot, an average of 10 assessments per day. The median age of those seen was 63 (58.0-67.0) years. Almost one third (57/203) were aged ≥75 years. After excluding those who were already admitted to the acute hospital and awaiting a bed when seen in the ED (n=29), 24% (41/174) of those seen were admitted to hospital. This compares to an admission rate of 33% (73/223) for the 2018 comparison group (p = 0.045). Conclusion This pilot study shows that it is feasible to embed specialist assessment for falls/syncope/presyncope in the ED. Initial pilot data suggests a significant reduction in admission rates for those seen by this service but needs to be confirmed over a more prolonged assessment period and alongside data on readmission and length of stay.

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Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

QJM ◽

10.1093/qjmed/hcaa261 ◽

2020 ◽

Author(s):

K Jusmanova ◽

C Rice ◽

R Bourke ◽

A Lavan ◽

C G McMahon ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Admission Rate ◽

Readmission Rates ◽

Specialist Service ◽

Admission Rates ◽

Potential Benefits ◽

Bed Days ◽

The Mean ◽

The Impact

Summary Background Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission. Aim To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness. Design Pre- and post-cohort study. Methods Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS). Results There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4–24.0] days compared to 18.2 (95% CI 14.6–21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030). Conclusion This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

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An Evaluation of a Modified CTAS at an Accident and Emergency Department in a Developing Country

Emergency Medicine International ◽

10.1155/2018/6821323 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

Shalini Pooransingh ◽

L. K. Teja Boppana ◽

Isaac Dialsingh

Keyword(s):

Emergency Department ◽

Admission Rate ◽

Cross Sectional Study ◽

Structural Factors ◽

Cross Sectional ◽

Admission Rates ◽

Accident And Emergency ◽

Triage Category ◽

Accident And Emergency Department ◽

Design And Methods

Objectives. To review the modified Canadian Triage and Acuity Scale used in an accident and emergency department in Trinidad and Tobago. Design and Methods. A cross-sectional study was carried out. Times from assignment of triage category to being seen by a physician were collected from the patient notes on the days of presentation and compared to the reference standards. Times from decision to admit to obtaining a bed were also recorded. Results. 200 patients were included in the study. The median waiting time for patients in the immediate/blue category was 3 minutes (range = 3); for the red category, it was 31.2 minutes (range = 121.8); in the yellow category, it was 61.8 minutes (range = 805.2). The overall admission rate was 30.5%, with an admission rate of 25% for the blue category; 20% of patients in the red category waited more than 4 hours for a hospital bed. Conclusion. The patients assigned to the blue category were being seen almost immediately. Less critical persons wait longer than the reference times and this may be due to structural factors such as staffing. The admission rates per category highlighted a low admission rate for the blue category (25%), which is unusual. This study highlights the need for a further study to review clinical presentation, assignment to triage category, and outcomes.

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Trends in Hospital Utilization for Acute Illness in a Large Population-Based Cohort of Children and Adolescents with Sickle Cell Disease (SCD): 2010–2017

Blood ◽

10.1182/blood-2018-99-120067 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 3528-3528

Author(s):

Kristina Lai ◽

Sonia Anand ◽

Maa-Ohui Quarmyne ◽

Carlton Dampier ◽

Peter A. Lane ◽

...

Keyword(s):

Sickle Cell Disease ◽

Acute Care ◽

Sickle Cell ◽

Large Population ◽

Admission Rate ◽

Acute Illness ◽

Hospital Utilization ◽

Acute Chest Syndrome ◽

Cell Disease ◽

Admission Rates

Abstract Disease severity and healthcare utilization varies widely among persons with sickle cell disease (SCD). Hydroxyurea (HU) has been demonstrated to reduce rates of pain and acute chest syndrome, the leading causes of inpatient utilization in patients with Hb SS and S β°-thalassemia in clinical trials. We recently reported that HU was clinically effective in reducing rates of pain and acute chest syndrome in patients who initiate treatment. Use of hydroxyurea in SS/S β°-thalassemia has increased markedly since 2010. Thus we sought to detemine trends of hospital utilization for acute illness during an 8 yr in which HU utilization increased markedly (2010-2017). Data from years 2010-201 were obtained from the SCD database and patient records at Children's Healthcare of Atlanta (CHOA). Utilization data were restricted to acute care admissions. Admissions for elective procedures, non-SCD related discharge diagnoses, rare SCD genotypes, and patients who had undergone bone marrow transplant were excluded. Patients were compared based on number of hospitalizations, age, sex, SCD genotype (SS/S β°-thalassemia vs Hb SC/S β+thalassemia), and discharge diagnosis. A total of 3,116 patients had at least one encounter between 2010 and 2017; 2,947 patients met inclusion criteria. From 2010-2017 the total number of active patients per year increased from 1,546 patients to 1,789 patients (+16%), while the total number acute care admissions increased from 1,295 admissions to 1,609 admissions (+24%). There were no significant differences in the proportion of patients with genotypes SS/S β° thalassemia genotypes (67.0% vs 63.9%, p=0.06). Overall patients with SS/S β° thalassemia had higher admission rates compared to SC/S β+ thalassemia patients (0.94 vs 0.57 admissions per patient per year). During the study period. overall admission rates in SCD (acute illness hospitalizations/patient/yr) increased from a low of 0.74 in 2011 to a high of 0.90 in 2017. The proportion of admissions attributed to SS/S β°-thalassemia patients decreased (79.2% in 2010 vs 72.3% in 2017, p<0.0001). However, admission rate in SC/S β+ thalassemia increased (0.53 to 0.69 admissions per patient per year). Overall, over 60% of patients were not admitted in any given year, and the proportion of patients with 0-1 admissions in a given year remained unchanged. However, the proportion of super high hospital utilizers (SHHU), patients with 8 or more admissions in a given year, increased by 185%. In 2001 this group made up 0.6% of all patients and accounted for 7.3% of admissions; in 2017 SHHU had increased 1.8% of patients and 24.3% of admissions. There was no difference in genotype or sex between SHHU and non-SHHU patients. SHHU were older (>90% of patients over age 8 years), and had greater percentages of admissions for pain and acute chest syndrome then non-SHHU. In conclusion, during a period in which HU utilization in SS/S β°-thalassemia increased significantly, hospital utilization for acute illness in SS/S β° thalassemia decreased as expected. However, during the same period there was an unexpected increase in overall hospital utilization for acute illness in SCD. This increase in hospital utilization was the result of 1) a marked increase in SHHU and 2) an overall increased utilization in SC/S β+ thalassemia. Disclosures Dampier: Pfizer: Research Funding.

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Improving Medication Timeliness in Pediatric Sickle Cell Disease Population Presenting to the Emergency Department with Vaso-Occlusive Episode

Blood ◽

10.1182/blood-2018-99-112482 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4696-4696

Author(s):

Derrick L Goubeaux ◽

Gerald Woods ◽

Valerie McDougall Kester

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Research Funding ◽

Severe Pain ◽

Pain Medication ◽

Cell Disease ◽

The Third ◽

Analgesic Therapy ◽

Order Sets ◽

Study Population

Abstract Background: Vaso-occlusive episode (VOE) is the most common acute complication for individuals with sickle cell disease (SCD) and most common reason to seek medical care. Rapid initiation of analgesia therapy, with timely subsequent doses as needed upon presenting to the emergency department (ED) for VOE are current established guidelines. Our center's initial analgesic approach aligns with NHLBI Guidelines of initial analgesic therapy within 60 minutes of registration and reassessment along with subsequent doses every 15 to 30 minutes if severe pain persists. Our center also recommends initiation of continuous infusion (CI) of pain medication within 60 minutes following third bolus dose of pain medication for those not achieving sufficient analgesia. Objective: This project's aim is to reduce time to initial dose of analgesic therapy in patients with SCD presenting to the ED with VOE to less than 60 minutes from registration in 90% of study population, decrease time interval between first and third dose of opioids to less than 60 minutes in 90% of study population, and initiate CI of pain medication within 60 minutes of third dose of opioids in 75% of individuals requiring further analgesic support. The goal is to achieve these measures within the completion of 6 monthly Plan-Do-Study-Act (PDSA) cycles. Methods: Three initial countermeasures were implemented within our institution to achieve the targeted objectives. (1) An adjustment to current ED order sets was made to include intranasal fentanyl as an initial one time option for a quicker analgesic option upon registration. (2) Another adjustment was made to the initial ED order set used upon presentation of the patient to include CI orders instead of the current system of having separate order sets for initial bolus dosing of analgesic therapy and CI order. (3) Final initial adjustment was made to change nursing prompt within the electronic medical record (EMR) for reassessment following bolus doses of pain medication; prompts were changed to every 20 minutes from every 30 minutes for the nurses with idea to better target goal of <30 minutes between doses for those who are in persistent severe pain. Results: Baseline data was obtained by retrospective chart review over a three month period. A median of 58.8% of patients were receiving an initial dose of analgesic therapy within 60 minutes of registration. Sixty minutes between first and third dose occurred in 53.8% of patients. Initiation of CI was occurring in 8.3% of patients within 60 minutes of the third dose of opioids. Over the first PDSA cycle, improvement has been noted across all 3 aims. For the initial dosing, 68% of patients were receiving within 60 minutes. Time between first and third dosing of less than 60 minutes occurred in 60% of patients. Initiation of CI within 60 minutes of the third dose is occurring in 36.3% of patients. Initial qualitative response from ED staff and nursing has been positive regarding countermeasures and care for the patients. Conclusions: This project identified the need for improvement efforts in patient care. The goal is to provide more efficient analgesic support; with these adjustments, quicker pain control can be achieved, with this leading to improvement in patient care. It is anticipated that with the eventual achievement of the aims, a decreased admission rate will be noted; for those individuals still requiring further analgesic support, it is felt faster initiation of CI will lead to quicker control of VOE and, subsequently, shorter hospitalizations. Additional countermeasures have been discussed in anticipation to adding to the current interventions to further improve the project's efforts; these ideas are currently being vetted to determine feasibility within our center and their ability to maintain the success of this project over time. Plan will be to continue to run monthly PDSA cycles for 6 months to evaluate response of timing to initial adjustments before integrating further interventions. Qualitative data will be obtained formally during quarterly meetings between hematology and ED representatives. Disclosures Woods: Global Blood Therapeutics: Research Funding; Pfizer: Research Funding; Guidepoint: Honoraria; Putman: Honoraria; Children's Mercy Hospital: Employment, Membership on an entity's Board of Directors or advisory committees.

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Frequency of Emergency Department Visits for Sickle Cell Disease Vaso-Occlusive Crisis and Its Contribution to Hospital Admission Rates

Blood ◽

10.1182/blood.v126.23.5569.5569 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5569-5569

Author(s):

Patrick Loeffler ◽

Taylor Mueller ◽

Abdullah Kutlar ◽

Robert Gibson ◽

LaShon Sturgis ◽

...

Keyword(s):

Emergency Department ◽

Sickle Cell Disease ◽

Hospital Admission ◽

Admission Rate ◽

Cell Disease ◽

Admission Rates ◽

Time Period ◽

Number Of Visits ◽

The Difference ◽

First Time

Abstract Background: Patients with sickle cell disease (SCD) vaso-occlusive crisis (VOC) frequently seek care in the emergency department (ED). To improve and increase consistency of care patients with uncomplicated VOC, are treated in the Emergency Department Observation Unit (EDOU) where they are treated with an individualized protocol-based pathway. EDOUs have been shown to be effective in meeting treatment guidelines and reducing hospital admission. Objective: This study examines the admission rates of individuals with SCD stratified by frequency of presentation at the EDOU. Methods: A retrospective review of an ED database was completed to explore the relationship between EDOU utilization and admission rate for patients with uncomplicated VOC. All patient records meeting pathway inclusion criteria for uncomplicated VOC during the time period September 2013 through May 2015 were included in the study. Visits were first associated with individual patients. Then, based on the number of visits per time period, patients were categorized as high users, moderate users, or low users. Categorization was done using the number of visits during the first, 12-month period (9/11/13 - 9/10/14), or the second, nine-month period (9/10/14 - 5/31/15). Adaptations to the categorization scheme for the nine-month time period were as follows. Low users were patients that had no more than one visit in either the first or second time period; moderate users were patients with two or three visits in the first time period or two visits in the second; high users were patients with four or more visits in the first time period, or three or more visits in the second time period. Admission rates were calculated as percentages of visits to the EDOU. Rates of admission for high, middle, and low users were compared using an unpaired, one-tailed Student's t-test. This study was approved by expedited review by the institution's Institutional Review Board (IRB). Results: A total of 727 visits for 154 patients were included in the analysis. High users (n=44) had a total of 539 visits and an average patient admission rate of 22% (n=118). Moderate users (n=49) had a total of 108 visits and an admission rate of 31% (n=33). Low users (N=61) had a total of 80 visits and an admission rate of 36% (n=29). The difference between the number of high user admissions and low user admissions was significant (p<0.01) as was the difference between the number of moderate-user visits and the number of high-user visits (p=0.04). The difference between the number of moderate and low user admissions was not significant (p=0.14). Conclusion: This study found that the difference in the number of admissions between high and low users and between high and moderate users was significant. The findings provide support for the value of the EDOU in reducing unnecessary hospital admissions. These findings also raise important questions regarding the phenotypic expression of pain in SCD and the availability of care. Although the criteria for categorization of patients in this study was limited and the time periods unequal the results suggest different patterns of personal response to pain and treatment seeking. It is unknown how these groups may be different in regards to access to care, treatment preferences, self-care practices, or severity of disease. It can be hypothesized from these results that there may be two different patterns of care seeking with some patients only using the EDOU when crisis is severe (low users) and other patients (high users) using the EDOU as part of their regular pain treatment strategy. To address these questions it is necessary to further examine the differences between these groups to look for explanations that can address increased utilization of the EDOU among some patients. Disclosures No relevant conflicts of interest to declare.

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152 Implementation of Older Persons Rapid Assessment Hub (OPRAH) in the Emergency Department (ED)

Age and Ageing ◽

10.1093/ageing/afz103.89 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Comfort Adedokun ◽

Rosa McNamara ◽

Nessa O’Herlihy

Keyword(s):

Older Adults ◽

Emergency Department ◽

Older People ◽

Rapid Assessment ◽

Admission Rate ◽

Clinical Decision ◽

Admission Rates ◽

Clinical Decision Unit ◽

Medical Referral ◽

The Impact

Abstract Background The Emergency Department (ED) is where most people, including older adults in crises, seek care. OPRAH was introduced in order to meet the needs of our changing population. The unit was developed out of existing resources within the ED and cohorts both older patients and staff to an area more suitable to carry out assessments. Methods We used a quality improvement framework to develop our service. OPRAH is led by an ED GEM (Geriatric Emergency Medicine) consultant, staffed using the existing ED team, housed within footprint of the ED as part of the Clinical Decision Unit (CDU) with the addition of an HCA (healthcare assistant) as required. To determine the impact of the service on admissions of older adults, we collated patient records prospectively. These were reviewed and coded by senior ED professionals blinded to outcomes, to determine medical-referral rate for admission in these cohort. Results In the first 3 weeks of implementation, 76 patients were assessed. Four were admitted and 2 transferred to other hospitals. Mean age was 83 years ranging 66-103 years with an average of 262 minutes in the ED prior to OPRAH admission. Blinded coders review determined 53 (76%) of these patients would have been referred for admission. The majority of the remainder would have completed their care in the ED, as they were not eligible for admission to CDU. Conclusion Introduction of OPRAH to the ED has improved access for older people to short-stay ED led care and reduced admission rates. We have identified a trend towards fewer episodes where care by in-house teams is completed within the ED. We are in an early phase of this project. Nonetheless, it is evident that by redesigning how we assess older people in the ED and using available outpatient resources, we could impact on admission rate and length of stay in the ED without compromising patient care. Implementation has increased the use of the integrated care team, hospital and community MDT (multidisciplinary team).

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Modelling and localizing a stem taper function for Pinus radiata in Spain

Canadian Journal of Forest Research ◽

10.1139/cjfr-2014-0276 ◽

2015 ◽

Vol 45 (6) ◽

pp. 647-658 ◽

Cited By ~ 18

Author(s):

Manuel Arias-Rodil ◽

Ulises Diéguez-Aranda ◽

Francisco Rodríguez Puerta ◽

Carlos Antonio López-Sánchez ◽

Elena Canga Líbano ◽

...

Keyword(s):

Random Effects ◽

Pinus Radiata ◽

Mixed Model ◽

Mixed Effects ◽

Stem Diameter ◽

Mixed Effects Models ◽

Stem Volume ◽

Diameter Measurement ◽

Data Set ◽

Taper Function

The parsimonious taper function proposed by Riemer et al. (1995. Allg. Forst.- Jagdztg. 166(7): 144–147) was fitted for radiata pine (Pinus radiata D. Don) stems in Spain by using a nonlinear mixed modelling approach. Eight candidate models (all possible expansion combinations of the three fixed parameters with random effects) were assessed, and the mixed model with three random effects performed the best according to the goodness-of-fit statistics. An evaluation data set was used to assess the performance of these models in predicting stem diameter along the bole, as well as total stem volume. Four prediction approaches were compared: one subject (tree) specific (SS) and three population specific (ordinary least squares (OLS), mean (M), and population averaged (PA)). The SS responses for a tree were estimated from a prior stem diameter measurement available for that tree, whereas OLS, M, and PA were obtained from the fixed-effects model, from the fixed parameters of mixed-effects models, and by computing mean predictions from the mixed-effects models over the distribution of random effects, respectively. Prediction errors were greater for the M and PA responses than for the OLS response, and therefore, from the prediction point of view, the use of the mixed-effects models is not recommended when an additional stem diameter measurement is not available. The mixed model with three random effects was also selected as the best model for SS estimations. Measurement of an additional stem diameter at a relative tree height of approximately 0.5 provided the best calibrations for stem diameters along the bole and total stem volume predictions. The SS approach increased the flexibility and efficiency of the selected mixed-effects model for localized predictions and thus improved the overall predictive capacity of the base model.

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