Nonfatal Injuries Among the Elderly Treated in Hospital Emergency Departments

Objectives: To characterize nonfatal injuries in the elderly treated in U.S. hospital emergency departments (EDs) during 2000 and 2001, and to model which characteristics are most highly associated with hospitalization as an outcome. Methods: This was a retrospective, cross-sectional study. Data were analyzed from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AlP). NEISS-AIP is operated by the U.S. Consumer Product Safety Commission and sponsored by the Centers for Disease Control and Prevention. It provides data on roughly 500,000 injury-related ED cases each year, representing approximately 31 million injuries. These data are drawn from a nationally representative sample of 66 NEISS-AlP hospitals, which were selected as a stratified probability sample of hospitals with a minimum of six beds and a 24-hour ED in the U.S. and its territories. Data from these cases were weighted by the inverse of the probability of selection to provide national estimates. Annualized estimates were based on weighted data for 36,752 nonfatal injuries among the elderly treated in EDs during January-December 2001 and 17,605 nonfatal injuries during July-December 2000. 2001 NEISS-AlP data were utilized to arrive at injury rates while 2000 NEISS-AIP data were utilized in bivariate and multivariate logistic regression modeling. U.S. Census Bureau population estimates for 2001 were utilized in order to arrive at injury rates. A direct variance estimation procedure was used to calculate 95% confidence intervals. Nonfatal injuries were defined as bodily harm resulting from acute exposure to an external force or substance, including unintentional and violence-related causes. Cases were excluded from this analysis if 1) the person was less than 65 years old or of unknown age; 2) the principal diagnosis was for a (a) non-injury illness, (b) pain only illness, or (c) unknown; and 3) the ED visit represented a fatality. Deaths were excluded from the analysis because they are not captured completely by NEISS-AIP. Ail injuries were classified according to the mechanism of injury, disposition, diagnosis, primary body part injured, location, and intent. Results: During 2001, an estimated 935,556 males and 1,731,640 females ages ≥ 65 were treated in EDs for nonfatal injuries. This represented 5.7% of all nonfatal injuries for males and 13.3% of all nonfatal injuries for females across all ages. The overall injury rate per 100,000 persons was higher among females (8,466) than males (6,404). The injury rate also increased with each higher age bracket for both females and males until it reached a rate of 15,272 for females ages ≥ 85 and 11,547 for males ages ≥ 85. Compared to all other mechanisms, falls caused the highest rates of injuries by far across this population (4,684); however, this mechanism of injury was disproportionately represented among females (67.1%) more than males (50.5%) (P < 0.0001). Yet, males had higher percentages of other causes of nonfatal injury, including being struck by or against (11.2% vs. 7.7%, P < 0.0001), occupying a motor vehicle (9.2% vs. 6.5%, P < 0.0001), and being cut or pierced (7.2% vs. 2.7%, P < 0.0001). Most injuries among the elderly were diagnosed as fractures (25.2%) or contusions/abrasions (23.2%) while the parts of the body typically affected were the head/neck (25.8%) or arms/hands (21.7%). Many nonfatal injuries among the elderly occurred in the home (47.8%). The majority of patients were treated and then released (82.5% ), although an important number were also hospitalized (15.1 %). Those characteristics for which hospitalization as an outcome were more highly associated include: older age groups (OR= 2.00 for those ages ≥ 85, P < 0.001); males (OR= 1.25 compared to females, P < 0.001); being a motor vehicle occupant (OR= 9.12, P < 0.001); having a hemorrhage (OR= 54.22, P < 0.001), concussion (OR= 30.06, P < 0.001), or fracture (OR= 25.66, P < 0.001); and self-harm (OR= 12.22, p < 0.001). Discussion: Injuries are generally considered a problem of the young. Consequently, not as much attention has been focused on injuries in the elderly population. While it is true that injuries do not account for as many fatalities when compared to other causes of death among senior Americans (8th leading cause in 2000 when grouping intentional and unintentional injuries together for ages ≥ 65), the rate for nonfatal injuries among this population is actually quite comparable to rates among younger age groups. In fact, starting around age 65, the rates for nonfatal injuries begin to increase again after having steadily declined after the late-20s, peaking as high as 14,141 per 100,000 persons among the ≥ 85 population. This was similar to the nonfatal injury rate in the 25-29 (13,925) or 10-14 (13,252) age groups. Other important findings included the disparities between male and female injury rates and patterns, the rate of hospitalization after a nonfatal injury among the elderly (1,217) was much higher than any younger age group, and the characteristics for which hospitalization as an outcome are more highly associated. These data establish that injuries are a significant public health problem among elderly Americans.Master of Public Healt

Effect of Testing and Treatment on Emergency Department Length of Stay Using a National Database

Objectives:  Testing and treatment are essential aspects of the delivery of emergency care. Recognition of the effects of these activities on emergency department (ED) length of stay (LOS) has implications for administrators planning efficient operations, providers, and patients regarding expectations for length of visit; researchers in creating better models to predict LOS; and policy‐makers concerned about ED crowding. Methods:  A secondary analysis was performed using years 2006 through 2008 of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide study of ED services. In univariate and bivariate analyses, the authors assessed ED LOS and frequency of testing (blood test, urinalysis, electrocardiogram [ECG], radiograph, ultrasound, computed tomography [CT], or magnetic resonance imaging [MRI]) and treatment (providing a medication or performance of a procedure) according to disposition (discharged or admitted status). Two sets of multivariable models were developed to assess the contribution of testing and treatment to LOS, also stratified by disposition. The first was a series of logistic regression models to provide an overview of how testing and treatment activity affects three dichotomized LOS cutoffs at 2, 4, and 6 hours. The second was a generalized linear model (GLM) with a log‐link function and gamma distribution to fit skewed LOS data, which provided time costs associated with tests and treatment. Results:  Among 360 million weighted ED visits included in this analysis, 227 million (63%) involved testing, 304 million (85%) involved treatment, and 201 million (56%) involved both. Overall, visits with any testing were associated with longer LOS (median = 196 minutes; interquartile range [IQR] = 125 to 305 minutes) than those with any treatment (median = 159 minutes; IQR = 91 to 262 minutes). This difference was more pronounced among discharged patients than admitted patients. Obtaining a test was associated with an adjusted odds ratio (OR) of 2.29 (95% confidence interval [CI] = 1.86 to 2.83) for experiencing a more than 4‐hour LOS, while performing a treatment had no effect (adjusted OR = 0.84; 95% CI = 0.68 to 1.03). The most time‐costly testing modalities included blood test (adjusted marginal effects on LOS = +72 minutes; 95% CI = 66 to 78 minutes), MRI (+64 minutes; 95% CI = 36 to 93 minutes), CT (+59 minutes; 95% CI = 54 to 65 minutes), and ultrasound (US; +56 minutes; 95% CI = 45 to 67 minutes). Treatment time costs were less substantial: performing a procedure (+24 minutes; 95% CI = 20 to 28 minutes) and providing a medication (+15 minutes; 95% CI = 8 to 21 minutes). Conclusions:  Testing and less substantially treatment were associated with prolonged LOS in the ED, particularly for blood testing and advanced imaging. This knowledge may better direct efforts at streamlining delivery of care for the most time‐costly diagnostic modalities or suggest areas for future research into improving processes of care. Developing systems to improve efficient utilization of these services in the ED may improve patient and provider satisfaction. Such practice improvements could then be examined to determine their effects on ED crowding.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/92123/1/j.1553-2712.2012.01353.x.pd

A latent variable approach to potential outcomes for emergency department admission decisions

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151329/1/sim8210.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151329/2/sim8210_am.pd

Validation of a tool predicting important findings on computed tomography among Crohn’s disease patients

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166167/1/ueg2bf00677.pd

Categorization, Designation, and Regionalization of Emergency Care: Definitions, a Conceptual Framework, and Future Challenges

This article reflects the proceedings of a breakout session, “Beyond ED Categorization—Matching Networks to Patient Needs,” at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Emergency Care.” It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.ACADEMIC EMERGENCY MEDICINE 2010; 17:1306–1311 © 2010 by the Society for Academic Emergency MedicinePeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79324/1/j.1553-2712.2010.00932.x.pd

Important Historical Efforts at Emergency Department Categorization in the United States and Implications for Regionalization

This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, “Beyond ED Categorization—Matching Networks to Patient Needs,” at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Emergency Care.” The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes.ACADEMIC EMERGENCY MEDICINE 2010; 17:e154–e160 © 2010 by the Society for Academic Emergency MedicinePeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79214/1/j.1553-2712.2010.00931.x.pd

Variation in practice patterns among specialties in the acute management of atrial fibrillation

Abstract Background Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center. Methods A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference. Results There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians. Conclusions Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.http://deepblue.lib.umich.edu/bitstream/2027.42/110777/1/12872_2015_Article_9.pd