Nonprice Barriers to Ambulatory Care After an Emergency Department Visit

Study objective: Availability of timely follow-up care is essential in emergency medicine. We describe nonprice barriers to care experienced by callers reporting to be emergency department (ED) patients in need of follow-up care. Methods: This was a secondary analysis of data collected during a survey of ambulatory clinics in 9 US cities. Research assistants called a random sample of 603 ambulatory clinics, generated from actual ED referral lists. Callers identified themselves as new patients referred by the local ED. Outcome measures were the percentage of callers experiencing failed appointment attempts for a variety of reasons and inconvenience factors associated with the appointment process: number and amount of time spent on hold, voicemail, repeated calls, and total telephone time. Results: Only 242 (23%) of 1065 total calls resulted in an appointment within one week, for an ultimate caller success rate of 40% (242/603 pseudopatient scenarios). Independent of insurance status, 43% of 603 initial calls to ED referral numbers were unsuccessful: 27% of initial call failures were due to clinic closures, busy signals, voicemail, or personnel too busy to take the call; 6% wrong numbers; 4% disconnected or extended holds; and 6% out of practice scope. If they reached clinic personnel, 55% of callers were placed on hold; average hold time was 2.43 minutes (median 1.35 minutes). Answering system time averaged 1.17 minutes (median 0.68 minutes; range 0.02 to 13.90 minutes). On average, it required 1.7 calls to reach appointment staff and 8% of clinic contacts required 4 or more attempts. Total telephone time averaged 11.1 minutes for successful appointments. Conclusion: There are important nonprice barriers to obtaining follow-up appointments for urgent conditions, independent of insurance status

Resuscitating the Physician-Patient Relationship: Emergency Department Communication in an Academic Medical Center

Study objective: We characterize communication in an urban, academic medical center emergency department (ED) with regard to the timing and nature of the medical history survey and physical examination and discharge instructions. Methods: Audiotaping and coding of 93 ED encounters (62 medical history surveys and physical examinations, 31 discharges) with a convenience sample of 24 emergency medicine residents, 8 nurses, and 93 nonemergency adult patients. Results: Patients were 68% women and 84% black, with a mean age of 45 years. Emergency medicine providers were 70% men and 80% white. Of 62 medical history surveys and physical examinations, time spent on the introduction and medical history survey and physical examination averaged 7 minutes 31 seconds (range 1 to 20 minutes). Emergency medicine residents introduced themselves in only two thirds of encounters, rarely (8%) indicating their training status. Despite physician tendency (63%) to start with an open-ended question, only 20% of patients completed their presenting complaint without interruption. Average time to interruption (usually a closed question) was 12 seconds. Discharge instructions averaged 76 seconds (range 7 to 202 seconds). Information on diagnosis, expected course of illness, self-care, use of medications, time-specified follow-up, and symptoms that should prompt return to the ED were each discussed less than 65% of the time. Only 16% of patients were asked whether they had questions, and there were no instances in which the provider confirmed patient understanding of the information. Conclusion: Academic EDs present unique challenges to effective communication. In our study, the physician-patient encounter was brief and lacking in important health information. Provision of patient-centered care in academic EDs will require more provider education and significant system support

Using a pacifier to decrease sudden infant death syndrome: an emergency department educational intervention

Background. Pacifier use decreases the risk of sudden infant death syndrome (SIDS). An emergency department (ED) visit may provide an opportunistic ‘teachable moment’ for parents.Objectives. To test the hypotheses (1) that caregivers were less familiar with the role of pacifiers in sudden infant death (SIDS) prevention than other recommendations, and (2) that an ED educational intervention would increase pacifier use in infants younger than six months, and (3) that otitis media would not occur more frequently in pacifier users.Methods. We did an intervention-group-only longitudinal study in a county hospital ED. We measured pacifier use infants and baseline knowledge of SIDs prevention recommendations in caregivers. We followed up three months later to determine pacifier use, and 12 months later to determine episodes of otitis media.Results. We analyzed data for 780 infants. Parents knew of advice against co-sleeping in 469/780 (60%), smoking in 660/776 (85%), and prone sleeping in 613/780 (79%). Only 268/777 (35%) knew the recommendation to offer a pacifier at bedtime. At enrollment 449/780 (58%) did not use a pacifier. Of 210/338 infants aged less than 6 months followed up 41/112 (37%) non-users had started using a pacifier at bedtime (NNT 3). Over the same period, 37/98 (38%) users had discontinued their pacifier. Otitis media did not differ between users and non-users at 12 months.Conclusion. Caregiver knowledge of the role of pacifiers in SIDS prevention was less than for other recommendations. Our educational intervention appeared to increase pacifier use. Pacifier use was not associated with increased otitis media