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1.  Development and Validation of a Risk-Adjustment Tool in Acute Asthma 
Health Services Research  2009;44(5 Pt 1):1701-1717.
To develop and prospectively validate a risk-adjustment tool in acute asthma.
Data Sources
Data were obtained from two large studies on acute asthma, the Multicenter Airway Research Collaboration (MARC) and the National Emergency Department Safety Study (NEDSS) cohorts. Both studies involved >60 emergency departments (EDs) and were performed during 1996–2001 and 2003–2006, respectively. Both included patients aged 18–54 years presenting to the ED with acute asthma.
Study Design
Retrospective cohort studies.
Data Collection
Clinical information was obtained from medical record review. The risk index was derived in the MARC cohort and then was prospectively validated in the NEDSS cohort.
Principle Findings
There were 3,515 patients in the derivation cohort and 3,986 in the validation cohort. The risk index included nine variables (age, sex, current smoker, ever admitted for asthma, ever intubated for asthma, duration of symptoms, respiratory rate, peak expiratory flow, and number of beta-agonist treatments) and showed satisfactory discrimination (area under the receiver operating characteristic curve, 0.75) and calibration (p=.30 for Hosmer–Lemeshow test) when applied to the validation cohort.
We developed and validated a novel risk-adjustment tool in acute asthma. This tool can be used for health care provider profiling to identify outliers for quality improvement purposes.
PMCID: PMC2754555  PMID: 19619246
Asthma; emergency department; hospital admission; profiling; risk adjustment
2.  Food Security, Health, and Medication Expenditures of Emergency Department Patients 
The Journal of emergency medicine  2009;38(4):524-528.
In the United States, 35 million people live in food-insecure households. Although food insecurity and hunger are undesirable in their own right, they also are potential precursors to nutritional, health, and developmental problems.
Study objectives
To examine the prevalence of household food insecurity and its association with health problems and medication expenditures among emergency department (ED) patients.
We conducted a cross-sectional study in four Boston-area EDs and enrolled consecutive adult patients during two 24-hour periods at each site. Food security status was measured using the validated 18-item US Household Food Security Survey Module.
Overall, 66 (13%; 95%CI, 10–17%) of 520 ED patients screened positive for food insecurity. Among these 66 patients, 32 (48%; 95% CI, 36–61%) reported food insecurity with hunger. Patients from food-insecure households differed from food-secure patients with respect to sociodemographic factors. Food-insecure patients were more likely than food-secure patients to report a variety of chronic and mental health problems (all P<0.05), including obesity. Food-insecure patients, compared to food-secure patients, also were more likely (all P<0.001) to put off paying for medication to have money for food (27% vs. 4%, respectively), to take medication less often because they couldn’t afford more (32% vs. 4%, respectively), to report needing to make a choice between buying medication and food (27% vs. 2%, respectively), and to report getting sick because they couldn’t afford to take medication (27% vs. 1%, respectively).
ED patients from food-insecure households report more chronic and mental health problems, and difficulty purchasing medication.
PMCID: PMC2891517  PMID: 19272731
food insecurity; hunger; emergency department
3.  Apnea in Children Hospitalized With Bronchiolitis 
Pediatrics  2013;132(5):e1194-e1201.
To identify risk factors for inpatient apnea among children hospitalized with bronchiolitis.
We enrolled 2207 children, aged <2 years, hospitalized with bronchiolitis at 16 sites during the winters of 2007 to 2010. Nasopharyngeal aspirates (NPAs) were obtained on all subjects, and real-time polymerase chain reaction was used to test NPA samples for 16 viruses. Inpatient apnea was ascertained by daily chart review, with outcome data in 2156 children (98%). Age was corrected for birth <37 weeks. Multivariable logistic regression was performed to identify independent risk factors for inpatient apnea.
Inpatient apnea was identified in 108 children (5%, 95% confidence interval [CI] 4%–6%). Statistically significant, independent predictors of inpatient apnea included: corrected ages of <2 weeks (odds ratio [OR] 9.67) and 2 to 8 weeks (OR 4.72), compared with age ≥6 months; birth weight <2.3 kg (5 pounds; OR 2.15), compared with ≥3.2 kg (7 pounds); caretaker report of previous apnea during this bronchiolitis episode (OR 3.63); preadmission respiratory rates of <30 (OR 4.05), 30 to 39 (OR 2.35) and >70 (OR 2.26), compared with 40 to 49; and having a preadmission room air oxygen saturation <90% (OR 1.60). Apnea risk was similar across the major viral pathogens.
In this prospective, multicenter study of children hospitalized with bronchiolitis, inpatient apnea was associated with younger corrected age, lower birth weight, history of apnea, and preadmission clinical factors including low or high respiratory rates and low room air oxygen saturation. Several bronchiolitis pathogens were associated with apnea, with similar apnea risk across the major viral pathogens.
PMCID: PMC3813402  PMID: 24101759
apnea; bronchiolitis; viral infections; infants; hospitalization
4.  The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): Method and Design Considerations 
Contemporary clinical trials  2013;36(1):14-24.
Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention.
The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes.
This paper summarizes the ED-SAFE’s study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1,440 suicidal individuals, from 8 general ED’s nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12 months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment.
While ‘classic’ randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multiphase, quasi-experimental design embedded in ‘real world’ clinical settings.
PMCID: PMC3979300  PMID: 23707435
suicide; research methods; mental health; emergency department
5.  Evaluating Current Patterns of Assessment for Self-Harm in Emergency Departments, A Multicenter Study 
To describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed.
This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt, suicidal ideation, or non-suicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity.
Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age ≥ 65 years (0.56, 95% CI = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males <65 years of age being more likely to be assessed (aRR 1.14, 95% CI = 1.02 to 1.37).
Emergency department assessment of self-harm was highly variable among institutions. Presence of specific assessment policies was associated with higher assessment rates. Assessment varied based upon patient characteristics. The identification of self-harm in 2.7% of ED patients indicates that a substantial proportion of current risk of self-harm may go unidentified, particularly in certain patient groups.
PMCID: PMC3775284  PMID: 24033624
6.  Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma☆,☆☆ 
The American journal of emergency medicine  2010;28(4):10.1016/j.ajem.2009.01.041.
The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians.
We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay).
Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled β-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1–0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2–0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1–4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (−6 points; 95% CI, −9 to −3 points). Supervised MLPs provided similar quality of care to that of physicians.
The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.
PMCID: PMC3838672  PMID: 20466230
7.  Vitamin D insufficiency in pregnant and nonpregnant women of childbearing age in the United States 
We evaluated vitamin D insufficiency in a nationally representative sample of women and assessed the role of vitamin supplementation.
We conducted secondary analysis of 928 pregnant and 5173 nonpregnant women aged 13–44 years from the National Health and Nutrition Examination Survey 2001–2006.
The mean 25-hydroxyvitamin D (25[OH]D) level was 65 nmol/L for pregnant women and 59 nmol/L for nonpregnant women. The prevalence of 25(OH)D <75 nmol/L was 69% and 78%, respectively. Pregnant women in the first trimester had similar 25(OH)D levels as nonpregnant women (55 vs 59 nmol/L), despite a higher proportion taking vitamin D supplementation (61% vs 32%). However, first-trimester women had lower 25(OH)D levels than third-trimester women (80 nmol/L), likely from shorter duration of supplement use.
Adolescent and adult women of childbearing age have a high prevalence of vitamin D insufficiency. Current prenatal multivitamins (400 IU vitamin D) helped to raise serum 25(OH)D levels, but higher doses and longer duration may be required.
PMCID: PMC3784988  PMID: 20060512
epidemiology; nutrition; pregnancy; supplementation; vitamin D
8.  Factors associated with delayed use or nonuse of systemic corticosteroids in emergency department patients with acute asthma 
Little is known about factors associated with systemic corticosteroid (SC) use in emergency department (ED) patients with acute asthma.
To determine the patient and system factors associated with delayed use or nonuse of SCs in the ED.
We analyzed the asthma component of the National Emergency Department Safety Study. Patients with acute asthma in 62 urban EDs in 23 US states between 2003 and 2006 were identified. The primary outcome measure was the pattern of SC use in the ED, which was categorized as timely use (≤60 minutes), delayed use (>60 minutes), or nonuse. Multinomial logistic regression was performed to identify factors associated with delayed use or nonuse of SCs.
A total of 2,559 of 3,798 patients with acute asthma (67.4%) received SCs. Of these, the median door-to-SC time was 62 minutes (interquartile range, 35–100 minutes), with 1,319 patients (51.5%) having delayed SC treatment. Nonuse of SCs was largely explained by markers of asthma exacerbations (never intubated for asthma, lower respiratory rate, and higher oxygen saturation). In contrast, in addition to these factors, delayed SC treatment was associated with age of 40 years or older, female sex, longer duration of symptoms, ED presentation between 8 AM and 11:59 PM, and ED with a longer average patient wait time.
Physicians in the ED seem to appropriately administer SCs to higher-acuity asthmatic patients; however, the additional nonmedical factors represent opportunities to improve the timeliness of SC treatment in the ED.
PMCID: PMC3769954  PMID: 19852196
9.  Trends in US Emergency Department Visits for Attempted Suicide and Self-inflicted Injury, 1993–2008 
General hospital psychiatry  2012;34(5):557-565.
To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.
Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950–E959) during 1993–2008.
Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury (1.50 [95% confidence interval (CI) 1.33–1.67] visits per 1,000 US population) and the average annual number for these ED visits more than doubled from 244,000 in 1993–1996 to 538,000 in 2005–2008. During the same timeframe, ED visits for these injuries per 1,000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82), and blacks (1.14 to 2.10). Visits were most common among ages 15–19 and the number of visits coded as urgent/emergent decreased.
ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.
PMCID: PMC3428496  PMID: 22554432
Suicide; Emergency Departments; Public Health
10.  Prospective Multicenter Study of Children With Bronchiolitis Requiring Mechanical Ventilation 
Pediatrics  2012;130(3):e492-e500.
To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis.
We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens.
There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7–11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1–1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0–2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2–2.1), presence of apnea (OR 4.8; 95% CI 2.5–8.5), inadequate oral intake (OR 2.5; 95% CI 1.3–4.3), severe retractions (OR 11.1; 95% CI 2.4–33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0–4.8). The optimism-corrected c-statistic for the final model was 0.80.
In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.
PMCID: PMC3428760  PMID: 22869823
bronchiolitis; continuous positive airway pressure; intubation; ICU; respiratory syncytial virus; human rhinovirus
11.  Increasing Critical Care Admissions From U.S. Emergency Departments, 2001–2009* 
Critical care medicine  2013;41(5):1197-1204.
Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009.
Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001–2009.
National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States.
ED patients admitted a critical care unit.
Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients.
Main Results
Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001–2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day.
The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.
PMCID: PMC3756824  PMID: 23591207
critical care; crowding; emergency service; health care disparities; hospital/workforce
12.  Prospective, multicenter study of viral etiology and hospital length-of-stay in children with severe bronchiolitis 
To determine if hospital length-of-stay (LOS) for acute bronchiolitis is influenced by the infecting pathogen
Prospective observational cohort over 3 consecutive years.
16 US hospitals
Children age <2 years hospitalized with bronchiolitis
Main Exposure
Nasopharyngeal aspirate (NPA) polymerase chain reaction pathogen results
Main Outcome Measure
Hospital LOS
Of 2,207 participants, 72% had respiratory syncytial virus (RSV), 26% had human rhinovirus (HRV), while all other viruses and bacteria were each ≤8%. Multiple pathogen infections were present in 30%. There were 1,866 (85%) children with either RSV and/or HRV. Among these 1,866 children, the median age was 4 months and 60% were male. The median LOS was 2 days (interquartile range [IQR], 1–4). Compared to children with RSV alone, LOS ≥3 days was less likely among children with HRV alone (adjusted odds ratio [AOR], 0.36; 95% confidence interval [CI], 0.20–0.63; P<0.001) and those with HRV + non-RSV pathogens (AOR, 0.39; 95%CI, 0.23–0.66; P<0.001), but more likely among children with RSV + HRV (AOR, 1.33; 95%CI, 1.02–1.73; P=0.04), controlling for 15 demographic and clinical factors.
In this multicenter study of children hospitalized with bronchiolitis, RSV was the most common viral etiology, but HRV was detected in one-quarter of children. Since 1 in 3 children had multiple virus infections and HRV was associated with LOS, these data challenge the effectiveness of current RSV-based cohorting practices, the sporadic testing for HRV in bronchiolitis research, and current thinking that the infectious etiology of severe bronchiolitis does not affect short-term outcomes.
PMCID: PMC3394902  PMID: 22473882
13.  Nasopharyngeal Lactate Dehydrogenase Concentrations Predict Bronchiolitis Severity in a Prospective Multicenter Emergency Department Study 
We re-examined the finding of an inverse relationship between values of nasopharyngeal lactate dehydrogenase (LDH), a marker of the innate immune response, and bronchiolitis severity. In a prospective, multicenter study of 258 children we found in a mutlivariable model that higher nasopharyngeal LDH values in young children with bronchiolitis were independently associated with a decreased risk of hospitalization.
PMCID: PMC3375381  PMID: 22517336
Severity of illness; biomarker; respiratory syncytial virus; human rhinovirus
14.  Multicenter Study of Predictors of Suicide Screening in Emergency Departments 
To provide estimates and predictors of screening for suicide in emergency departments (EDs).
Eight geographically diverse U.S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening.
The cohort of 800 patients had a median age of 41 years (interquartile range 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%), or intentional illegal or prescription drug misuse (36%).
The presence of known psychiatric problems and substance use had the strongest associations with suicide screening; yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.
PMCID: PMC3664554  PMID: 22288721
15.  Predictors of Successful Telephone Contact After Emergency Department-based Recruitment into a Multicenter Smoking Cessation Cohort Study 
Emergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.
This study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.
Of 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99–1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04–2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2–4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03–3.8]) and Medicare (AOR 5.7 [95%CI, 1.5–22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6–6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00–1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01–1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07–1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.
Successful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations.
PMCID: PMC4323181
16.  Quality of Care for Acute Myocardial Infarction in 58 U.S. Emergency Departments 
The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance.
The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.
The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, −1.5; 95% confidence interval [CI] = −2.4 to −0.5) and southern EDs (beta-coefficient, −5.2; 95% CI = −9.6 to −0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7).
Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes.
PMCID: PMC3547596  PMID: 20836774
acute myocardial infarction; emergency department; guidelines; quality of care
17.  A Survey of Workplace Violence Across 65 U.S. Emergency Departments 
Workplace violence is a concerning issue. Healthcare workers represent a significant portion of the victims, especially those who work in the emergency department (ED). The objective of this study was to examine ED workplace violence and staff perceptions of physical safety.
Data were obtained from the National Emergency Department Safety Study (NEDSS), which surveyed staff across 69 U.S. EDs including physicians, residents, nurses, nurse practitioners, and physician assistants. The authors also conducted surveys of key informants (one from each site) including ED chairs, medical directors, nurse managers, and administrators. The main outcome measures included physical attacks against staff, frequency of guns or knives in the ED, and staff perceptions of physical safety.
A total of 5,695 staff surveys were distributed, and 3,518 surveys from 65 sites were included in the final analysis. One-fourth of surveyed ED staff reported feeling safe sometimes, rarely, or never. Key informants at the sampled EDs reported a total of 3,461 physical attacks (median of 11 attacks per ED) over the 5-year period. Key informants at 20% of EDs reported that guns or knives were brought to the ED on a daily or weekly basis. In multivariate analysis, nurses were less likely to feel safe “most of the time” or “always” when compared to other surveyed staff.
This study showed that violence and weapons in the ED are common, and nurses were less likely to feel safe than other ED staff.
PMCID: PMC3530386  PMID: 18976337
emergency department; violence; weapons; safety; workplace
18.  National inventory of emergency departments in Singapore 
Emergency departments (EDs) are the basic units of emergency care. We performed a national inventory of all Singapore EDs and describe their characteristics and capabilities.
Singapore EDs accessible to the general public 24/7 were surveyed using the National ED Inventories instrument ( ED staff members were asked about ED characteristics with reference to calendar year 2007.
Fourteen EDs participated (100% response). All EDs were located in hospitals, and most (92%) were independent departments. One was a psychiatric ED; the rest were general EDs. Among general EDs, all had a contiguous layout, with medical and surgical care provided in one area. All but two EDs saw both adults and children; one ED was adult-only, and the other saw only children. Six were in the public sector and seven in private health-care institutions, with public EDs seeing the majority (78%) of ED patients. Each private ED had an annual patient census of <30,000. These EDs received 2% of ambulances and had an inpatient admission rate of 7%. Each public ED had an annual census of >60,000. They received 98% of ambulances and had an inpatient admission rate of 30%. Two public EDs reported being overcapacity; no private EDs did. For both public and private EDs, availability of consultant resources in EDs was high, while technological resources varied.
Characteristics and capabilities of Singapore EDs varied and were largely dependent on whether they are in public or private hospitals. This initial inventory establishes a benchmark to further monitor the development of emergency care in Singapore.
PMCID: PMC3518169  PMID: 23114079
International emergency medicine; Emergency department classification; Emergency department utilisation; Singapore; Health policy
19.  Quality of care for acute asthma in 63 US emergency departments 
Little is known about the quality of acute asthma care in the emergency department (ED).
We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission.
We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance.
The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63–83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (β-coefficient, −8.2; 95% CI, −13.8 to −2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others.
Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.
PMCID: PMC3447084  PMID: 19070357
Acute asthma; emergency department; guidelines; quality of care
20.  Continued rise in the use of mid-level providers in US emergency departments, 1993–2009 
Emergency department (ED) visits in the US have risen dramatically over the past 2 decades. In order to meet the growing demand, mid-level providers (MLPs) – both physician assistants (PAs) and nurse practitioners (NPs) – were introduced into emergency care. Our objective was to test the hypothesis that MLP usage in US EDs continues to rise.
We analyzed ED data from the National Hospital Ambulatory Medical Care Survey to identify trends in ED visits seen by MLPs. We also compared MLP-only visits (defined as visits where the patient was seen by a MLP without being seen by a physician) with those seen by physicians only. During 1993 to 2009, 8.4% (95%CI, 7.6–9.2%) of all US ED visits were seen by MLPs. These summary data include marked changes in MLP utilization: PA visits rose from 2.9% to 9.9%, while NP visits rose from 1.1% to 4.7% (both Ptrend < 0.001). Together, MLP visits accounted for almost 15% of 2009 ED visits and 40% of these were seen without involvement of a physician. Compared to physician only visits, those seen by MLPs only were less likely to arrive by ambulance (16% vs 6%) and be admitted (14% vs 3%).
Mid-level provider use is rising in US EDs. By 2009, approximately one in seven visits involved MLPs, with PAs managing twice as many visits as NPs. Although patients seen by MLPs only are generally of lower acuity, these nationally representative data confirm that MLP care extends beyond minor presentations.
PMCID: PMC3410759  PMID: 22621709
emergency department; workforce; mid-level providers; physician assistants; nurse practitioners; trends; NHAMCS
21.  Patient preferences for emergency department-initiated tobacco interventions: a multicenter cross-sectional study of current smokers 
The emergency department (ED) visit provides a great opportunity to initiate interventions for smoking cessation. However, little is known about ED patient preferences for receiving smoking cessation interventions or correlates of interest in tobacco counseling.
ED patients at 10 US medical centers were surveyed about preferences for hypothetical smoking cessation interventions and specific counseling styles. Multivariable linear regression determined correlates of receptivity to bedside counseling.
Three hundred seventy-five patients were enrolled; 46% smoked at least one pack of cigarettes per day, and 11% had a smoking-related diagnosis. Most participants (75%) reported interest in at least one intervention. Medications were the most popular (e.g., nicotine replacement therapy, 54%), followed by linkages to hotlines or other outpatient counseling (33-42%), then counseling during the ED visit (33%). Counseling styles rated most favorably involved individualized feedback (54%), avoidance skill-building (53%), and emphasis on autonomy (53%). In univariable analysis, age (r = 0.09), gender (average Likert score = 2.75 for men, 2.42 for women), education (average Likert score = 2.92 for non-high school graduates, 2.44 for high school graduates), and presence of smoking-related symptoms (r = 0.10) were significant at the p < 0.10 level and thus were retained for the final model. In multivariable linear regression, male gender, lower education, and smoking-related symptoms were independent correlates of increased receptivity to ED-based smoking counseling.
In this multicenter study, smokers reported receptivity to ED-initiated interventions. However, there was variability in individual preferences for intervention type and counseling styles. To be effective in reducing smoking among its patients, the ED should offer a range of tobacco intervention options.
PMCID: PMC3414814  PMID: 22966410
Smoking; Tobacco; Cigarettes; Emergency medicine; Counseling; Patient preference
22.  Characterizing emergency departments to improve understanding of emergency care systems 
International emergency medicine aims to understand different systems of emergency care across the globe. To date, however, international emergency medicine lacks common descriptors that can encompass the wide variety of emergency care systems in different countries. The frequent use of general, system-wide indicators (e.g. the status of emergency medicine as a medical specialty or the presence of emergency medicine training programs) does not account for the diverse methods that contribute to the delivery of emergency care both within and between countries. Such indicators suggest that a uniform approach to the development and structure of emergency care is both feasible and desirable. One solution to this complex problem is to shift the focus of international studies away from system-wide characteristics of emergency care. We propose such an alternative methodology, in which studies would examine emergency department-specific characteristics to inventory the various methods by which emergency care is delivered. Such characteristics include: emergency department location, layout, time period open to patients, and patient type served. There are many more ways to describe emergency departments, but these characteristics are particularly suited to describe with common terms a wide range of sites. When combined, these four characteristics give a concise but detailed picture of how emergency care is delivered at a specific emergency department. This approach embraces the diversity of emergency care as well as the variety of individual emergency departments that deliver it, while still allowing for the aggregation of broad similarities that might help characterize a system of emergency care.
PMCID: PMC3250095  PMID: 21756328
23.  Variable Access to Immediate Bedside Ultrasound in the Emergency Department 
Use of bedside emergency department (ED) ultrasound has become increasingly important for the clinical practice of emergency medicine (EM). We sought to evaluate differences in the availability of immediate bedside ultrasound based on basic ED characteristics and physician staffing.
We surveyed ED directors in all 351 EDs in Colorado, Georgia, Massachusetts, and Oregon between January and April 2009. We assessed access to bedside ED ultrasound by the question: “Is bedside ultrasound available immediately in the ED?” ED characteristics included location, visit volume, admission rate, percent uninsured, total emergency physician full-time equivalents and proportion of EM board-certified (BC) or EM board-eligible (BE) physicians. Data analysis used chi-square tests and multivariable logistical regression to compare differences in access to bedside ED ultrasound by ED characteristics and staffing.
We received complete responses from 298 (85%) EDs. Immediate access to bedside ultrasound was available in 175 (59%) EDs. ED characteristics associated with access to bedside ultrasound were: location (39% for rural vs. 71% for urban, P<0.001); visit volume (34% for EDs with low volume [<1 patient/hour] vs. 79% for EDs with high volume [≥3 patients/hour], P<0.001); admission rate (39% for EDs with low [0–10%] admission rates vs. 84% for EDs with high [>20%] rates, P<0.001); and EM BC/BE physicians (26% for EDs with a low percentage [0–20%] vs.74% for EDs with a high percentage [≥80%], P<0.001).
U.S. EDs differ significantly in their access to immediate bedside ultrasound. Smaller, rural EDs and those staffed by fewer EM BC/BE physicians more frequently lacked access to immediate bedside ultrasound in the ED.
PMCID: PMC3088382  PMID: 21691479
24.  Implementation of crowding solutions from the American College of Emergency Physicians Task Force Report on Boarding 
Study Objective
We sought to measure the self-reported implementation of the crowding solutions outlined in the 2008 American College of Emergency Physicians (ACEP) Boarding Task Force report “Emergency Department Crowding: High-Impact Solutions.” We also tested the hypothesis that the self-reported crowding of emergency departments (EDs) was positively associated with the implementation of these solutions.
In early 2009, we mailed a survey to all medical or nursing directors from EDs in four US states asking for information regarding their EDs in 2008. Geographic information about the EDs was included in the analysis, along with survey responses about their ED capacity status and implementation of specific ACEP crowding solutions.
A total of 284 of 351 EDs responded (81%). The majority of EDs were in urban areas (56%), non-teaching hospitals (93%), and not critical access hospitals (76%). The percentage of EDs “over capacity” ranged from 10–49% in each state. The mean number of crowding solutions used in EDs that were at or over capacity ranged from 3.6–4.6 in each state. EDs with visit volumes greater than or equal to three patients/hour were more likely to be over capacity than at capacity or at a good balance (46% vs. 31% and 15%, respectively). In terms of the use of high-impact crowding solutions, hospitals over capacity were more likely to utilize inpatient full capacity protocols (40% vs. 25% and 25%) but not inpatient discharge coordination (29% vs. 27% and 34%) or surgical schedule smoothing (31% vs. 28% and 32%). Hospitals over capacity were also more likely to have fast track units (44% vs. 32% and 16%) and physicians at triage (48% vs. 29% and 17%).
Less than half of EDs in each state reported operation above capacity. Implementation of some crowding solutions was more common in the above-capacity EDs, although these solutions were not consistently used across geographic locations and hospitals. Given that the majority of EDs were not over capacity, the implementation of these solutions does not seem to be universally necessary.
PMCID: PMC3047841  PMID: 21373293
Emergency department crowding; ACEP; Crowding solutions
25.  Access to Emergency Care in the United States 
Annals of emergency medicine  2009;54(2):261-269.
Rapid access to emergency services is essential for emergency care sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We sought to determine US population access to an emergency department (ED).
The National Emergency Department Inventories (NEDI) – USA was used to identify the location, annual visit volume, and teaching status of all EDs in the US. EDs were categorized as 1) any ED, 2) by patient volume, and 3) by teaching status. Driving distances, driving speeds, and prehospital times were estimated using validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified time intervals.
Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs.
Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care sensitive conditions. The development of a regionalized emergency care delivery system should be explored.
PMCID: PMC2728684  PMID: 19201059

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