BACKGROUND:Early noninvasive cardiac testing (NIT) is often performed in the initial workup of patients who present to the emergency department (ED) with suspected acute coronary syndrome (ACS). Our study objective was to calculate the cost-effectiveness of adopting early NIT for risk stratification to avoid future nonfatal acute myocardial infarction (MI) or death. METHODS:To obtain the incremental difference in cost and clinical outcomes, we first conducted a multicenter retrospective cohort study within the member population of the Kaiser Permanente Southern California integrated health care delivery system. We then adapted existing cost effectiveness models to generate long-term costs and quality-adjusted life-years (QALYs) gained by NIT. RESULTS:The cohort included 89,387 patients (mean age 57 years, 58% female) and 19% received early NIT. Total cost was higher by $2357 (95% confidence interval [CI] $77 to $4821) for early NIT compared to no early NIT and was mainly due to the increased cost of the index ED visit. Early NIT was associated with lower composite risk of death/nonfatal MI (absolute risk difference -3.7%, 95% CI -4.4% to -3.01%) during a 1-year follow-up. From a payor's perspective, early NIT was cost-effective at $5268/QALYs. CONCLUSIONS:In patients with suspected ACS evaluated in the ED, incorporation of early NIT was associated with an overall increase in cost of health care that was driven by increased cost of the initial ED visit. However, due to the significant clinical benefits, early NIT was cost-effective in the low- and intermediate-risk patients while it is a dominant strategy in high-risk patients saving cost and QALYs.

Current guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in high-risk atrial fibrillation (AF) patients. However, emergency department (ED) prescribing is inconsistent. The provider factors influencing OAC prescribing in the ED are unknown. This study aimed to identify factors that prevent and support OAC prescribing for AF by ED physicians.

Prescription opioid overdoses represent a major public health crisis. In an effort to reduce emergency department (ED) visits by Medicaid patients, Washington State mandated seven hospital “best practices” in June 2012. These mandates include efforts to reduce ED opioid prescribing and visits related to chronic pain, such as provider registration in the Prescription Monitoring Program, adherence to strict opioid prescribing guidelines, and tracking of potential ED shopping. We assessed the impact of the Washington state mandates on rates of ED opioid prescribing and pain-related ED visits. We performed a difference-in-differences study for 18 months before and 18 months after implementation of the hospital mandates. We compared outcomes following ED visits (intervention group) and primary care provider (PCP) visits (control group). Because the hospital mandates specifically affect ED visits, we postulated that PCP visits would provide an ideal control group to account for temporal trends. We analyzed medical and pharmacy claims of Washington Medicaid beneficiaries. The primary outcome was any prescription opioid dispensing within 3 days following an ED or PCP visit. Dispensed opioids were matched by unique billing identifier or specialty type of index visit provider. Secondary outcomes include >150 morphine milligram equivalents (MMEs) of dispensed opioids and pain-related discharge diagnoses. We conducted visit-level, multivariate logistic regressions to control for age, sex, race/ ethnicity, and presence of Medicaid qualifying disability; we controlled for clustering of visits by unique patient. The association between the hospital mandates and outcomes was identified by the difference between ED and PCP visits in the pre-post time differences. We created dummy variables indicating (1) whether a visit was to an ED or to a PCP and (2) if the visit was before or after the implementation of hospital mandates. The interaction term of these 2 variables was the difference-in-differences estimator. Our study cohort included 929,866 unique Medicaid beneficiaries who accounted for 797,732 ED and 3,248,588 primary care visits between Jan 1, 2011- Dec 31, 2013. The table displays unadjusted outcome rates. In adjusted analyses, we found substantial outcome reductions associated with post-mandate ED visits for any dispensed opioid (OR 0.75, 95% CI 0.74-0.76) and dispensed opioids >150 MMEs (OR 0.80, 95% CI 0.78-0.83). There was a modest reduction in ED pain-related diagnoses (OR 0.93, 95% CI 0.92-0.94). Hospital “best practice” mandates were associated with reductions in any ED related prescription opioid dispensing, dispensing of >150 MMEs, and pain-related ED visits.Tabled 1Unadjusted OutcomesOUTCOMESPRE-MANDATEPOST-MANDATEAny Dispensed OpioidsED Visits26%17%PCP Visits13%11%>150 MMEs DispensedED Visits6%4%PCP Visits10%8%Pain-Related DiagnosisED Visits38%36%PCP Visits31%31% Open table in a new tab

Study Objectives: Syncope, defined as a transient loss of consciousness, accounts for over 700,000 emergency department (ED) visits per year. Because of uncertainty about potentially dangerous causes, patients are frequently hospitalized after an episode of unexplained syncope. However, current admission patterns account for over $2.4 billion annual hospital costs with little evidence of benefit. We evaluated an emergency department Observation Syncope Protocol (EDOSP) as an alternative to routine admission. We hypothesized that EDOSP would reduce health service use and result in equivalent safety and quality-of-life outcomes compared to routine care. Methods: This was a randomized trial at 5 emergency departments (EDs). Eligible patients had a chief complaint of syncope or near syncope, were aged 50 years or greater, and were classified as intermediate risk for subsequent serious outcomes. Treating physicians used semi-structured criteria to assign a determination of low, intermediate, or high risk. Patients with dangerous conditions identified in the ED were excluded. EDOSP arm patients received serial troponin testing, 12-24 hours of cardiac monitoring, and selective echocardiogram testing in an ED observation unit. Additional testing and final disposition was at the discretion of the ED treatment team. Control arm patients received routine and unstructured care by an inpatient medical team. Direct patient follow-up and chart review was performed at 30 days and 6 months. Primary outcomes included hospitalization rate and length of stay. Secondary outcomes included 30-day hospital costs, safety events, and quality of life scores. Hospital costs were estimated using Medicare payment tables. Safety events included serious clinical conditions (eg, death, arrhythmia, myocardial infarction, stroke, pulmonary embolism, anemia requiring transfusion) occurring after hospital discharge at 30 days and 6 months. General health utility and symptom specific quality-of-life were measured using the Quality of Well Being Scale and the Syncope Functional Status Questionnaire, respectively. All analyses were intent-to-treat and included site fixed-effects. Results: Of 1,235 screened patients who met eligibility criteria prior to risk stratification, ED physicians excluded 315 as “low-risk” and 633 as “high risk.” Of the remaining 287 patients who met all eligibility criteria, 123 provided informed consent and were randomized. Compared to routine admission, EDOSP resulted in a lower admission rate (11% versus 78%, p<0.001) and shorter hospital length-of-stay (29 versus 46 hours, p<0.001). EDOSP resulted in lower 30-day hospital costs ($2,100 versus $3,600, p=0.02). There were no significant differences in safety event rates between the 2 arms (30d: EDOSP=3%, control=0%, p=0.2; 6-mo: EDOSP=3%, control=6%, p=0.4). There were no differences in general health utility (p=0.5) or symptom-specific quality of life (p=0.3). Conclusion: EDOSP can be replicated in multiple ED settings, and it represents a cost-effective alternative to routine admission for intermediate-risk patients with syncope. Safety events were not significantly different between the 2 arms; however, this study was not formally powered to demonstrate non-inferiority of clinical outcome rates. Future research is needed to definitively demonstrate the safety of EDOSP.

Study Objectives: Emergency department (ED) crowding is prevalent, and existing research suggests that ED crowding is associated with increased patient mortality. However, prior studies are limited by small hospital samples, inclusion of specific patient subgroups, and inadequate case mix adjustment; furthermore, studies are not directly comparable because of different measures of ED crowding. As a result, the external validity and causal mechanisms of ED crowding measures are unclear. Identification of valid metrics is critical for the proper design of public reporting and pay-for-performance initiatives. Our aim was to assess the predictive validity of multiple ED crowding measures for inpatient mortality. Methods: We performed a retrospective cohort study using data from a regional, integrated health system (Kaiser Permanente Southern California- KPSC). We included ED visits from 2008 to 2010 occurring at 13 KPSC hospitals which resulted in hospital admission. All hospitals had implemented a systemwide, electronic medical records system during the study period. Exclusion criteria included age<18 years, visits by non-members, transfers to other hospitals, discharges from the ED, and patients receiving observation status care. The outcome was inpatient mortality. The unit of analysis was an ED visit. We assessed system- and visit-level measures of ED crowding. System metrics included exposures to ED occupancy and external length of stay, both at ED arrival and averaged over an index visitor's length of stay (LOS). Visit metrics included waiting, evaluation, and boarding time, as well as total LOS, experienced by an index visitor. To assess for non-linear effects, all ED crowding measures were categorized into quintiles. Hierarchical logistic regression models accounted for visit clustering by hospital and person. Covariates included demographic characteristics, 29 pre-existing co-morbidities noted from health service records in the preceding year, Emergency Severity Index triage level, triage vital signs, primary hospital diagnosis, time variables for year, month, day, and shift, and ED site. Results: The study cohort included 326,487 ED visits resulting in hospitalization by 201,036 unique patients. Prior to covariate adjustment, all system metrics, boarding time, and total LOS were predictive of inpatient mortality (p<0.05). In adjusted analyses, boarding time was strongly predictive of mortality, with a threshold effect seen at 1.6 hours (1.7-2.8 hours, OR: 1.1, 95%CI: 1.02, 1.2; >2.9 hours, OR: 1.2, 95%CI: 1.1, 1.3). None of the other system or person-level metrics predicted inpatient mortality after covariate adjustment (p>0.3). Conclusion: Surprisingly, system measures of ED crowding and most visit-level time intervals were poorly predictive of mortality, suggesting that threats to patient safety is driven by the experience of boarding rather than general exposure to ED crowding. Our findings suggest that measurement efforts and patient safety interventions should focus on boarding time. Other potential measures may be confounded by patient case mix or hospital level factors.

Emergency department (ED) crowding has strained the acute care system to its breaking point. Two of the most visible symptoms of ED crowding, ambulance diversion and "left before being seen" visit rates, have dramatically increased over time and are now routine in many centers. ED crowding causes delays in evaluation and treatment, which in turn may contribute to adverse outcomes. Consequently, the American College of Emergency Physicians has identified ED crowding as one of the top problems threatening the safety and quality of emergency care. However, policymakers and health system leaders have failed to address ED crowding as a top public health priority. The primary reason for inaction is the paucity of data on community disparities in ED crowding and the impact of ED crowding on patient outcomes. In order to assess patterns and outcomes of ED crowding, we propose a retrospective cohort study of all 2007 ED visits in Los Angeles County. This analysis will include 2.2 million discharges and 460,000 hospitalizations from 77 EDs. We will use daily ambulance diversion hours and "left before being seen" (LBBS) visit rates as measures of ED crowding. This study has the following specific aims: 1. Identify community level predictors of emergency department crowding. 2. Assess the relationship between emergency department crowding and 7-day bounce-back hospitalizations after emergency department discharge. 3. Assess the relationship between emergency department crowding and inpatient outcomes, including death, length of stay, and costs. This exploratory study will provide important insights into the determinants and impact of ED crowding. It will also lay the methodological foundations for future studies of multi-year, statewide data to understand this critical health policy issue.

STUDY OBJECTIVE:We identify predictors of 30-day serious events after syncope in older adults. METHODS:We reviewed the medical records of older adults (age > or =60 years) who presented with syncope or near syncope to one of 3 emergency departments (EDs) between 2002 and 2005. Our primary outcome was occurrence of a predefined serious event within 30 days after ED evaluation. We used multivariable logistic regression to identify predictors of 30-day serious events. RESULTS:Of 3,727 potentially eligible patients, 2,871 (77%) met all eligibility criteria. We excluded an additional 287 patients who received a diagnosis of a serious clinical condition while in the ED. In the final study cohort (n=2,584), we identified 173 (7%) patients who experienced a 30-day serious event. High-risk predictors included age greater than 90 years, male sex, history of an arrhythmia, triage systolic blood pressure greater than 160 mm Hg, abnormal ECG result, and abnormal troponin I level. A low-risk predictor was a complaint of near syncope rather than syncope. A risk score, generated by summing high-risk predictors and subtracting the low-risk predictor, can stratify patients into low- (event rate 2.5%; 95% confidence interval [CI] 1.4% to 3.6%), intermediate- (event rate 6.3%; 95% CI 5.1% to 7.5%), and high-risk (event rate 20%; 95% CI 15% to 25%) groups. CONCLUSION:We identified predictors of 30-day serious events after syncope in adults aged 60 years and greater. A simple score was able to stratify these patients into distinct risk groups and, if externally validated, might have the potential to aid ED decisionmaking.

Although standard blood cardioplegia provides good myocardial protection for cardiac operations in adults, protection of the cyanotic, immature myocardium remains suboptimal. Calcium, which has been implicated in reperfusion injury and in the development of "stone heart" in mature myocardium, is routinely lowered in standard cardioplegic solutions. Immature, neonatal myocardium has lower intracellular calcium stores and is more reliant on extracellular calcium for contraction. To determine if normocalcemic cardioplegia would result in improved cardiac function in the neonatal heart, we conducted a series of experiments using an isolated, blood-perfused working heart model. Thirty-two neonatal piglet hearts (24 to 48 hours) were excised without intervening ischemia and were placed directly on a blood-perfused circuit. Baseline stroke work index was assessed. Hearts were then arrested with cold cardioplegic solution delivered at 45 mm Hg for 2 minutes: group I, low-calcium blood cardioplegic solution (Ca = 0.6 mmol/L); group II, normal-calcium blood cardioplegic solution (Ca = 1.1 mmol/L); group III, University of Wisconsin solution; and group IV, University of Wisconsin solution with added calcium (Ca = 1.0 mmol/L). Cardioplegic solution was administered every 20 minutes for 2 hours and topical hypothermia was used. Hearts were then reperfused with warm whole blood. Functional recovery, expressed as a percentage of control stroke work index, was determined minutes after reperfusion. Hearts preserved with normocalcemic cardioplegic solution (groups II and IV) had complete functional recovery at 60 minutes, whereas hearts preserved with low-calcium cardioplegic solution (groups I and III) achieved functional recoveries of only 80% and 65%, respectively, at a left atrial pressure of 9 mm Hg. Electron micrographs taken 1 hour after reperfusion showed minimal edema and only mild myofibrillar changes. They were identical in both the low-calcium and normocalcemic groups. Complete functional recovery is possible in immature myocardium when calcium is added to either blood or an intracellular crystalloid cardioplegic solution. The addition of calcium does not result in ultrastructural damage and does result in good functional recovery.