Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine whether there are differences in emergency department (ED) pain assessment and treatment for older and younger adults. DESIGN/METHODS:Retrospective observational cohort. SETTING/METHODS:Urban, academic tertiary care ED during July and December 2005. PARTICIPANTS/METHODS:Adult patients with conditions warranting ED pain care. MEASUREMENTS/METHODS:Age, Charlson comorbidity score, number of prior medications, sex, race and ethnicity, triage severity, degree of pain, treating clinician, and final ED diagnosis. Pain care process measures were pain assessment and treatment and time of activities. RESULTS:One thousand thirty-one ED visits met inclusion criteria; 92% of these had a documented pain assessment. Of those reporting pain, 41% had follow-up pain assessments, and 59% received analgesic medication (58% of these as opioids, 24% as nonsteroidal anti-inflammatory drugs (NSAIDs)). In adjusted analyses, there were no differences according to age in pain assessment and receiving any analgesic. Older patients (65-84) were less likely than younger patients (18-64) to receive opioid analgesics for moderate to severe (odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.22-0.88) and were more likely to more likely to receive NSAIDs for mild pain (OR = 3.72, 95% CI = 0.97-14.24). Older adults had a lower reduction of initial to final recorded pain scores (P = .002). CONCLUSION/CONCLUSIONS:There appear to be differences in acute ED pain care for older and younger adults. Lower overall reduction of pain scores and less opioid use for the treatment of painful conditions in older patients highlight disparities of concern. Future studies should determine whether these differences represent inadequate ED pain care.

BACKGROUND:An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated. OBJECTIVES/OBJECTIVE:The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs). METHODS:We reviewed the English-language literature for the years 1989-2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,""ED overcrowding,""mortality,""time to treatment,""patient satisfaction,""quality of care," and others. RESULTS:A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints. CONCLUSIONS:A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.

OBJECTIVE:Headache is a common presenting complaint in the emergency department (ED). Physicians may choose to screen for causes of headache using computed tomography (CT). It is not known whether patient characteristics influence this decision. This study sought to identify patient demographic factors associated with CT evaluation for adult patients with headache. METHODS:This study used a retrospective cohort review at an academic, urban ED. Study eligibility was based on chief complaint of headache and final diagnosis of the same. Detailed demographic (age, sex, race/ethnicity, insurance) and clinical (Emergency Severity Index [ESI], Charlson comorbidity score, pain score) data were abstracted from the ED medical record. The main outcome studied was whether a head CT was part of clinical evaluation. RESULTS:One hundred fifty-five patients were reviewed. Mean age was 42 years (SD, +/-18 years); 75% female, 17% white, 41% black, and 33% Hispanic; 73% were insured; mean ESI was 3.06 (SD, +/-0.64); and Charlson score was 0.60 (SD, +/-1.55). Thirty-seven percent of patients underwent head CT. In multivariable analyses, patients were more likely to undergo head CT if they had greater acuity (ESI < or = 3; odds ratio [OR], 5.11; P < .01) but were less likely to undergo head CT if they were black (OR, 0.21; P < .01) when adjusting for each other as well as older age, sex, comorbidity, insurance status, and history of migraine. CONCLUSION/CONCLUSIONS:In this study, patients who were black were significantly less likely to undergo head CT during their ED evaluation for headache, independent of clinical and demographic factors.

OBJECTIVES/OBJECTIVE:Emergency departments (EDs), similar to other health care environments, are concerned with improving the quality of patient care. Older patients comprise a large, growing, and particularly vulnerable subset of ED users. The project objective was to develop ED-specific quality indicators for older patients to help practitioners identify quality gaps and focus quality improvement efforts. METHODS:The Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, including members representing the American College of Emergency Physicians (ACEP), selected three conditions where there are quality gaps in the care of older patients: cognitive assessment, pain management, and transitional care in both directions between nursing homes and EDs. For each condition, a content expert created potential quality indicators based on a systematic review of the literature, supplemented with expert opinion when necessary. The original candidate quality indicators were modified in response to evaluation by four groups: the Task Force, the SAEM Geriatric Interest Group, and audiences at the 2007 SAEM Annual Meeting and the 2008 American Geriatrics Society Annual Meeting. RESULTS:The authors offer 6 quality indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing homes and EDs. CONCLUSIONS:These quality indicators will help researchers and clinicians target quality improvement efforts. The next steps will be to test the feasibility of capturing the quality indicators in existing medical records and to measure the extent to which each quality indicator is successfully met in current emergency practice.

OBJECTIVES/OBJECTIVE:The objective of this study was to evaluate the association of emergency department (ED) crowding factors with the quality of pain care. METHODS:This was a retrospective observational study of all adult patients (> or =18 years) with conditions warranting pain care seen at an academic, urban, tertiary care ED from July 1 to July 31, 2005, and December 1 to December 31, 2005. Patients were included if they presented with a chief complaint of pain and a final ED diagnosis of a painful condition. Predictor ED crowding variables studied were 1) census, 2) number of admitted patients waiting for inpatient beds (boarders), and 3) number of boarders divided by ED census (boarding burden). The outcomes of interest were process of pain care measures: documentation of clinician pain assessment, medications ordered, and times of activities (e.g., arrival, assessment, ordering of medications). RESULTS:A total of 1,068 patient visits were reviewed. Fewer patients received analgesic medication during periods of high census (>50th percentile; parameter estimate = -0.47; 95% confidence interval [CI] = -0.80 to -0.07). There was a direct correlation with total ED census and increased time to pain assessment (Spearman r = 0.33, p < 0.0001), time to analgesic medication ordering (r = 0.22, p < 0.0001), and time to analgesic medication administration (r = 0.25, p < 0.0001). There were significant delays (>1 hour) for pain assessment and the ordering and administration of analgesic medication during periods of high ED census and number of boarders, but not with boarding burden. CONCLUSIONS:ED crowding as measured by patient volume negatively impacts patient care. Greater numbers of patients in the ED, whether as total census or number of boarders, were associated with worse pain care.

With the aging of the population and the demographic shift of older adults in the healthcare system, the emergency department (ED) will be increasingly challenged with complexities of providing care to geriatric patients. The special care needs of older adults unfortunately may not be aligned with the priorities for how ED physical design and care is rendered. Rapid triage and diagnosis may be impossible in the older patient with multiple comorbidities, polypharmacy, and functional and cognitive impairments who often presents with subtle clinical signs and symptoms of acute illness. The use of Geriatric Emergency Department Interventions, structural and process of care modifications addressing the special care needs of older patients, may help to address these challenges.

OBJECTIVES/OBJECTIVE:To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults. DESIGN/METHODS:Retrospective review of ED records from a prospective cohort study. SETTING/METHODS:Urban, academically affiliated, tertiary medical center. PARTICIPANTS/METHODS:One hundred fifty-eight patients, aged 50 and older, evaluated and hospitalized from the ED with hip fracture. MEASUREMENTS/METHODS:Patient-related risk factors: age, sex, nursing home residence, ED triage status, dementia, Acute Physiology in Age and Chronic Health Evaluation II physiological score, and RAND comorbidity score. ED crowding risk factors: ED census and mean length of stay. OUTCOMES/RESULTS:documentation of pain assessment, time to pain assessment, time to pain treatment, patients reporting pain receiving analgesia, and meperidine use. RESULTS:Mean age was 83 (range 52-101), 81.0% of patients complained of pain, mean time to pain assessment was 40 minutes (range 0-600), time to treatment was 141 minutes (range 10-525), and mean delay to treatment was 122 minutes (range 0-526). Of those with pain, 35.9% received no analgesia, 7.0% received nonopioids, and 57.0% received opioids. Of those receiving opioids, 32.8% received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment (P = .05) and longer times to pain assessment (P = .01). CONCLUSION/CONCLUSIONS:Older adults with hip fracture are at risk for underassessment of pain, considerable delays in analgesic administration after pain is identified, and treatment with inappropriate analgesics (e.g., meperidine) in the ED. Higher levels of ED census are significantly associated with poorer pain management.

Three recently published Institute of Medicine reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, examined the current state of emergency care in the United States. They concluded that the emergency medicine system as a whole is overburdened, underfunded, and highly fragmented. These reports did not specifically discuss the effect the aging population has on emergency care now and in the future and did not discuss special needs of older patients. This report focuses on the emergency care of older patients, with the intent to provide information that will help shape discussions on this issue.

OBJECTIVES/OBJECTIVE:Emergency Medicine Patients' Access To Healthcare (EMPATH) was a cross-sectional, observational study conducted to identify the principal reasons why patients seek care in hospital emergency departments (EDs) in the United States. METHODS:Twenty-eight U.S. hospitals, stratified by geographic region and hospital characteristics, participated in this study. Demographic, clinical, and insurance data were collected for a 24-hour period at each site, using chart reviews and a structured interview administered to all consenting adult patients seeking treatment during that period. Patients' reasons for presenting to the ED were assessed by their level of agreement (on a three-point Likert scale) with 21 carefully worded statements designed to capture a range of possible reasons for seeking care in the ED. Factor analysis was used to consolidate highly correlated responses and to identify the principal factors explaining patients' reasons for coming to the ED. RESULTS:A total of 1,579 patient interviews and 2,004 chart reviews were obtained from a diverse sample that was 55.4% female, 58.3% white, 28.3% African American, 7.0% Hispanic, and 6.0% other ethnic groups. This exploratory analysis yielded five factors characterizing patients' principal reasons for seeking ED care, with medical necessity the most frequent, followed by ED preference, convenience, affordability, and limitations of insurance. CONCLUSIONS:Use of the ED is, for most people, an affirmative choice over other providers rather than a last resort; it is often a choice driven by lack of access to or dissatisfaction with other sources of care.

OBJECTIVES/OBJECTIVE:To examine how emergency department (ED) overcrowding has been defined in the medical literature. METHODS:Using the National Library of Medicine's PubMed and MEDLINE databases (1966 to 2002), a comprehensive review of the English-language medical literature was conducted to identify explicit criteria for defining ED overcrowding. Inclusion criteria were original articles, editorials, and reviews; news articles and letters to the editor were excluded. Using a standardized extraction form, publications were described as primary if the title or an objective statement in the introductory or methods paragraph referred to crowding or overcrowding; all other citations were categorized as secondary. Each report was then evaluated to determine whether crowding or overcrowding was defined explicitly or implicitly. Explicit definitions included phrases such as "Crowding was defined as ..." or "Overcrowding occurred when ..."; other definitions were characterized as implicit. RESULTS:A total of 231 candidate articles were identified; 91 met inclusion criteria, and 53 (58%) were primary articles about ED crowding or overcrowding. Among these primary articles, 23 (43%) had explicit definitions of crowding or overcrowding. The definitions varied widely in content and focus, including ED, hospital, or external (nonhospital) factors. CONCLUSIONS:Although ED overcrowding has been a topic of frequent investigation, current definitions of the problem are often implicit or focus on factors outside of the ED itself. A more consistent approach to defining ED overcrowding would help to clarify the distinctions between causes, characteristics, and outcomes of overcrowding.