Faculty Bibliography

Background: The ED is a point of frequent contact for medically vulnerable, chronically homeless patients with alcohol use disorders, or chronic public inebriates (CPI). Despite this population's exposure to health and social agencies, its outcomes suffer due, in part, to lack of stable housing and fragmented, 'treat and street' medical care. Objectives: NYU School of Medicine and the Bellevue Hospital Center ED partnered with the Department of Homeless Services (DHS) to implement a multifaceted pilot initiative. This integration of services is hypothesized to improve access to housing and comprehensive medical care resulting in reduced costly ED and inpatient admissions, and homelessness. Engaging the ED as a point of intervention, a cohort of CPIs received needs assessments, enhanced care management, and coordination with DHS outreach. Methods: CPIs were identified primarily through an administrative database search and chart reviews. At the time of this 10-month analysis, 20 of the 56 patients who met inclusion criteria were enrolled. Enrolled (Figure presented) patients had a minimum of 20 ED visits in a 24-month period with at least one visit within 5 months of the pilot commencement in January 2011 and met the DHS standard for chronic homelessness. Preference was given to those with greater visit frequency, co-morbidities, or staff referral. The intervention for enrolled patients included the ongoing implementation of individualized multidisciplinary action plans, case management, and coordination with the housing outreach team upon discharge. Results: Eighteen of the 20 enrolled patients were placed in housing. After first housing placement (mean length, 4.7 months), monthly ED and inpatient use declined 48% and 40%, respectively. ED and inpatient use by the nonenrolled remained stable throughout the study period. Prior to intervention, hospital use had increased over time for the enrolled patients (Figures 1,2). Conclusion: ED-based collaboration amongst medical and social services for a small cohort of CPIs resulted in housing placements and reduced ED and inpatient visits. While promising, the results of this interim pilot data are limited by the non-random sampling method, power, duration, and singular location. Further study is needed to determine the intervention's effect on public health expenditures and patient outcomes

TAD and AAA are two of the highest risk disease entities in emergency medicine. Emergency physicians should be vigilant in their approach to patients who have symptoms compatible with acute aortic disease. In chest and abdominal pain presentations, the chart must look like there was a search for the TAD and AAA. By having a sound knowledge of atypical cases;, having an appreciation for how subtle TAD and AAA can be; and recording and documenting a thorough history, physical examination, and risk factor profile, the emergency physician may reduce substantially the risk of missing a diagnosis and subsequently being sued. Emergency physicians cannot diagnose every case of acute aortic disease; what they can do is practice with a sound understanding of risk management principles and consider these diagnoses in all patients with chest, back, or abdominal pain.Ultimately, this strategy would provide protection for the patient and the physician