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Article
Peer Reviewed

Impact of skilled nursing facility (SNF) 3-day hospitalization requirement waiver during the COVID-19 pandemic on emergency department and inpatient SNF discharges in California.

UC San Diego Previously Published Works (2024)

OBJECTIVE: We sought to study the impact of the Centers for Medicare & Medicaid services (CMS) waiver of the 3-day hospitalization requirement for skilled nursing facility (SNF) care implemented as part of the Federal COVID-19 response on emergency department (ED) and inpatient hospital SNF discharges. METHODS: We conducted a multicenter retrospective cohort study of hospital ED and inpatient visits in California during 18 months before (prewaiver, September 2018-February 2020) and 18 months after (waiver, March 2020-August 2021) waiver implementation. Data were collected from all adult ED and admitted patients utilizing California Department of Health Care Access and Information datasets from all acute care hospitals licensed in the state. Prewaiver and waiver periods were compared for SNF discharge/disposition rates stratified by patient demographic and hospital data with differences in the proportion and 95% confidence interval [CI] reported (SPSS). RESULTS: SNF discharges decreased from the prewaiver to waiver periods from the ED (-7.4% [CI -8.1%, -6.6%]), along with larger declines occurring from the inpatient hospital setting (-18.1% [CI -18.4%, -17.9%]). For Medicare beneficiaries, there was a smaller decrease in ED SNF rates (-3.8% [CI -4.7%, -2.9%]), and there was no significant change for SNF discharge rates for inpatient admissions with a length of stay (LOS) <3 days (+1.0% [CI 0.0%, 2.1%]). CONCLUSION: In California, the CMS waiver did not result in an increase, but an actual decrease rate of SNF discharges from the ED and inpatient setting, though with smaller declines for the ED, Medicare patients, and those with a LOS <3 days.

Cover page: Impact of skilled nursing facility (SNF) 3-day hospitalization requirement waiver during the COVID-19 pandemic on emergency department and inpatient SNF discharges in California.

Article
Peer Reviewed

Trends in emergency department visits associated with cannabis use among older adults in California, 2005-2019.

UC San Diego Previously Published Works (2023)

BACKGROUND: The use of cannabis among older adults is increasing in the United States. While cannabis use has been suggested to help alleviate chronic symptoms experienced by older adults, its potential adverse effects may lead to unintended consequences, including increased acute healthcare utilization related to its use. The objective of this study was to examine trends in cannabis-related emergency department (ED) visits in California. METHODS: Using data from the Department of Healthcare Access and Information, we conducted a trend analysis of cannabis-related ED visits from all acute care hospitals in California from 2005 to 2019. For each calendar year, we determined the cannabis-related ED visit rate per 100,000 ED visits for adults aged ≥65 utilizing primary or secondary diagnosis codes. We estimated the absolute and relative changes in overall cannabis-related visit rates during the study period and by subgroup, including age (65-74, 75-84, ≥85), race/ethnicity, sex, payer/insurance, Charlson comorbidity index score, and cannabis-related diagnosis code. RESULTS: The cannabis-related ED visit rate increased significantly for adults aged ≥65 and all subgroups (p < 0.001). The overall rate increased from 20.7 per 100,000 visits in 2005 to 395.0 per 100,000 ED visits in 2019, a 1804% relative increase. By race/ethnicity, older Black adults had the highest ED visit rate in 2019 and the largest absolute increase while older males had a higher ED visit rate in 2019 and a greater absolute increase than older women. Older adults with a higher Charlson score had a higher ED visit rate in 2019 and a larger absolute increase during the study period. CONCLUSION: Cannabis-related ED visits are increasing among older adults in California and are an adverse effect of cannabis use. Asking about cannabis use and providing education about its use should be a part of routine medical care for older adults.

Cover page: Trends in emergency department visits associated with cannabis use among older adults in California, 2005-2019.

Article
Peer Reviewed

Who’s My Doctor? Using an Electronic Tool to Improve Team Member Identification on an Inpatient Pediatrics Team

UC San Diego Previously Published Works (2016)

Objectives

Increase parent/caregiver ability to correctly identify the attending in charge and define terminology of treatment team members (TTMs). We hypothesized that correct TTM identification would increase with use of an electronic communication tool. Secondary aims included assessing subjects' satisfaction with and trust of TTM and interest in computer activities during hospitalization.

Methods

Two similar groups of parents/legal guardians/primary caregivers of children admitted to the Pediatric Hospital Medicine teaching service with an unplanned first admission were surveyed before (Phase 1) and after (Phase 2) implementation of a novel electronic medical record (EMR)-based tool with names, photos, and definitions of TTMs. Physicians were also surveyed only during Phase 1. Surveys assessed TTM identification, satisfaction, trust, and computer use.

Results

More subjects in Phase 2 correctly identified attending physicians by name (71% vs. 28%, P < .001) and correctly defined terms intern, resident, and attending (P ≤ .03) compared with Phase 1. Almost all subjects (>79%) and TTMs (>87%) reported that subjects' ability to identify TTMs moderately or strongly impacted satisfaction and trust. The majority of subjects expressed interest in using computers to understand TTMs in each phase.

Conclusions

Subjects' ability to correctly identify attending physicians and define TTMs was significantly greater for those who used our tool. In our study, subjects reported that TTM identification impacted aspects of the TTM relationship, yet few could correctly identify TTMs before tool use. This pilot study showed early success in engaging subjects with the EMR in the hospital and suggests that families would engage in computer-based activities in this setting.

Cover page: Who’s My Doctor? Using an Electronic Tool to Improve Team Member Identification on an Inpatient Pediatrics Team

Article

Physiological effects of a spit sock

Independent Study Projects (2018)

Healthcare providers and law enforcement utilize spit socks to provide a direct method of universal precautions to prevent exposure to communicable diseases transmitted by bodily fluid projection from an agitated or altered individual. There are cases in which death of an individual is reported in part to have occurred from adequate breathing being limited or reduced by use of a spit sock. There are no formally published studies on the use and safety of spit socks in the medical literature. The aim of this study was to evaluate whether there is a clinically significant impact on breathing and ventilation in subjects with a protective spit sock placed on their head. This prospective study evaluated the effect of spit sock application on vital signs and ventilatory parameters of health adult volunteers, compared to baseline parameters without the spit sock. The subjects were placed on a chair and baseline vital signs and ventilatory parameters were taken, including heart rate, oxygen saturation, blood pressure, respiratory rate, and end-tidal CO₂. The subjects then sat with the spit mask over their heads for 15 minutes and their vital signs and ventilatory parameters were recorded after 5min, 10min and 15min of wearing the mask. Vital signs and ventilatory parameters at 5, 10, and 15 minutes after wearing the spit sock were compared to baseline using student's t-test with 95% confidence intervals using SPSS. Results: a total of 15 subjects completed the study. The median age was 28 years and 53% were male. There was no significant difference between baseline and wearing the spit sock for 5, 10, or 15 minutes for heart rat (p=0.250, p=0.181, p=0.546 respectively), oxygen saturation (p=o.334, p=1.00, p=0.173 respectively), end-tidal pCO₂ (p=0.135, p-0.384, p=0.187 respectively), and diastolic blood pressure (p=0.485, p-0.508, p=0.915 respectively). For respiratory rate, the difference between baseline rate and rate after spit sock application was not significant after 5 and 10 minutes (p=0.898 and p=0.583, respectively), but had a statistically significant decrease at 15 minutes (p=0.048). The systolic blood pressure was significantly lower after 5 and 10 minutes of spit sock applications (p=0.028 and p=0.045, respectively), but not significantly different at 15 minutes (p=0.146). No subject indicated any distress nor did the study need to be terminated early due to pre-determined concerning vital signs or ventilatory parameters. Conclusions: In healthy subjects there were no clinically significant changes in the physiologic parameters of breathing while wearing a spit sock. This study offers a foundation for further research into the use and safety of spit socks.

Cover page: Physiological effects of a spit sock

Article
Peer Reviewed

Inpatient Readmissions and Emergency Department Visits within 30 Days of a Hospital Admission

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 16, Issue 7 (2015)

Introduction: Inpatient hospital readmissions have become a focus for healthcare reform and cost-containment efforts. Initiatives targeting unanticipated readmissions have included care coordination for specific high readmission diseases and patients and health coaching during the post-discharge transition period. However, little research has focused on emergency department (ED) visits following an inpatient admission. The objective of this study was to assess 30-day ED utilization and all-cause readmissions following a hospital admission.

Methods: This was a retrospective study using inpatient and ED utilization data from two hospitals with a shared patient population in 2011. We assessed the 30-day ED visit rate and 30-day readmission rate and compared patient characteristics among individuals with 30-day inpatient readmissions, 30-day ED discharges, and no 30-day visits.

Results: There were 13,449 patients who met the criteria of an index visit. Overall, 2,453 (18.2%) patients had an ED visit within 30 days of an inpatient stay. However, only 55.6% (n=1,363) of these patients were admitted at one of these 30-day visits, resulting in a 30-day all-cause readmission rate of 10.1%.

Conclusion: Approximately one in five patients presented to the ED within 30 days of an inpatient hospitalization and over half of these patients were readmitted. Readmission measures that incorporate ED visits following an inpatient stay might better inform interventions to reduce avoidable readmissions.

Cover page: Inpatient Readmissions and Emergency Department Visits within 30 Days of a Hospital Admission

Creative Commons 'BY' version 4.0 license

Article
Peer Reviewed

Geriatric Falls: Patient Characteristics Associated with Emergency Department Revisits

Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 23, Issue 5 (2022)

Introduction: Falls are the leading cause of traumatic injury among elderly adults in the United States, which represents a significant source of morbidity and leads to exorbitant healthcare costs. The purpose of this study was to characterize elderly fall patients and identify risk factors associated with seven-day emergency department (ED) revisits.

Methods: This was a multicenter, retrospective, longitudinal cohort study using non-public data from 321 licensed, nonfederal, general, and acute care hospitals in California obtained from the Department of Healthcare Access and Information from January 1–December 31, 2017. Included were patients 65 and older who had a fall-related ED visit identified by International Classification of Diseases codes W00x to W19x. Primary outcome was a return visit to the ED within a seven-day window following the index encounter. Demographics collected included age, gender, ethnicity/race, patient payer status, Charlson Comorbidity Index (CCI), psychiatric diagnoses, and alcohol/substance use disorder diagnoses. We performed multivariate logistic regression to identify characteristics associated with seven-day ED revisit.

Results: We identified a total of 2,758,295 ED visits during the study period with 347,233 (12.6%) visits corresponding to fall-related injuries. After applying exclusion criteria, 242,572 index ED visits were identified, representing 206,612 patients. Of these, 24,114 (11.7%) patients returned to an ED within seven days (revisit). Within this revisit population, 6,161 (22.6%) presented to a facility that was distinct from their index visit, and 4,970 (18.2%) were ultimately discharged with the same primary diagnosis as their index visit. Characteristics with the largest independent associations with a seven-day ED revisit were presence of a psychiatric diagnosis (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.69 to 1.80), presence of an alcohol or substance use disorder (OR 1.70; 95% CI 1.64 to 1.78), and CCI ≥ 3 (OR 2.79; 95% CI 2.68 to 2.90).

Conclusion: In this study we identified 24,114 elderly fall patients who experienced a seven-day ED revisit. Patients with multiple comorbidities, a substance use disorder, or a psychiatric diagnosis exhibited increased odds of experiencing a return visit to the ED within seven days of a fall-related index visit. These findings will help target at-risk elderly fall patients who may benefit from preventative multidisciplinary intervention during index ED visits to reduce ED revisits.

Cover page: Geriatric Falls: Patient Characteristics Associated with Emergency Department Revisits

Article
Peer Reviewed

Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department.

UC San Diego Previously Published Works (2021)

Background

There is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults.