Introduction: Previous studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States.

Methods: We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18-54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge.

Results: The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic severity, those with no insurance were less likely to have guideline-recommended chronic asthma care – i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status.

Conclusion: In this multicenter observational study of ED patients with acute asthma, we found significant discrepancies in chronic asthma severity and management by insurance status. By contrast, there were no differences in acute asthma management among the insurance groups.

Introduction: 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.

Methods: 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.

Results: 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.

Conclusions: 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. [West J Emerg Med. 2013;14(3):287–295.]

Introduction: Despite the growing number of freestanding emergency departments (FSED) in the United States (US), FSED definitions differ across major US data sources of healthcare facilities and use. We compare these sources and propose a universal definition of FSED (and its two major types) to improve communications regarding these facilities and their patients.

Methods: We collected definitions of FSEDs from 11 national data sources using their websites, email, and telephone communications. For each source, we asked how they define FSEDs, whether being open 24/7 is a requirement to be called an ED, and whether they maintain a dataset of FSEDs.

Results: Definitions varied across the data sources. All sources recognize FSEDs in their definitions, regardless of type; only one (the National Health Intervew Survey) does not differentiate them from other EDs. Five of the 11 sources (45%) omit autonomous FSEDs from their definitions and do not separately identify satellite FSEDs from their affiliated hospitals. One source does separately identify satellite FSEDs from their affiliated hospitals, but also omits autonomous FSEDs. Furthermore, three of the 11 sources (27%) do not require being open 24/7, while all others (73%) employ this criterion. Six of the 11 (55%) maintain datasets of FSEDs using their definition.

Conclusion: As FSEDs continue to change the landscape of emergency care, it is important that they also be represented in national ED data sources. The current differences in the definition of an FSED make it difficult to provide accurate and longitudinal analysis for these facilities and patients who receive services at these facilities. We propose a universal definition of FSEDs as described by both the American College of Emergency Physicians and the National Emergency Department Inventory. Implementing a standard definition would facilitate a more accurate representation of FSEDs in national data sources and enhance ongoing efforts to improve the quality of emergency care delivered in FSEDs.

Introduction: Growing evidence supports emergency physician (EP)-performed point-of-care ultrasound (PoC US). However, there is a utilization gap between academic emergency departments (ED) and other emergency settings. We elucidated barriers to PoC US use in a multistate sample of predominantly non-academic EDs to inform future strategies to increase PoC US utilization, particularly in non-academic centers.

Methods: In 2010, we surveyed ED directors in five states (Arkansas, Hawaii, Minnesota, Vermont, and Wyoming; n=242 EDs) about general ED characteristics. In four states we determined barriers to PoC US use, proportion of EPs using PoC US, use privileges, and whether EPs can bill for PoC US.

Results: Response rates were >80% in each state. Overall, 47% of EDs reported PoC US availability. Availability varied by state, from 34% of EDs in Arkansas to 85% in Vermont. Availability was associated with higher ED visit volume, and percent of EPs who were board certified/board eligible in emergency medicine. The greatest barriers to use were limited training (70%), expense (39%), and limited need (perceived or real) (32%). When PoC US was used by EPs, 50% used it daily, 44% had privileges not requiring radiology confirmation, and 34% could bill separately for PoC US. Only 12% of EPs used it ≥80% of the time when placing central venous lines.

Conclusion: Only 47% of EDs in our five-state sample of predominantly non-academic EDs had PoC US immediately available. When available, the greatest barriers to use were limited training, expense, and limited need. Recent educational and technical advancements may help overcome these barriers.

Introduction: Epidemiological surveillance data for emergency department (ED) visits by children areimperative to guide resource allocation and to develop health policies that advance pediatric emergencycare. However, there are sparse population-based data on patient-level information (e.g., the number ofchildren who present to the emergency department [ED]). In this context, we aimed to investigate boththe patient- and visit-level rates of ED utilization by children.

Methods: This was a retrospective cohort study using population-based multipayer data – state EDdatabases (SEDD) and state inpatient databases (SID) – from six geographically-dispersed U.S. states(California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all childrenaged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visitrate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDDand SID data. We also repeated the analysis using the 2010 data to determine the consistency of theresults across different years.

Results: In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states.At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of thesechildren, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across thestates (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At thevisit-level, 6.7 million ED visits were made by children in 2011 – 34 ED visits per 100 children annually.ED visits by children accounted for 22% of all ED visits (including both adults and children), with arelatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the2010 data gave similar results for the ED utilization by children.

Conclusion: By using large population-based data, we found a substantial burden of ED visits at bothpatient- and visit-levels. These findings provide a strong foundation for policy makers and professionalorganizations to strengthen emergency care for children.

Objective: 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.

Methods: 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.

Results: 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, P20%] 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).

Conclusion: 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. [West J Emerg Med. 2011;12(1):96-99.]

Introduction: Although bronchiolitis is a common reason for infant hospitalization, significant heterogeneity persists in its management. The American Academy of Pediatrics currently recommends that inhaled albuterol not be used in routine care of children with bronchiolitis. Our objective was to identify factors associated with pre-admission (e.g., emergency department or primary care) use of albuterol among infants hospitalized for bronchiolitis.

Methods: We analyzed data from a 17-center observational study of 1,016 infants (age <1 year) hospitalized with bronchiolitis between 2011-2014. Pre-admission albuterol use was ascertained by chart review, and data were available for 1,008 (99%) infants. We used multivariable logistic regression to identify infant characteristics independently associated with pre-admission albuterol use.

Results: Half of the infants (n=508) received at least one albuterol treatment before admission. Across the 17 hospitals, pre-admission albuterol use ranged from 23-84%. In adjusted analysis, independent predictors of albuterol use were the following: age ≥2 months (age 2.0-5.9 months [odds ratio (OR) 2.09, 95% confidence interval (CI) {1.45-3.01}] and age 6.0-11.9 months [OR 2.89, 95% CI {1.99-4.19}]); prior use of a bronchodilator (OR 1.89, 95% CI [1.24-2.90]); and presence of wheezing documented in pre-admission chart (OR 3.94, 95% CI [2.61-5.93]). By contrast, albuterol use was less likely among those with ≥7 days since the start of breathing problem (OR 0.66, 95% CI [0.44-1.00]) and parent-reported fever (OR 0.75, 95% CI [0.58-0.96]).

Conclusion: Variation in pre-admission albuterol use suggests that local practice had a strong influence on use, but that patient characteristics also influenced the decision. While we agree with current guidelines in recommending against albuterol for all infants with bronchiolitis, our understanding of possible subgroups of responders may improve through investigation of infants with the identified characteristics.

Introduction: Telemedicine connects emergency departments (ED) with resources necessaryfor patient care; its use has not been characterized nationally, or even regionally. Our primaryobjective was to describe the prevalence of telemedicine use in New England EDs and theclinical applications of use. Secondarily, we aimed to determine if telemedicine use wasassociated with consultant availability and to identify ED characteristics associated withtelemedicine use.

Methods: We analyzed data from the National Emergency Department Inventory-New Englandsurvey, which assessed basic ED characteristics in 2014. The survey queried directors of everyED (n=195) in the six New England states (excluding federal hospitals and college infirmaries).Descriptive statistics characterized ED telemedicine use; multivariable logistic regressionidentified independent predictors of use.

Results: Of the 169 responding EDs (87% response rate), 82 (49%) reported usingtelemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of nonusers,p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); andless likely to have 24/7 access to neurology (p<0.001), neurosurgery (p<0.001), orthopedics(p=0.01), plastic surgery (p=0.01), psychiatry (p<0.001), and hand surgery (p<0.001)consultants. Neuro/stroke (68%), pediatrics (11%), psychiatry (11%), and trauma (10%) were themost commonly reported applications. On multivariable analysis, telemedicine was more likely inrural EDs (odds ratio [OR] 4.39, 95% confidence interval [CI] 1. 30-14.86), and less likely in EDswith 24/7 neurologist availability (OR 0.21, 95% CI [0.09-0.49] ), and annual volume <20,000 (OR0.24, 95% CI [0.08-0.68]).

Conclusion: Telemedicine is commonly used in New England EDs. In 2014, use was morecommon among rural EDs and EDs with limited neurology consultant availability. In contrast,telemedicine use was less common among very low-volume EDs.

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