Identifying trigger concepts to screen emergency department visits for diagnostic errors.

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.

Diagnostic Decision-Making in the Emergency Department.

Emergency medicine requires diagnosing unfamiliar patients with undifferentiated acute presentations. This requires hypothesis generation and questioning, examination, and testing. Balancing patient load, care across the severity spectrum, and frequent interruptions create time pressures that predispose humans to fast thinking or cognitive shortcuts, including cognitive biases.

True Costs of Medical Clearance: Accuracy and Disagreement between Psychiatry and Emergency Medicine Providers.

Introduction: Medical clearance is required to label patients with mental illness as free of acute medical concerns. However, tests may extend emergency department lengths of stay and increase costs to patients and hospitals. The objective of this study was to determine how knowledgeable emergency and psychiatric providers are about the costs of tests used for medical clearance.

The Role of Mental Health Disease in Potentially Preventable Hospitalizations: Findings From a Large State.

Background: Preventable hospitalizations are markers of potentially low-value care. Addressing the problem requires understanding their contributing factors.

Objective: The objective of this study is to determine the correlation between specific mental health diseases and each potentially preventable hospitalization as defined by the Agency for Healthcare Research and Quality.

Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury.

Objective: Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation.

Methods: We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures.

"What Do People Do If They Don't Have Insurance?": ED-to-ED Referrals.

Objective: Up to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore 1) whether patients making a repeat ED visit are self-referred or indirectly referred from the other ED and 2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits.

Methods: This mixed-methods study conducted over a 10-week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint.

The Changing Health Policy Environment and Behavioral Health Services Delivery.

Deinstitutionalization has left an inadequate supply of inpatient psychiatric beds. Simultaneous cuts to public funding and insurance coverage for outpatient mental health treatment have increased the frequency of acute psychiatric crises. The resulting lack of available options has shifted the burden of treatment to emergency departments and the criminal justice system.

The imperative for emergency medicine to create its own alternative payment model.

Seven years after the Affordable Care Act legislated Alternative Payment Models, it is time for Emergency Medicine to find its place within this value-based trend by developing its own Alternative Payment Model.

Value-Based Approaches for Emergency Care in a New Era.

Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients' longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care.

Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke.

Background: Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government-sponsored insurance had worse quality of care or in-hospital outcomes in acute ischemic stroke.

Methods And Results: Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in-hospital mortality and postdischarge destination.

Factors Associated With Potentially Preventable Pediatric Admissions Vary by Diagnosis: Findings From a Large State.

Objectives: The objective of this study was to determine characteristics associated with potentially preventable pediatric admissions as defined by the Agency for Healthcare Research and Quality.

Methods: The Texas Inpatient Public Use Data File, an administrative database of hospital admissions, identified 747 040 pediatric admissions ages 0 to 17 years to acute care facilities between 2005 and 2008. Potentially preventable admissions included 5 diagnoses: asthma, perforated appendicitis, diabetes, gastroenteritis, and urinary tract infection.

Indirect Referral of Orthopaedic Patients to a Safety-Net Hospital.

Objective: Patients seen in emergency departments (EDs) not requiring admission are typically discharged with appropriate follow-up. Sometimes hospitals indirectly refer, or redirect, patients to a different hospital's ED. Anecdotally, indirect referrals are commonly received in safety-net hospitals.

"I Broke My Ankle": Access to Orthopedic Follow-up Care by Insurance Status.

Objectives: While the Affordable Care Act seeks to reduce emergency department (ED) visits for outpatient-treatable conditions, it remains unclear whether Medicaid patients or the uninsured have adequate access to follow-up care. The goal of this study was to determine the availability of follow-up orthopedic care by insurance status.

Methods: Using simulated patient methodology, all 102 eligible general orthopedic practices in Dallas-Fort Worth, Texas, were contacted twice by a caller requesting follow-up for an ankle fracture diagnosed in a local ED using a standardized script that differed by insurance status.

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program.

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption.

Diagnostic errors related to acute abdominal pain in the emergency department.

Objective: Diagnostic errors in the emergency department (ED) are harmful and costly. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns.

Design: We conducted a retrospective chart review of ED patients >18 years at an urban academic hospital.

Nodal stage of surgically resected non-small cell lung cancer and its effect on recurrence patterns and overall survival.

Purpose: Current National Comprehensive Cancer Network guidelines recommend postoperative radiation therapy (PORT) for patients with resected non-small cell lung cancer (NSCLC) with N2 involvement. We investigated the relationship between nodal stage and local-regional recurrence (LR), distant recurrence (DR) and overall survival (OS) for patients having an R0 resection.

Methods And Materials: A multi-institutional database of consecutive patients undergoing R0 resection for stage I-IIIA NSCLC from 1995 to 2008 was used.

Injury type and emergency department management of orthopaedic patients influences follow-up rates.

Background: Orthopaedic clinic follow-up is required to ensure optimal management and outcome for many patients who present to the emergency department (ED) with an orthopaedic injury. While several studies have shown that demographic variables influence patient follow-up after discharge from the ED, the objective of this study was to examine orthopaedic-related and other factors associated with the failure to return for orthopaedic outpatient management, so-called "no-show," after an ED visit.

Methods: A chart review was conducted at a large academic public hospital.

Derangements of potassium.

Changes in potassium elimination, primarily due to the renal and GI systems, and shifting potassium between the intracellular and extracellular spaces cause potassium derangement. Symptoms are vague, but can be cardiac, musculoskeletal, or gastrointestinal. There are no absolute guidelines for when to treat, but it is generally recommended when the patient is symptomatic or has ECG changes.

Preparing for effective communications during disasters: lessons from a World Health Organization quality improvement project.

Background: One hundred ninety-four member nations turn to the World Health Organization (WHO) for guidance and assistance during disasters. Purposes of disaster communication include preventing panic, promoting appropriate health behaviors, coordinating response among stakeholders, advocating for affected populations, and mobilizing resources.

Methods: A quality improvement project was undertaken to gather expert consensus on best practices that could be used to improve WHO protocols for disaster communication.

Matched-pair and propensity score comparisons of outcomes of patients with clinical stage I non-small cell lung cancer treated with resection or stereotactic radiosurgery.

Background: Stereotactic body radiotherapy (SBRT) is an alternative to surgery for clinical stage I non-small cell lung cancer (NSCLC), but comparing its effectiveness is difficult because of differences in patient selection and staging.

Methods: Two databases were combined which contained patients treated from 1999 to 2008 by lobectomy (LR, n = 132), sublobar resection (SLR, n = 48), and SBRT (n = 137) after negative staging. Univariate and multivariate analysis were performed for survival (OS), total recurrence control (TRC comprises local-regional and distant control), and locoregional control (LRC) in our entire population.

Surgical management of early-stage non-small cell lung carcinoma and the present and future roles of adjuvant therapy: a review for the radiation oncologist.

We review the evidence for optimal surgical management and adjuvant therapy for patients with stages I and II non-small cell lung cancer (NSCLC) along with factors associated with increased risks of recurrence. Based on the current evidence, we recommend optimal use of mediastinal lymph node dissection, adjuvant chemotherapy, and post-operative radiation therapy, and make suggestions for areas to explore in future prospective randomized clinical trials.