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Background and objectives: A better characterization of deaths in children following emergency care is needed to inform timely interventions. This study aimed to describe the timing, location, and causes of death to 1 year among a cohort of injured and medically ill children. Methods: We conducted a retrospective cohort study of children <18 years requiring emergency care in six states from January 1, 2012, through December 31, 2017, with follow‐up through December 31, 2018, for patients who were not discharged from the emergency department (ED). In this cohort, 1‐year mortality, time to death within 1 year, and causes of death were assessed from ED, inpatient, and vital status records. Results: There were 546,044 children during the 6‐year period. The 1‐year mortality rate was 2.2% (n = 1356) for injured children and 1.4% (n = 6687) for medically ill children. Matched death certificates were available for 861 (63.5%) of 1356 deaths in the injury cohort and for 4712 (70.5%) of 6687 deaths in the medical cohort. Among deaths in the injury cohort, 1274 (94.0%) occurred in the ED or hospital. The most common causes of death were motor vehicle collisions, firearm injuries, and pedestrian injuries. Among the 6687 deaths in the medical cohort, 5081 (76.0%) children died in the ED or hospital (primarily in the ED) and 1606 (24.0%) occurred after hospital discharge. The most common causes of death were sudden infant death syndrome, suffocation and drowning, and congenital conditions. Conclusions: The 1‐year mortality of children presenting to an ED is 2.2% for injured children and 1.4% for medically ill children with most deaths occurring in the ED. Future interventional trials, quality improvement efforts, and health policy focused in the ED could have the potential to improve outcomes of pediatric patients. [ABSTRACT FROM AUTHOR]

Whether ambulance transport patterns are optimized to match children to high-readiness emergency departments (EDs) and the resulting effect on survival are unknown. We quantified the number of children transported by 9-1-1 emergency medical services (EMS) to high-readiness EDs, additional children within 30 minutes of a high-readiness ED, and the estimated effect on survival. This was a cross-sectional study using data from the National EMS Information System for 5,461 EMS agencies in 28 states from 1/1/2012 through 12/31/2019, matched to the 2013 National Pediatric Readiness Project assessment of ED pediatric readiness. We performed a geospatial analysis of children 0 to 17 years requiring 9-1-1 EMS transport to acute care hospitals, including day-, time-, and traffic-adjusted estimates for driving times to all EDs within 30 minutes of the scene. We categorized receiving hospitals by quartile of ED pediatric readiness using the weighted Pediatric Readiness Score (wPRS, range 0-100) and defined a high-risk subgroup of children as a proxy for admission. We used published estimates for the survival benefit of high readiness EDs to estimate the number of lives saved. There were 808,536 children transported by EMS, of whom 253,541 (31.4%) were high-risk. Among the 2,261 receiving hospitals, the median wPRS was 70 (IQR 57-85, range 26-100) and the median number of receiving hospitals within 30 minutes was 4 per child (IQR 2-11, range 1 to 53). Among all children, 411,685 (50.9%) were taken to EDs in the highest quartile of pediatric readiness, and 180,547 (22.3%) children transported to lower readiness EDs were within 30 minutes of a high readiness ED. Findings were similar among high-risk children. Based on high-risk children, we estimated that 3,050 pediatric lives were saved by transport to high-readiness EDs and an additional 1,719 lives could have been saved by shifting transports to high readiness EDs within 30 minutes. Approximately half of children transported by EMS were taken to high-readiness EDs and an additional one quarter could have been transported to such an ED, with measurable effect on survival. [ABSTRACT FROM AUTHOR]

Introduction: Older adults who fall commonly require emergency services, but research on longterm outcomes and prognostication is sparse. We evaluated older adults transported by ambulance after a fall in the Northwestern United States (US) and longitudinally tracked subsequent healthcare use, transitions to skilled nursing, hospice, mortality, and prognostication to one year. Methods: This was a planned secondary analysis of a cohort study of community-dwelling older adults enrolled from January 1--December 31, 2011, with follow-up through December 31, 2012. We included all adults ≥ 65 years transported by 44 emergency medical services agencies in seven Northwest counties to 51 hospitals after a fall. We matched Medicare claims, state inpatient data, state trauma registry data, and death records. Outcomes included mortality, healthcare use, and new claims for skilled nursing and hospice to one year. Results: There were 3,159 older adults, with 147 (4.7%) deaths within 30 days and 665 (21.1%) deaths within one year. There was an initial spike in inpatient days, followed by increases in skilled nursing and hospice. We identified four predictors of mortality: respiratory diagnosis; serious brain injury; baseline disability; and Charlson Comorbidity Index ≥ 2. Having any of these predictors was 96.6% sensitive (95% confidence interval [CI]: 95.7, 97.5%) and 21.4% specific (95% CI: 19.9, 22.9%) for 30-day mortality, and 91.6% sensitive (95% CI: 89.5, 93.8%). and 23.8% specific (95% CI: 22.1, 25.5%) for one-year mortality. Conclusion: Community-dwelling older adults requiring ambulance transport after a fall have marked increases in healthcare use, institutionalized living, and mortality over the subsequent year. Most deaths occur following the acute care period and can be identified with high sensitivity at the time of the index visit, yet with low specificity. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVE: The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community‐dwelling older adults who fell and required ambulance transport, including acute versus post‐acute periods, the primary drivers of cost, and comparison to baseline expenditures. DESIGN: Retrospective cohort analysis. SETTING: Forty‐four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow‐up through December 31, 2012. PARTICIPANTS: We included 2,494 community‐dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee‐for‐service Medicare coverage. MEASUREMENTS: The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post‐acute periods and by cost category. We included 48 variables in a standardized risk‐adjustment model to generate adjusted cost estimates. RESULTS: The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634–$68,086), including acute care median $1,957 (IQR = $1,298–$12,924) and post‐acute median $20,560 (IQR = $5,673–$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479–$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = −$185 to $51,189). CONCLUSION: Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post‐acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs. [ABSTRACT FROM AUTHOR]

Introduction: Current U.S. cardiology guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in selected patients with atrial fibrillation (AF), but no formal AF OAC recommendations exist to guide emergency medicine clinicians in the acute care setting. We sought to characterize emergency department (ED) OAC prescribing practices after an ED AF diagnosis. Methods: This retrospective study included index visits for OAC-naive patients ≥18 years old who were discharged home from the ED at an urban, academic, tertiary hospital with a primary diagnosis of AF from 2012-2014. Five hypothesis-blinded, chart reviewers abstracted data from patient problem lists and medical history in the electronic health record to assess stroke (CHA2DS2-VASc) and bleeding risk (HAS-BLED). The primary outcome was the provision of an OAC prescription at discharge in OAC-naive patients with high stroke risk. Descriptive statistics and multivariable logistic regression assessed associations between OAC prescription and patient characteristics. Results: We included 138 patient visits in our analysis, of whom 39.9% (n = 55) were low stroke risk (CHA2DS2-VASc = 0 in males and 1 in females), 15.9% (n = 22) were intermediate risk (CHA2DS2-VASc = 1 in males), and 44.2% (n = 61) were high risk (CHA2DS2-VASc ≥ 2). Of patients with high stroke risk and low-to-intermediate bleeding risk (n = 57), 80.7% were not prescribed an OAC at discharge. Cardiology consultation and female gender, but not stroke risk (CHA2DS2-VASc score), were predictors of an ED provider prescribing an OAC to an OAC-naive AF patient at ED discharge. Conclusion: The majority of OAC-eligible patients were discharged home without an OAC prescription. In OAC-naive patients discharged home from the ED, cardiology consultation and female gender were associated with OAC prescription. Our findings suggest that access to expert opinion may improve provider comfort with OAC prescribing and highlight the need for improved guidelines specific to ED-management of AF. [ABSTRACT FROM AUTHOR]

Objectives: Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30‐day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems. Methods: This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow‐up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30‐day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS). Results: There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI] = 83.0% to 91.5%) and 30.6% specificity (95% CI = 29.3% to 31.9%) for 30‐day mortality (area under the receiving operating characteristic curve [AUROC] = 0.589, 95% CI = 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI). Conclusions: Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high‐risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive. [ABSTRACT FROM AUTHOR]

Objective The Institute of Medicine identified emergency department (ED) crowding as a critical threat to patient safety. We assess the association between changes in publicly reported ED length of stay (LOS) and changes in quality-of-care measures in a national cohort of hospitals. Methods Longitudinal analysis of 2012 and 2013 data from the American Hospital Association (AHA) Survey, Center for Medicare and Medicaid Services (CMS) Cost Reports, and CMS Hospital Compare. We included hospitals reporting Hospital Compare timeliness measure of LOS for admitted patients. We used AHA and CMS data to incorporate hospital predictors of interest. We used the method of first differences to test for relationships in the change over time between timeliness measures and six hospital-level measures. Results The cohort consisted of 2,619 hospitals. Each additional hour of ED LOS was associated with a 0.7% decrease in proportion of patients giving a top satisfaction rating, a 0.7% decrease in proportion of patients who would 'definitely recommend' the hospital, and a 6-minute increase in time to pain management for long bone fracture (p < 0.01 for all). A 1-hour increase in ED LOS is associated with a 44% increase in the odds of having an increase in left without being seen (95% confidence interval = 25% to 68%). ED LOS was not associated with hospital readmissions (p = 0.14) or time to percutaneous coronary intervention (p = 0.14). Conclusion In this longitudinal study of hospitals across the United States, improvements in ED timeliness measures are associated with improvements in the patient experience. [ABSTRACT FROM AUTHOR]

Introduction: Oral anticoagulation (OAC) can reduce stroke and mortality risk in patients with atrial fibrillation (AF); however, clinical outcomes associated with OAC prescription after a US emergency department (ED) discharge are unknown. Objective: To determine the impact of early OAC prescribing on ischemic stroke and major bleeding after ED evaluation for AF. Methods: This retrospective study included Medicare, fee-for-service patients (age ≥65yrs) discharged from the ED in 2011-2012 with newly diagnosed actionable AF— high-stroke risk (by CHA2DS2-VASc) with low-bleeding risk (by HAS-BLED), and no OAC prescription filled 90 days prior. Patients were stratified as receipt of an early OAC prescription (by any provider) within 10 days of ED diagnosis and no early OAC. Ischemic strokes were identified via ICD-9 codes from inpatient claims. Major bleeding was identified using prior validated algorithms by ICD-9 diagnosis with requirement of admission. A blanking period of 10 days was used to exclude patients who were in the process of having an ischemic stroke at the index visit. Time to ischemic stroke and major bleeding in patients with actionable AF were compared using Kaplan Meier curves and a Cox proportional hazards model with propensity score weights and a correction for clustering on facility. Results: Of 3,983 with new actionable AF, 25.4% were prescribed an early OAC, who were similar in mean age (77.4 vs. 78.2 yrs) and co-morbidities (mean Charlson score 2.1 vs. 2.3) to no early OAC group, but less likely to be female (69.4% vs. 76.3%) (p<0.001). Patients were followed for a median of 330 days with a maximum of 640 days. Among patients with actionable AF, there were no differences in hazards of ischemic stroke [HR 0.67(0.33-1.40)] nor major bleed [HR 1.45 (0.91-2.30)] (p>0.05) between the early vs. no OAC groups. However, KM curves suggest a trend towards fewer events among patients with early OACs, especially early in follow-up after ED visit. Conclusion: In patients with a new ED diagnosis of actionable AF, early OAC did not statistically affect clinical outcomes. However, there may be a clinically meaningful difference among those prescribed. Large and prospective studies are needed to elucidate the impact of early OAC prescribing on clinical outcomes. [ABSTRACT FROM AUTHOR]

Study Objective: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding.Methods: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators).Results: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability.Conclusion: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding. [ABSTRACT FROM AUTHOR]