The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis

Retrospective Cohort Study of the 12-Month Epidemiology, Treatment Patterns, Outcomes, and Healthcare Costs Among Adult Patients with Complicated Urinary Tract Infections

Background

Limited data are available in the United States on the 12-month epidemiology, outpatient (OP) antibiotic treatment patterns, outcomes, and costs associated with complicated urinary tract infections (cUTIs) in adult patients.

Methods

A retrospective observational cohort study of adult patients with incident cUTIs in IBM MarketScan Databases between 2017 and 2019 was performed. Patients were categorized as OP or inpatient (IP) based on initial setting of care for index cUTI and were stratified by age (<65 years vs ≥65 years). OP antibiotic treatment patterns, outcomes, and costs associated with cUTIs among adult patients over a 12-month follow-up period were examined.

Results

During the study period, 95 322 patients met inclusion criteria. Most patients were OPs (84%) and age <65 years (87%). Treatment failure (receipt of new unique OP antibiotic or cUTI-related ED visit/IP admission) occurred in 23% and 34% of OPs aged <65 years and ≥65 years, respectively. Treatment failure was observed in >38% of IPs, irrespective of age. Across both cohorts and age strata, >78% received ≥2 unique OP antibiotics, >34% received ≥4 unique OP antibiotics, >16% received repeat OP antibiotics, and >33% received ≥1 intravenous (IV) OP antibiotics. The mean 12-month cUTI-related total health care costs were $4697 for OPs age <65 years, $8924 for OPs age >65 years, $15 401 for IPs age <65 years, and $17 431 for IPs age ≥65 years.

Conclusions

These findings highlight the substantial 12-month health care burden associated with cUTIs and underscore the need for new outpatient treatment approaches that reduce the persistent or recurrent nature of many cUTIs.

The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community

Introduction: Scant data are available on the 30-day financial burden associated with incident complicated urinary tract infections (cUTIs) in a cohort of predominately elderly patients. This study sought to examine total and cUTI-related 30-day Medicare spending (MS), a proxy for healthcare costs, among Medicare fee-for-service (FFS) beneficiaries who resided in the community with newly diagnosed cUTIs. Methods: A retrospective multicenter cohort study of adult beneficiaries in the Medicare FFS database with a cUTI between 2017 and 2018 was performed. Patients were included if they were enrolled in Medicare FFS and Medicare Part D from 2016 to 2019, had a cUTI first diagnosis in 2017–2018, no evidence of any UTI diagnoses in 2016, and residence in the community between 2016 and 2018. Results: During the study period, 723,324 cases occurred in Medicare beneficiaries who met the study criteria. Overall and cUTI-related 30-day MS were $7.6 and $4.5 billion, respectively. The average overall and cUTI-related 30-day MS per beneficiary were $10,527 and $6181, respectively. The major driver of cUTI-related 30-day MS was acute care hospitalizations ($3.2 billion) and the average overall and cUTI-related 30-day MS per hospitalizations were $16,431 and $15,438, respectively. Conclusion: Overall 30-day MS for Medicare FSS patients who resided in the community with incident cUTIs was substantial, with cUTI-related MS accounting for 59%. As the major driver of cUTI-related 30-day MS was acute care hospitalizations, healthcare systems should develop well-defined criteria for hospital admissions that aim to avert hospitalizations in clinically stable patients and expedite the transition of patients to the outpatient setting to complete their care.

Hospital admission patterns of adult patients with complicated urinary tract infections who present to the hospital by disease acuity and comorbid conditions: How many admissions are potentially avoidable?

BACKGROUND

Hospital admissions for complicated urinary tract infections (cUTI) in the United States are increasing but there are limited information on the acuity of patients who are admitted.

OBJECTIVE

Describe hospitalization patterns among adult cUTI patients who present to the hospital with cUTI and to determine the proportion of admissions that were of low acuity.

METHODS

A retrospective multi-center analysis using data from the Premier Healthcare Database (2013-2018) was performed.

INCLUSION CRITERIA

age ≥ 18 years, cUTI diagnosis, positive blood or urine culture. Hospital admissions were stratified by presence of sepsis, systemic symptoms but no sepsis, and Charlson Comorbidity Index (CCI).

RESULTS

187,789 patients met the inclusion criteria. The mean (SD) age was 59.7 (21.9), 40.4% were male, 29.4% had sepsis, 16.7% had at least 1 systemic symptom (but no sepsis), and 53.9% had no sepsis or systemic symptoms. The median [inter-quartile range] CCI was 1 [0, 3]. Sixty-four percent of patients were admitted to hospital, and 18.9% of admissions occurred in patients with low acuity (no sepsis or systemic symptoms and a CCI ≤ 2). The median [IQR] LOS and costs for low acuity inpatients who were admitted were 3 [2, 5] days and $5,575 [$3,607, $9,133], respectively.

CONCLUSION

Nearly 1 in 5 cUTI hospital admissions occurred in patients with low acuity, and therefore may be avoidable.

Management of acute pyelonephritis in the emergency department observation unit

INTRODUCTION

This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre.

METHODS

We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes.

RESULTS

Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful.

CONCLUSION

EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

Acute Pyelonephritis in Emergency Medicine Ward: A Four Years Retrospective Review

Objective

To study the characteristics of patients with acute pyelonephritis (AP) admitted to the emergency medicine ward (EMW) and sensitivity pattern of bacteria cultured from urine as well as to find out which antibiotic should be the best empirical treatment.

Methods

This was a retrospective study. All patient diagnosed with AP admitted to the EMW in Tuen Mun Hospital from January 2007 to December 2010 were included in this study. Data on patients' demographics, length of stay, urine culture and antibiotic sensitivity results as well as the types of antibiotics administered to them were collected and analysed.

Results

Altogether 308 patients were admitted to the EMW during the study period, accounting for 58% of all hospital admissions with the same diagnosis. There were comparatively more female patients (p<0.001) and fewer patients with diabetes (p<0.001) admitted to the EMW compared with other departments. The mean length of stay in EMW (2.2 days) was significantly shorter than that in other departments (7.1 days) (p<0.001). E. Coli was the commonest cultured bacterium, accounting for 94% of all positive growths. Cefuroxime sodium had high sensitivity (84%) in treating AP, which was significantly higher than that of amoxicillin-clavulanate (75%) (p<0.001). Levofloxacin also had high sensitivity (86%) but the difference between cefuroxime sodium and levofloxacin was not statistically significant (p=0.67).

Conclusions

Patients with AP admitted to local EMWs should be given either cefuroxime sodium intravenously or levofloxacin orally (if they can tolerate oral intake) as empirical treatments. Oral levofloxacin can be continued upon discharge.

Expedited Discharge from an Academic Emergency Department: A Pilot Program

BACKGROUND

As the numbers of emergency department (ED) visits and inpatient admissions continue to increase, there is growing interest in alternatives to inpatient hospitalization.

OBJECTIVE

Our aim was to investigate a novel approach to expediting discharges from the ED with multidisciplinary discharge services to prevent an avoidable admission into the hospital.

METHODS

This pilot study was conducted at a large urban tertiary-care ED in 2016. All patients presenting to the ED with planned inpatient or observation admission were considered for discharge with enhanced discharge planning services. The patients selected, discharge diagnoses, and outcomes were analyzed by descriptive statistics. This study was approved by the study site's Institutional Review Board, including waiver of patient consent.

RESULTS

During the pilot period, 57 out of 143 (40%) selected patients with planned admission were discharged with enhanced discharge planning services. Median ED length of stay was 17.2 h and mean patient age was 73 years old. Of these patients, 7 (12%) returned within 72 h and 4 (0.07%) were subsequently admitted to the hospital.

CONCLUSIONS

In this pilot study, a novel approach to expediting discharges from the ED with multidisciplinary discharge services was feasible and resulted in fewer admissions to the hospital.

Observation Units as Substitutes for Hospitalization or Home Discharge

STUDY OBJECTIVE

Observation unit admissions have been increasing, a trend that will likely continue because of recent changes in reimbursement policies. The purpose of this study is to determine the effect of the availability of observation units on hospitalizations and discharges to home for emergency department (ED) patients.

METHODS

We studied ED visits with a final diagnosis of chest pain in the National Hospital Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an observation unit admission were propensity-score matched to visits at hospitals without an observation unit. We used logistic regression to develop a prediction model for hospitalization versus discharge home for matched patients treated at nonobservation hospitals. The model was applied to matched observation unit patients to determine the likely alternative disposition had the observation unit not been available.

RESULTS

There were 1,325 eligible visits that represented 5,079,154 visits in the United States. Two hundred twenty-seven visits resulted in an observation unit admission. The predictive model for hospitalization had a c statistic of 0.91; variables significantly associated with subsequent hospitalization included age, history of coronary atherosclerosis, systolic blood pressure less than 115 beats/min, and administration of antianginal medications. When the model was applied to matched observation unit patients, 49.9% of them were categorized as discharge home likely.

CONCLUSION

In this study, we estimated that half of ED visits for chest pain that resulted in an observation unit admission were made by patients who may have been discharged home had the observation unit not been available. Increased availability of observation units may result in both decreased hospitalizations and decreased discharges to home.

Assessing the Physical Environment of Emergency Departments

Background:

Emergency Department (ED) is considered to be the heart of a hospital. Based on many studies, a well-organized physical environment can enhance efficacy.

Objectives:

In this study, we aimed to investigate the influence of physical environment in EDs on efficacy.

Materials and Methods:

This analytical cross-sectional study was conducted via the faculty members of the ED and residents of Shahid Beheshti University of Medical Sciences in Tehran, Iran. Data were collected using a predefined questionnaire. Descriptive statistics and ANOVA were used to analyze the data.

Results:

Sixty-two participants, including 21 females and 41 males, completed the questionnaires. The mean age of the participants was 37 years (SD: 8.42). The mean work experience was 8 years (SD: 4.52) and all the studied variables varied within a range of 3.3 - 4.2. Time indices had the highest mean among variables followed by capacity, work space, treatment units, critical care units and, triage indices, respectively.

Conclusions:

In general, time indices including length of patient stay in the ED and space capacity, emphasizing the need to address these shortcomings.

Variation in readmission rates by emergency departments and emergency department providers caring for patients after discharge

BACKGROUND

The role of the emergency department (ED) provider and ED facility in readmissions of recently discharged patients who visit the ED has not been studied.

OBJECTIVE

To determine the variation in readmission rates by ED facility and ED providers caring for patients after discharge.

DESIGN

Retrospective cohort study using multilevel, multivariable models of 100% Texas Medicare claims data from the years 2007 to 2011.

SETTING

Texas acute-care hospitals and ED facilities.

PATIENTS

Medicare beneficiaries who visited an ED within 30 days of discharge from a hospital.

INTERVENTION

None.

MEASUREMENT

Readmission after an ED visit within 30 days of discharge from an initial hospitalization defined as a hospitalization starting the day of or the day following the ED visit.

RESULTS

The mean readmission rate following an ED visit was 52.67%. In 2-level models, 14.2% of ED providers readmitted significantly more patients (mean readmission rate of 67.2%) than the mean; 14.7% of ED providers readmitted significantly fewer patients (mean readmission rate of 36.8%) than the mean. After accounting for the ED facility in 3-level models, the variance for the ED providers decreased 65% from 0.2532 to 0.0893.

CONCLUSIONS

The risk of readmission varies by ED provider caring for patients after discharge. A large part of this variation is explained by the ED facility in which the ED providers practice. Thus, ED provider practices patterns and ED facility systems of care may be a target for interventions to reduce readmissions.

Emergency department observation units and the older patient

An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.

Using Data to Drive Emergency Department Design: A Metasynthesis

Objective:

There has been an uptick in the field of emergency department (ED) operations research and data gathering, both published and unpublished. This new information has implications for ED design. The specialty suffers from an inability to have these innovations reach frontline practitioners, let alone design professionals and architects. This paper is an attempt to synthesize for design professionals the growing data regarding ED operations.

Methods:

The following sources were used to capture and summarize the research and data collections available regarding ED operations: the Emergency Department Benchmarking Alliance database; a literature search using both PubMed and Google Scholar search engines; and data presented at conferences and proceedings.

Results:

Critical information that affects ED design strategies is summarized, organized, and presented. Data suggest an optimal size for ED functional units. The now-recognized arrival and census curves for the ED suggest a department that expands and contracts in response to changing census. Operational improvements have been clearly identified and are grouped into three categories: input, throughput, and outflow. Applications of this information are suggested.

Conclusion:

The sentinel premise of this meta-synthesis is that data derived from improvement work in the area of ED operations has applications for ED design. EDs can optimize their functioning by marrying good processes and operations to good design. This review paper is an attempt to bring this new information to the attention of the multidisciplinary team of architects, designers, and clinicians.

Effect of advanced age and vital signs on admission from an ED observation unit

OBJECTIVES

The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission.

METHODS

We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol.

RESULTS

Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72).

CONCLUSIONS

Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.