Impact of the San Diego Serial Inebriate Program on Use of Emergency Medical Resources

Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors

OBJECTIVE

Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis.

METHODS

We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023).

RESULTS

Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20).

CONCLUSION

In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.

Comparison of 4 tests' utility for predicting need for emergency department care in patients with alcohol-related complaints

INTRODUCTION

Intoxication is a common presenting complaint in emergency departments (ED), but many patients with intoxication do not need emergency care. Three screens (BLINDED, Brown, and San Francisco) attempt to determine which intoxicated patients can be triaged to a lower level of care.

METHODS

Observational multi-center cohort study of patients presenting to one of three ED with complaints consistent with acute intoxication. When a qualifying patient was brought to the emergency department, a team member interviewed the triaging provider. Interviews covered all three screens and the provider's gestalt. Receiver operating curve (ROC) analysis was used to determine which screen performed best. Cases were reviewed to determine need for emergency care.

RESULTS

Of the 199 subjects studied, 91% (181/199) were male and were 50 years old on average (SD = 12 years). Of the 55 subjects tested (28%), their average alcohol level was 251 mg/dL (SD = 146 mg/dL). Only 117 subjects (59%) had complete information for inclusion in the final comparison of screens. Provider gestalt performed best (AUC = 0.69), but there were no meaningful differences between any of the screens (AUC = 0.62-0.66, p > 0.05 for all comparisons). Inability to sit up was sensitive for needing emergent care (88%), but it was non-specific (17%). Similarly, signs of trauma were specific (99%) for ED care, but insensitive (18%).

CONCLUSIONS

The three formal screens and provider gestalt performed similarly.

Sobering centers, emergency medical services, and emergency departments: A review of the literature

BACKGROUND

Acute alcohol intoxication accounts for a large proportion of potentially unnecessary emergency department visits and expenditure. Sobering centers are a cheaper alternative treatment option for alcohol intoxication and can provide an opportunity to treat the psychosocial aspects of alcohol use disorder.

OBJECTIVE OF THE REVIEW

The objective of this review is to analyze the existing literature regarding the use of sobering centers, EMS and their role in transporting to sobering centers, and the appropriate triage of the intoxicated patient.

DISCUSSION

Excessive alcohol consumption accounts for an estimated $24.6 billion in healthcare costs and patients are often referred to the emergency department for expensive care. Current literature suggests sobering centers are an alternative to acute hospitalization and are safe, relatively inexpensive, and may facilitate more aggressive connection to resources such as longitudinal rehabilitation programs for the acutely intoxicated patient. EMS plays a pivotal role in triage and transportation of intoxicated individuals, but demonstration of outcomes in lacking.

CONCLUSIONS

Sobering centers are a cost effective alternative to emergency department visits for acute alcohol intoxication and further research is required to identify safe, effective protocols for EMS to triage patients to appropriate treatment destinations.

Cost impact of sobering centers on national health care spending in the United States

Acute alcohol intoxication is responsible for a sizable share of emergency department visits. Intoxicated individuals without other medical needs may not require the high level of care provided by an emergency department. We estimate the impact on U.S. health care spending if individuals with uncomplicated, acute alcohol intoxication were treated in sobering centers instead of the emergency department. We performed a budget impact analysis from the perspective of the U.S. health care system based on published and gray literature reports. Ninety-five percent confidence intervals (CI) were estimated using Monte Carlo modeling with random variation for three variables (cost of an emergency department visit, cost of a sobering center visit, and start-up costs per sobering center visit) and the percentage of cases diverted from emergency departments to sobering centers. Outcomes were expressed in terms of national savings in 2017 U.S. dollars. Assuming a diversion rate of 50% based on previous studies, national savings range from $230 million to $1.0 billion annually. In the Monte Carlo modeling, we found annual national savings of $99.02 million (95% CI: $95.89-$102.19 million), $792.34 million (95% CI: $767.09-$817.58 million), and $1,185.51 million (95% CI: $1,150.64-$1,226.37 million) with diversion rates of 5%, 40%, and 60%, respectively. Implementing sobering centers as a treatment alternative for individuals with uncomplicated acute alcohol intoxication could yield substantial cost savings for the U.S. health care system.

Frequent Emergency Department Visitors Associated With a Pain-Discharge Diagnosis

BACKGROUND

Emergency departments (EDs) have experienced an increase in annual patient visits and length of stay over the past decade. Management of frequent-user patients with pain-related diagnoses are challenging in a time-limited setting.

OBJECTIVE

The purpose of this study was to describe characteristics of frequent ED users with pain-related diagnoses.

METHODS

This was a retrospective longitudinal cohort study of hospital ED visits from two EDs in using encounters from September 2016 to August 2018. Frequent users were characterized as having four or more visits in a 1-year period and were further classified into three categories based on the number of pain-related visits in the study period. Descriptive statistics and regression analysis results are reported for all demographic and clinical characteristics for index encounters, patient level data, and pain subgroups.

RESULTS

Of all patients, 11.3% (n = 5174) were identified as frequent users, accounting for 38.9% (n = 91,114) of all ED visits. Overall, frequent pain users were more likely to be of middle age (odds ratio [OR] 1.70, 95% confidence interval [CI] 0.80-1.72), female (OR 2.43, 95% CI 1.79-3.29), have commercial insurance (OR 1.91, 95% CI 1.37-2.66), and have 10 or more ED encounters (super user status) in a 12-month period (OR 23.66, 95% CI 17.12-32.71).

CONCLUSION

Understanding characteristics of ED frequent users with pain-related diagnoses may inform community-based interventions designed to reduce episodic care and thereby improve care coordination and management.

Evaluating alcohol intoxication management services: the EDARA mixed-methods study

Background

Front-line health-care services are under increased demand when acute alcohol intoxication is most common, which is in night-time environments. Cities have implemented alcohol intoxication management services to divert the intoxicated away from emergency care.

Objectives

To evaluate the effectiveness, cost-effectiveness and acceptability to patients and staff of alcohol intoxication management services and undertake an ethnographic study capturing front-line staff’s views on the impact of acute alcohol intoxication on their professional lives.

Methods

This was a controlled mixed-methods longitudinal observational study with an ethnographic evaluation in parallel. Six cities with alcohol intoxication management services were compared with six matched control cities to determine effects on key performance indicators (e.g. number of patients in the emergency department and ambulance response times). Surveys captured the impact of alcohol intoxication management services on the quality of care for patients in six alcohol intoxication management services, six emergency departments with local alcohol intoxication management services and six emergency departments without local alcohol intoxication management services. The ethnographic study considered front-line staff perceptions in two cities with alcohol intoxication management services and one city without alcohol intoxication management services.

Results

Alcohol intoxication management services typically operated in cities in which the incidence of acute alcohol intoxication was greatest. The per-session average number of attendances across all alcohol intoxication management services was low (mean 7.3, average minimum 2.8, average maximum 11.8) compared with the average number of emergency department attendances per alcohol intoxication management services session (mean 78.8), and the number of patients diverted away from emergency departments, per session, required for services to be considered cost-neutral was 8.7, falling to 3.5 when ambulance costs were included. Alcohol intoxication management services varied, from volunteer-led first aid to more clinically focused nurse practitioner services, with only the latter providing evidence for diversion from emergency departments. Qualitative and ethnographic data indicated that alcohol intoxication management services are acceptable to practitioners and patients and that they address unmet need. There was evidence that alcohol intoxication management services improve ambulance response times and reduce emergency department attendance. Effects are uncertain owing to the variation in service delivery.

Limitations

The evaluation focused on health service outcomes, yet evidence arose suggesting that alcohol intoxication management services provide broader societal benefits. There was no nationally agreed standard operating procedure for alcohol intoxication management services, undermining the evaluation. Routine health data outcomes exhibited considerable variance, undermining opportunities to provide an accurate appraisal of the heterogenous collection of alcohol intoxication management services.

Conclusions

Alcohol intoxication management services are varied, multipartner endeavours and would benefit from agreed national standards. Alcohol intoxication management services are popular with and benefit front-line staff and serve as a hub facilitating partnership working. They are popular with alcohol intoxication management services patients and capture previously unmet need in night-time environments. However, acute alcohol intoxication in emergency departments remains an issue and opportunities for diversion have not been entirely realised. The nurse-led model was the most expensive service evaluated but was also the most likely to divert patients away from emergency departments, suggesting that greater clinical involvement and alignment with emergency departments is necessary. Alcohol intoxication management services should be regarded as fledgling services that require further work to realise benefit.

Future work

Research could be undertaken to determine if a standardised model of alcohol intoxication management services, based on the nurse practitioner model, can be developed and implemented in different settings. Future evaluations should go beyond the health service and consider outcomes more generally, especially for the police. Future work on the management of acute alcohol intoxication in night-time environments could recognise the partnership between health-care, police and ambulance services and third-sector organisations in managing acute alcohol intoxication.

Trial registration

Current Controlled Trials ISRCTN63096364.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 24. See the NIHR Journals Library website for further project information.

Identifying Chicago's High Users of Police-Involved Emergency Services

OBJECTIVES

To identify individuals at risk for behavioral health (BH)-involved encounters with police in Chicago, Illinois.

METHODS

We linked Chicago Police Department (CPD) arrest and Fire Department (CFD) BH-involved ambulance event data. We identified at-risk individuals who accumulated at least 1 BH-involved ambulance and at least 1 arrest event between May 2016 and April 2017. We identified a high-use subgroup displaying most intensive services use. We identified high-use locations with highest volume of ambulance events with only CFD data.

RESULTS

Of 83 392 individuals and 116 105 events in the linked emergency events data, 1842 at-risk individuals accounted for 2.2% of individuals, 5.6% of all events, and 16% of BH-involved CFD events with police involvement. A total of 330 high-use individuals accounted for 0.4% of individuals, 2% of events, and 4.7% of CFD events with police involvement. Top-100 high-use locations accounted for 9% of CFD events, and individuals of high-use location events are largely distinct from high-use individuals.

CONCLUSIONS

Integrated police and ambulance data hold promise to identify individuals at risk for BH-involved encounters with police and to support proactive interventions to prevent or improve response at these encounters.

Alcohol as a Factor in 911 Calls in Denver

BACKGROUND

Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system.

OBJECTIVES

The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs.

METHODS

This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data.

RESULTS

During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29-59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded $14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time.

CONCLUSIONS

Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.

Impact of a Mass Gathering Alcohol Sobering Facility on Emergency Resources

OBJECTIVE

Alcohol consumption has been implicated as an important factor driving the demand for medical care at mass gatherings. Patients exhibiting signs of possible alcohol intoxication are frequently diverted from traditional medical support facilities located within mass gathering events due to their disruptive behavior or need for prolonged observation. This conventional strategy can place additional stress on Emergency Medical Services (EMS) and Emergency Department (ED) resources. The purpose of this study was to determine if incorporation of an on-site alcohol sobering facility to supplement existing on-site medical support resources was associated with changes in EMS and ED resource utilization during an annual mass gathering.

METHODS

This retrospective observational study of a large, annual mass gathering included prospectively collected data from before and after the deployment of an on-site alcohol sobering facility. One year of EMS data along with 2 years of ED data from the pre-deployment time period were compared to 3 years of post-deployment data. The primary outcomes for this study were the number of EMS transports and ED visits.

RESULTS

Average single day event attendance was 176,116 during the 2012-13 time period before the ACS was deployed and 183,544 in the 3 years following. The odds of an EMS transport from the event to the ED decreased in the post-deployment period, OR 0.37 (95% CI = 0.16-0.86; p = 0.01). ED volume increased by 7.23% (p = 0.56) and ED LOS increased by 1.29% (p = 0.97) in the post-deployment period.

CONCLUSION

This study reports on a unique strategy to improve resource utilization at large mass gatherings and the impact of this strategy on EMS and ED resource utilization. It appears that the addition of an on-site alcohol sobering facility to existing medical support services was associated with a significant decrease in EMS transports but no change in ED resource utilization. Further work is needed to determine if these findings can be reproduced at other mass gatherings.

Managing alcohol-related attendances in emergency care: can diversion to bespoke services lessen the burden?

Acute alcohol intoxication (AAI) has a long history of burdening emergency care services. Healthcare systems around the world have explored a variety of different services that divert AAI away from EDs to better manage their condition. Little formal evaluation has been undertaken, particularly in the UK where alcohol misuse is one of the highest in the world. In this article, we outline a brief history of diversionary services, introduce the concept of Alcohol Intoxication Management Services (AIMS) and describe examples of AIMS in the UK. We then describe Evaluating the Diversion of Alcohol-Related Attendances, a natural experiment including six cities with AIMS compared with six cities without, that involves an ethnographic study, records patient experiences in both AIMS and EDs, assesses impact on key performance indicators in healthcare and evaluates the cost-effectiveness of AIMS.

Utilization of a Sobering Center for Acute Alcohol Intoxication

OBJECTIVE

The objective was to describe the population utilizing a sobering center for public alcohol intoxication and compare between single-visit users, repeat users, and high users.

METHODS

We conducted a secondary analysis of 1,271 adults cared for in a sobering center from July 2014 to June 2015. We divided the population into three groups-single use (one visit), repeat users (two to five visits), and high (six or more) users-and evaluated demographics, lifetime health diagnoses utilizing the Elixhauser Comorbidity Index, rates of public service utilization including ambulance and emergency department, and related costs.

RESULTS

The population was primarily male, middle-aged, and ethnically diverse. Compared to single-visit users (n = 869), repeat (n = 287) and high users (n = 115) were older, were more likely to be currently homeless, and had spent more time homeless. Repeat and high users had significantly higher rates of hypertension, liver disease, diabetes, depression, psychoses, and drug abuse diagnoses compared to single-visit users. In addition to sobering visits, utilization of ambulance and ED and related costs were significantly greater for the high users compared to repeat and single-visit users.

CONCLUSIONS

From an overall heterogeneous population, more frequent utilizers of the sobering center, both high and repeat users compared to low users, had significantly greater prevalence of chronic disorders, service utilization, and homelessness. Findings indicate that a sobering center can have a prominent role in the care for those with acute alcohol intoxication, particularly those individuals with chronic public intoxication who are likewise homeless. Further longitudinal research could offer important insights as to the population served over time, investigating changes in utilization and efforts toward health and housing stabilization.

Revising the paradigm for jail diversion for people with mental and substance use disorders: Intercept 0

A conceptual model for community-based strategic planning to address the criminalization of adults with mental and substance use disorders, the Sequential Intercept Model has provided jurisdictions with a framework that overcomes traditional boundaries between the agencies within the criminal justice and behavioral health systems. This article presents a new paradigm, Intercept 0, for expanding the utility of the Sequential Intercept Model at the front end of the criminal justice system. Intercept 0 encompasses the early intervention points for people with mental and substance use disorders before they are placed under arrest by law enforcement. The addition of Intercept 0 creates a conceptual space that enables stakeholders from the mental health, substance use, and criminal justice systems to consider the full spectrum of real-world interactions experienced by people with mental and substance use disorders with regard to their trajectories, or lack thereof, through the criminal justice system.

Alcohol-Related Visits to US Emergency Departments, 2001-2011

AIMS

Alcohol intoxication is a source of significant illness and injury commonly resulting in emergency department (ED) visits. We characterize recent trends in alcohol-related visits to US EDs using nationally representative data.

METHODS

We conducted a retrospective review of data on national ED visits among patients aged 18 years or older with alcohol intoxication between 2001 and 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Demographic and resource utilization trends in alcohol-related visits were examined. We also assessed ED length of stay (LOS) across the study period, as well as the total hours spent on ED care for alcohol-related complaints.

RESULTS

Between 2001-2002 and 2010-2011, alcohol-related visits increased from 2,459,748 to 3,856,346 (P = 0.049). Utilization of resources such as laboratory tests, medications and radiography increased, with the use of advanced imaging (i.e. computed tomography and magnetic resonance imaging) increasing 232.2% (P < 0.001) from 2001-2002 to 2010-2011. Overall LOS increased 16.1% (P = 0.028), while LOS among patients admitted to the hospital increased 24.9% (P = 0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2011, an increase of 108.5% (P < 0.001) compared with an increase in overall ED hours of 54.0% (P < 0.001).

CONCLUSION

Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden on hospital resources.

Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Introduction

There is a paucity of literature supporting the use of electronic alerts for patients with high frequency emergency department (ED) use. We sought to measure changes in opioid prescribing and administration practices, total charges and other resource utilization using electronic alerts to notify providers of an opioid-use care plan for high frequency ED patients.

Methods

This was a randomized, non-blinded, two-group parallel design study of patients who had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care groups”. Between the years before and after randomization, we compared as primary outcomes the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) studies, and 5) inpatient admissions.

Results

A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the proportion of morphine mg equivalents received in the post-period compared with the pre-period was 15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the pre-period was 4.5% (ratio=0.29, 95% CI [0.07–1.12]; p=0.07). For discharged patients in the “Usual Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01–0.092]; p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT or MRI or inpatient admissions.

Conclusion

Electronic care plans were associated with an incremental decrease in opioids (in morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED use.

In their own words: Content analysis of pathways to recovery among individuals with the lived experience of homelessness and alcohol use disorders

BACKGROUND

Alcohol use disorders (AUDs) are more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by alcohol-related morbidity and mortality. Unfortunately, abstinence-based approaches are neither desirable to nor highly effective for most members of this population. Recent research has indicated that homeless people aspire to clinically significant recovery goals beyond alcohol abstinence, including alcohol harm reduction and quality-of-life improvement. However, no research has documented this population's preferred pathways toward self-defined recovery. Considering principles of patient-centred care, a richer understanding of this population's desired pathways to recovery may help providers better engage and support them.

METHODS

Participants (N=50) had lived experience of homelessness and AUDs and participated in semi-structured interviews regarding histories of homelessness, alcohol use, and abstinence-based treatment as well as suggestions for improving alcohol treatment. Conventional content analysis was used to ascertain participants' perceptions of abstinence-based treatment and mutual-help modalities, while it additionally revealed alternative pathways to recovery.

RESULTS

Most participants reported involvement in abstinence-based modalities for reasons other than the goal of achieving long-term abstinence from alcohol (e.g., having shelter in winter months, "taking a break" from alcohol use, being among "like-minded people"). In contrast, most participants preferred alternative pathways to recovery, including fulfilling basic needs (e.g., obtaining housing), using harm reduction approaches (e.g., switching from higher to lower alcohol content beverages), engaging in meaningful activities (e.g., art, outings, spiritual/cultural activities), and making positive social connections.

CONCLUSIONS

Most people with the lived experience of homelessness and AUDs we interviewed were uninterested in abstinence-based modalities as a means of attaining long-term alcohol abstinence. These individuals do, however, have creative ideas about alternative pathways to recovery that treatment providers may support to reduce alcohol-related harm and enhance quality of life.

Identifying Frequent Users of an Urban Emergency Medical Service Using Descriptive Statistics and Regression Analyses

This retrospective cohort study provides a descriptive analysis of a population that frequently uses an urban emergency medical service (EMS) and identifies factors that contribute to use among all frequent users. For purposes of this study we divided frequent users into the following groups: low- frequent users (4 EMS transports in 2012), medium-frequent users (5 to 6 EMS transports in 2012), high-frequent users (7 to 10 EMS transports in 2012) and super-frequent users (11 or more EMS transports in 2012). Overall, we identified 539 individuals as frequent users. For all groups of EMS frequent users (i.e. low, medium, high and super) one or more hospital admissions, receiving a referral for follow-up care upon discharge, and having no insurance were found to be statistically significant with frequent EMS use (P<0.05). Within the diagnostic categories, 41.61% of super-frequent users had a diagnosis of "primarily substance abuse/misuse" and among low-frequent users a majority, 53.33%, were identified as having a "reoccurring (medical) diagnosis." Lastly, relative risk ratios for the highest group of users, super-frequent users, were 3.34 (95% CI [1.90-5.87]) for obtaining at least one referral for follow-up care, 13.67 (95% CI [5.60-33.34]) for having four or more hospital admissions and 5.95 (95% CI [1.80-19.63]) for having a diagnoses of primarily substance abuse/misuse. Findings from this study demonstrate that among low- and medium-frequent users a majority of patients are using EMS for reoccurring medical conditions. This could potentially be avoided with better care management. In addition, this study adds to the current literature that illustrates a strong correlation between substance abuse/misuse and high/super-frequent EMS use. For the subgroup analysis among individuals 65 years of age and older, we did not find any of the independent variables included in our model to be statistically significant with frequent EMS use.

Housing First is associated with reduced use of emergency medical services

OBJECTIVE

Chronically homeless adults with severe alcohol problems are disproportionately burdened with health-care problems and are high utilizers of emergency medical services (EMS). Single-site Housing First (HF), which provides immediate, permanent, low-barrier, nonabstinence-based, supportive housing, has been associated with reduced publicly funded service utilization. The aims of the current study were to determine whether time spent in single-site HF predicted decreases in EMS contacts 2 years subsequent to single-site HF move-in, and to describe medical conditions and injuries associated with EMS contacts in a sample of chronically homeless individuals with severe alcohol problems.

METHODS

Participants were 91 chronically homeless adults with severe alcohol problems who were enrolled in a single-site HF program between December 2005 and March 2007 in Seattle, Washington. We obtained administrative data on exposure to HF and EMS utilization for the 2 years prior to and the 2 years subsequent to participants' move-in date. EMS utilization variables included patient type (i.e., primary presenting problem), trauma/injury mechanism (i.e., EMS classification of the cause of the trauma or injury), level of care (i.e., basic life support, advanced life support), and transport destination.

RESULTS

After controlling for baseline EMS contacts, participants evinced 3% fewer EMS contacts for each additional month of single-site HF exposure. From the baseline to follow-up period, the mean number of EMS contacts declined from 15.85 (SD = 22.96) to 9.54 (SD = 15.08), representing a 54% reduction in the number of EMS contacts. Most calls were responded to by EMTs providing basic life support, and the majority resulted in transport to a local level I trauma center. The most common presenting difficulties were medical illness and trauma. Substance use and psychiatric difficulties were infrequently documented as the primary problem.

CONCLUSIONS

Our findings support recent assertions that housing is health care and indicate that the amount of time spent in single-site HF is associated with significant reductions in EMS utilization for at least 2 years subsequent to move-in. These findings also underscore the high levels of medical illness and trauma exposure among chronically homeless adults with severe alcohol problems.

Harm reduction with pharmacotherapy for homeless people with alcohol dependence: protocol for a randomized controlled trial

BACKGROUND

Interventions requiring abstinence from alcohol are neither preferred by nor shown to be highly effective with many homeless individuals with alcohol dependence. It is therefore important to develop lower-threshold, patient-centered interventions for this multimorbid and high-utilizing population. Harm-reduction counseling requires neither abstinence nor use reduction and pairs a compassionate style with patient-driven goal-setting. Extended-release naltrexone (XR-NTX), a monthly injectable formulation of an opioid receptor antagonist, reduces craving and may support achievement of harm-reduction goals. Together, harm-reduction counseling and XR-NTX may support alcohol harm reduction and quality-of-life improvement.

AIMS

Study aims include testing: a) the relative efficacy of XR-NTX and harm-reduction counseling compared to a community-based, supportive-services-as-usual control, b) theory-based mediators of treatment effects, and c) treatment effects on publicly funded service costs.

METHODS

This RCT involves four arms: a) XR-NTX+harm-reduction counseling, b) placebo+harm-reduction counseling, c) harm-reduction counseling only, and d) community-based, supportive-services-as-usual control conditions. Participants are currently/formerly homeless, alcohol dependent individuals (N=300). Outcomes include alcohol variables (i.e., craving, quantity/frequency, problems and biomarkers), health-related quality of life, and publicly funded service utilization and associated costs. Mediators include 10-point motivation rulers and the Penn Alcohol Craving Scale. XR-NTX and harm-reduction counseling are administered every 4weeks over the 12-week treatment course. Follow-up assessments are conducted at weeks 24 and 36.

DISCUSSION

If found efficacious, XR-NTX and harm-reduction counseling will be well-positioned to support reductions in alcohol-related harm, decreases in costs associated with publicly funded service utilization, and increases in quality of life among homeless, alcohol-dependent individuals.

Identifying frequent users of emergency department resources

BACKGROUND

There is growing focus on frequent users of acute care resources. If these patients can be identified, interventions can be established to offer more consistent management plans to decrease inappropriate utilization.

OBJECTIVE

To compare a hospital-specific approach with a region-wide approach to identify frequent Emergency Department (ED) users.

METHODS

A retrospective multi-center cohort study of hospital ED visits from all 18 nonmilitary, acute care hospitals serving the San Diego region (population 3.2 million) between 2008 and 2010 using data submitted to the California Office of Statewide Health Planning and Development. Frequent users and super users were defined as having 6 to 20 and 21 or more visits, respectively, during any consecutive 12 months in the study period. Comparisons between community-wide and hospital-specific methods were made.

RESULTS

There were 925,719 individual patients seen in an ED, resulting in 2,016,537 total visits. There were 28,569 patients identified as frequent users and 1661 identified as super users, using a community-wide approach. Individual hospitals could identify 15.6% to 62.4% of all frequent users, and from 0.3% to 15.2% of all the super users who visited their facility. Overall, the hospital-specific approach identified 20,314 frequent users and 571 super users, failing to identify 28.9% of frequent users and 65.6% of super users visiting San Diego County EDs that would otherwise have been identified using a community-wide approach.

CONCLUSIONS

A community-wide identification method resulted in greater numbers of individuals being identified as frequent and super ED users than when utilizing individual hospital data.

Frequent emergency department visits are more prevalent in psychiatric, alcohol abuse, and dual diagnosis conditions than in chronic viral illnesses such as hepatitis and human immunodeficiency virus

BACKGROUND

Repeat users of Emergency Departments (ED), so-called "frequent visitors," place a substantial burden on limited ED resources. The illness features of frequent visitors have not been well defined, though chronic medical and psychiatric illness and substance abuse are implicated.

STUDY OBJECTIVES

This study assessed whether chronic conditions such as hepatitis C (HCV) and human immunodeficiency virus (HIV) are more prevalent in frequent ED users compared to a viral condition with relatively less disability, hepatitis B (HBV). As a comparison, psychiatric complaints and alcohol abuse were also compared in frequent and non-frequent visitors.

METHODS

All visits to a university ED in a particular calendar year were retrospectively reviewed. Frequent visitors were defined as those who made four or more visits. Presenting complaints and past medical history were examined for HCV, HIV, HBV, psychiatric complaints, and alcohol abuse.

RESULTS

Frequent visitors accounted for 28% of all ED visits. HCV, HIV, and alcohol abuse were more prevalent in frequent visitors than non-frequent visitors. People with HBV comprised a small proportion of both groups. Frequent visitors with psychiatric complaints were more prevalent than those with HBV or alcohol abuse. Psychiatric history comorbid with alcohol abuse and HCV with alcohol abuse were more prevalent in frequent vs. non-frequent visitors.

CONCLUSION

Although chronic hepatitis and psychiatric complaints are both implicated in frequent ED visits, patients with psychiatric complaints present to the ED more often. Patients with a "dual diagnosis" of psychiatric condition and alcohol abuse are likely to be frequent visitors. This population should be targeted for creative intervention strategies, both within and outside of the emergency system, that comprehensively screen for symptomatology and integrate mental health treatment with substance abuse interventions.

Effects of an emergency medical services-based resource access program on frequent users of health services

BACKGROUND

A small group of adults disproportionately and ineffectively use acute services including emergency medical services (EMS) and emergency departments (EDs). The resulting episodic, uncoordinated care is of lower quality and higher cost and simultaneously consumes valuable public safety and acute care resources.

OBJECTIVE

To address this issue, we measured the impact of a pilot, EMS-based case management and referral intervention termed the San Diego Resource Access Program (RAP) to reduce EMS, ED, and inpatient (IP) visits.

METHODS

This was a historical cohort study of RAP records and billing data of EMS and one urban hospital for 51 individuals sequentially enrolled in the program. The study sample consisted of adults with ≥ 10 EMS transports within 12 months and others reported by prehospital personnel with significant recent increases in transports. Data were collected over a 31-month time period from December 2006 to June 2009. Data were collected for equal pre- and postenrollment time periods based on date of initial RAP contact, and comparisons were made using the Wilcoxon signed-rank test. Overall use for subjects is reported.

RESULTS

The majority of subjects were male (64.7%), homeless (58.8%), and 40 to 59 years of age (72.5%). Between the pre and post periods, EMS encounters declined 37.6% from 736 to 459 (p = 0.001), resulting in a 32.1% decrease in EMS charges from $689,743 to $468,394 (p = 0.004). The EMS task time and mileage decreased by 39.8% and 47.5%, respectively, accounting for 262 (p = 0.008) hours and 1,940 (p = 0.006) miles. The number of ED encounters at the one participating hospital declined 28.1% from 199 to 143, which correlated with a 12.7% decrease in charges from $413,410 to $360,779. The number of IP admissions declined by 9.1% from 33 to 30, corresponding to a 5.9% decrease in IP charges from $687,306 to $646,881. Hospital length of stay declined 27.9%, from 122 to 88 days. Across all services, total charges declined by $314,406.

CONCLUSIONS

This pilot study demonstrated that an EMS-based case management and referral program was an effective means of decreasing EMS transports by frequent users, but had only a limited impact on use of hospital services.

Factors associated with use of urban emergency departments by the U.S. homeless population

OBJECTIVE

Homeless individuals frequently use emergency departments (EDs), but previous studies have investigated local rather than national ED utilization rates. This study sought to characterize homeless people who visited urban EDs across the U.S.

METHODS

We analyzed the ED subset of the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED), a nationally representative probability survey of ED visits, using methods appropriate for complex survey samples to compare demographic and clinical characteristics of visits by homeless vs. non-homeless people for survey years 2005 and 2006.

RESULTS

Homeless individuals from all age groups made 550,000 ED visits annually (95% confidence interval [CI] 419,000, 682,000), or 72 visits per 100 homeless people in the U.S. per year. Homeless people were older than others who used EDs (mean age of homeless people = 44 years compared with 36 years for others). ED visits by homeless people were independently associated with male gender, Medicaid coverage and lack of insurance, and Western geographic region. Additionally, homeless ED visitors were more likely to have arrived by ambulance, to be seen by a resident or intern, and to be diagnosed with either a psychiatric or substance abuse problem. Compared with others, ED visits by homeless people were four times more likely to occur within three days of a prior ED evaluation, and more than twice as likely to occur within a week of hospitalization.

CONCLUSIONS

Homeless people who seek care in urban EDs come by ambulance, lack medical insurance, and have psychiatric and substance abuse diagnoses more often than non-homeless people. The high incidence of repeat ED visits and frequent hospital use identifies a pressing need for policy remedies.

Does mandatory inpatient alcohol detoxification reduce emergency department recidivism, hospital admissions, and emergency medical services transports for patients with chronic, severe alcohol dependence?

BACKGROUND

In Massachusetts, patients with chronic alcohol dependence can be committed to 30 days of mandatory inpatient alcohol detoxification (MAD).

STUDY OBJECTIVES

To examine the effects of MAD on the number of emergency department (ED) visits, hospital admissions, and emergency medical service (EMS) transports.

METHODS

This retrospective study identified patients in our urban ED committed to MAD. We compared the number of ED visits and admissions to our hospital and Boston EMS transports to any facility in the 1, 3, and 6 months pre- and post-MAD, excluding the 30-day MAD period. Paired t tests were used for analysis of mean values across time.

RESULTS

Ten subjects were enrolled. Comparing pre- and post-MAD, the mean number of ED visits fell 6.5 to 2.7 (p = 0.05) in the first month, 14.2 to 9.3 (p = 0.18) in 3 months, and 25.6 to 17.7 (p = 0.15) in 6 months. Mean number of hospital admissions declined: 1.3 to 0.1 (p = 0.03) in 1 month, 2.3 to 0.9 (p = 0.06) in 3 months, and 3.2 to 1.9 (p = 0.08) in 6 months. Mean number of EMS transports fell 4.6 to 2.3 (p = 0.21) in the first month, 9.2 to 5.6 (p = 0.14) in 3 months, and 13.9 to 10.0 (p = 0.26) in 6 months pre- and post-MAD.

CONCLUSIONS

MAD was associated with an immediate reduction in ED visits and hospital admissions that did not remain statistically significant long term, and a non-significant reduction in EMS transports.