Medical Mondays: ED Utilization for Medicaid Recipients Depends on the Day of the Week, Season, and Holidays

Adult kitchen-related burn injuries: The impact of COVID-19

INTRODUCTION

Kitchen-related burn injuries are common and preventable. To limit the spread of COVID-19, public health orders encouraged the public to stay at home which may have led to an increase in kitchen-related burn injuries.

OBJECTIVE

To assess adult kitchen-related burns treated in an outpatient setting in general, and especially looking at the impact of the COVID-19 pandemic on the incidence and epidemiology of these burns.

METHODS

For this retrospective, population-based study, data were obtained for adult patients who suffered burn injuries resulting in a visit to a Canadian tertiary Burn Clinic between April 2016 and March 2021 specifically looking at demographics, burn etiology, severity and anatomical location and the need for surgery. Separately, we compared the patients before and after the beginning of the COVID-19 pandemic (April 1, 2020).

RESULTS

A total of 1380 burn patients were identified. Of these, 38 % (N = 521) sustained a kitchen-related burn. The median patient age was 40 years (range 18-95) and 282 (54.1 %) were female. The most common etiology and location were scald (76.8 %) and anterior arm (28.5 %), respectively. Thirty-two (6.1 %) patients required admission to the Burn Unit and 26 of these had surgeries. Additionally, 72 (13.8 %) patients had surgery as an outpatient. During the COVID-19 pandemic, East Asian patients saw a significant increase in kitchen burns (p < 0.01).

CONCLUSION

Over 1/3 of burns at the outpatient burn clinic were kitchen-related. About 94 % of these were treated as outpatient only. The incidence of kitchen-related burns did not change during the COVID-19 pandemic, but we found significant differences in ethnic distribution. These results provide a unique opportunity to focus on communication and education and set up preventative measures.

Public health nursing workforce and learning needs: A national sample survey analysis

OBJECTIVES

Generate national estimates of the public health nursing workforce's (1) demographic and work characteristics and (2) continuing education learning needs in the United States.

DESIGN

Secondary data analysis of the 2018 National Sample Survey of Registered Nurses.

SAMPLE

Total 7352 of the 50,273 survey respondents were categorized as public health nurses (PHNs), representing an estimated 467,271 national workforce.

MEASUREMENTS

Survey items for demographics, practice setting, training topics, and language(s) spoken fluently were analyzed.

RESULTS

Workforce demographic characteristics are included. Mental health training was the most frequently endorsed topic by PHNs, followed by patient-centered care and evidence-based care. Training topic needs vary by practice setting.

CONCLUSIONS

Results here can be used as a needs assessment for national public health nursing professional development and education initiatives. Further research is needed to refine and survey a nationally representative sample in a manner meaningful to public health nursing practice.

Visits to the accident and emergency department in hot season of a city with subtropical climate: association with heat stress and related meteorological variables

BACKGROUND

Literature reporting the association between heat stress defined by universal thermal climate index (UTCI) and emergency department visits is mainly conducted in Europe. This study aimed to investigate the association between heat stress, as defined by the UTCI, and visits to the accident and emergency department (AED) in Hong Kong, which represents a subtropical climate region.

METHODS

A retrospective study involving 13,438,846 AED visits in the public sector from May 2000 to September 2016, excluding 2003 and 2009, was conducted in Hong Kong. Age-sex-specific ANCOVA models of daily AED rates on heat stress and prolonged heat stress, adjusting for air quality, prolonged poor air quality, typhoon, rainstorm, year, day of the week, public holiday, summer vacation, and fee charging, were used.

RESULTS

On a day with strong heat stress (32.1 °C ≤ UTCI ≤ 38.0 °C), the AED visit rate (per 100,000) increased by 0.9 (95% CI: 0.5, 1.3) and 1.7 (95% CI: 1.3, 2.1) for females and males aged 19-64 and 4.1 (95% CI: 2.7, 5.4) and 4.1 (95% CI: 2.6, 5.6) for females and males aged ≥ 65, while keeping other variables constant. On a day with very strong heat stress (38.1 °C ≤ UTCI ≤ 46.0 °C), the corresponding rates increased by 0.6 (95% CI: 0.1, 1.2), 2.2 (95% CI: 1.7, 2.7), 4.9 (95% CI: 3.1, 6.7), and 4.7 (95% CI: 2.7, 6.6), respectively. The effect size of heat stress associated with AED visit rates was negligible among those aged ≤ 18. Heat stress showed the greatest effect size for males aged 19-64 among all subgroups.

CONCLUSION

Biothermal condition from heat stress was associated with the health of the citizens in a city with a subtropical climate and reflected in the increase of daily AED visit. Public health recommendations have been made accordingly for the prevention of heat-related AED visits.

Changing temporal trends in patient volumes in a pediatric emergency department during a COVID-19 pandemic lockdown: A retrospective cohort study

Objective

Emergency department (ED) teams have had to adjust limited staffing resources to meet the fluctuating levels of patient volume and acuity during the COVID-19 pandemic. Historically, Mondays have had the highest reported ED volumes. We are unaware of any studies reporting on the change of this Monday effect during the COVID-19 pandemic.

Methods

This retrospective, observational study of a single pediatric ED compared a pandemic lockdown period (3/23/2020-11/1/2020) with a seasonally comparative period (3/25/2019-11/3/2019). We compared the mean number of patients who arrived on Monday versus any other specific weekday (Tuesday, Wednesday, Thursday, or Friday) and the aggregate of other weekdays (Tuesday to Friday) for both study periods. Secondary analyses investigated overall mean volumes, admission rates, and differences in triage acuity levels.

Results

There were 31,377 and 18,098 patients in the comparative and pandemic periods. The mean number of ED visits on Mondays in the comparative period was significantly more than any other weekday and the aggregate of weekdays (latter p<0.001). In contrast, there were no significant differences in the mean number of ED visits on Mondays in the pandemic period relative to any other weekday and the aggregate of weekdays (all p>0.05). The pandemic period had significantly lower mean volumes, higher admission rates, and more patients with higher acuity levels.

Conclusion

The previously experienced Monday effect of increased relative ED patient volumes was not seen during the pandemic period. This change has operational implications for scheduling ED staffing resources. Larger database studies are needed to determine the generalizability of these findings.

Burns During Coronavirus Disease 19 Lockdown: a Multi-Center Retrospective Study in Israel

The coronavirus disease 2019 (COVID-19) pandemic forced many countries into lockdowns to limit the spread of infection. Israel's containment measures included school closures, mobility restrictions, and workforce reductions. Our study evaluated the effect of COVID-19 on the occurrence and patterns of burn injuries. The study data was obtained via retrospective chart review of burn patients treated between March 15, 2020 and April 30, 2020, namely the period of strict national lockdown. This data was compared against data from paralleling periods between 2017 and 2019. A total of 686 patients were treated for burn injuries in the two study periods. Age group analysis revealed an increased ratio of pediatric patients aged 0-3 years during the lockdown (55.91% vs 40.79%, P = .002). In contrast, there were fewer patients presenting with burn injuries in the 7-16 and 17-29 age groups (9.66% vs 3.15%, P = .017; 16.46% vs 7.09%, P = .007, respectively). During both study periods, scald injuries were the most common burn etiology and burn injuries occurred most often at home. This predominance was further pronounced during the lockdown (71.65% vs 58.68%, P = .007; 90.55% vs 74.60%, P = .0001, respectively). The lockdown period underlined the danger faced by pediatric patients in their household environment. This danger was possibly compounded by an improper level of adult supervision as parents transitioned to remote work. These findings can educate us about factors that render burn injuries more likely not only during lockdowns, but also during regular times, thus shaping the development of burn prevention practices.

Weekend Versus Weekday Asthma-Related Emergency Department Utilization

OBJECTIVE

To assess variation in asthma-related emergency department (ED) use between weekends and weekdays.

METHODS

Cross-sectional administrative claims-based analysis using California 2016 Medicaid data and Vermont 2016 and Massachusetts 2015 all-payer claims databases. We defined ED use as the rate of asthma-related ED visits per 100 child-years. A weekend visit was a visit on Saturday or Sunday, based on date of ED visit claim. We used negative binomial regression and robust standard errors to assess variation between weekend and weekday rates, overall and by age group.

RESULTS

We evaluated data from 398,537 patients with asthma. The asthma-related ED visit rate was slightly lower on weekends (weekend: 18.7 [95% confidence interval (CI): 18.3-19.0], weekday: 19.6 [95% CI, 19.3-19.8], P < .001). When stratifying by age group, 3- to 5-year-olds had higher rates of asthma-related ED visits on weekends than weekdays (weekend: 33.7 [95% CI, 32.6-34.7], weekday: 29.8 [95% CI, 29.1-30.5], P < .001) and 12- to 17-year-olds had lower rates of ED visits on weekends than weekdays (weekend: 13.0 [95% CI: 12.5-13.4], weekday: 16.3 [95% CI: 15.9-16.7], P < .001). In the other age groups (6-11, 18-21 years) there were not statistically significant differences between weekend and weekday rates (P > .05).

CONCLUSIONS

In this multistate analysis of children with asthma, we found limited overall variation in pediatric asthma-related ED utilization on weekends versus weekdays. These findings suggest that increasing access options during the weekend may not necessarily decrease asthma-related ED use.

Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income

INTRODUCTION

In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities.

METHODS

We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019.

RESULTS

Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased.

CONCLUSION

Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Trends in Burn Injuries in Northern Israel During the COVID-19 Lockdown

Coronavirus disease 2019 obliged many countries to apply lockdown policies to contain the spread of infection. The restrictions in Israel included limitations on movement, reduction of working capacity, and closure of the educational system. The present study focused on patients treated at a referral center for burns in northern Israel. Their goal was to investigate temporal variations in burn injuries during this period. Data were retrospectively extracted from the medical records of burn patients treated at our hospital between March 14, 2020 and April 20, 2020 (ie, the period of aggravated lockdown). Data from this period were compared with that from paralleling periods between 2017 and 2019. During the lockdown and paralleling periods, 178 patients were treated for burn injuries, of whom 44% were under 18. Although no restrictions were enforced during the virus outbreak period with regard to seeking medical care, we noticed a decrease in the number of patients admitted to the emergency room for all reasons. Of particular interest was a 66% decrease in the number of adult burn patients (P < .0001). Meanwhile, among the pediatric population, no significant decrease was observed. Nonetheless, subgroups with higher susceptibility to burn injuries included children aged 2 to 5 years (56.3% vs 23.8%, P = .016) and female patients from all pediatric age groups (57.1% vs 25%, P = .027). These findings may be explained by the presumably busier kitchen and dining areas during the lockdown. Overall, the study results can assist with building a stronger understanding of varying burn injuries and with developing educational and preventive strategies.

Effects of weather, air pollution and Oktoberfest on ambulance-transported emergency department admissions in Munich, Germany

BACKGROUND

Climate change and increasing risks of extreme weather events affect human health and lead to changes in the emergency department (ED) admissions and the emergency medical services (EMS) operations. For a better allocation of resources in the healthcare system, it is essential to predict ED numbers based on environmental variables. This publication aims to quantify weather, air pollution and calendar-related effects on daily ED admissions.

METHODS

Analyses were based on 575,725 admissions from the web-based IVENA system recording all patients in the greater Munich area with pre-hospital emergency care in ambulance operations during 2014-2018. Linear models were used to identify statistically significant associations between daily ED admissions and calendar, meteorological and pollution factors, allowing for lag effects of one to three days. Separate analyses were performed for seasons, with additional subset analyses by sex, age and surgical versus internal department.

RESULTS

ED admissions were exceptionally high during the three-week Oktoberfest, particularly for males and on the weekends, as well as during the New Year holiday. Admissions significantly increased during the years of study, decreased in spring and summer holidays, and were lower on Sundays while higher on Mondays. In the warmer seasons, admissions were significantly associated with higher temperature, adjusting for the effects of sunshine and humidity in all age groups except for the elderly. Adverse weather conditions in non-summer seasons were either linked to increasing ED admissions (from storms, gust) or decreasing them from rain. Mostly, but not exclusively, in winter, increasing ED admissions were associated with colder minimum temperatures as well as with higher NO and PM₁₀ concentrations.

CONCLUSIONS

In addition to standard calendar-related factors, incorporating seasonal weather, air pollutant and interactions with patient demographics into resource planning models can improve the daily allocation of resources and staff of EMS operations at hospital and city levels.

The Impact of Longer Consultation Time: A Simulation-Based Approach

BACKGROUND

Maintaining a sufficient consultation length in primary health care (PHC) is a fundamental part of providing quality care that results in patient safety and satisfaction. Many facilities have limited capacity and increasing consultation time could result in a longer waiting time for patients and longer working hours for physicians. The use of simulation can be practical for quantifying the impact of workflow scenarios and guide the decision-making.

OBJECTIVE

To examine the impact of increasing consultation time on patient waiting time and physician working hours.

METHODS

Using discrete events simulation, we modeled the existing workflow and tested five different scenarios with a longer consultation time. In each scenario, we examined the impact of consultation time on patient waiting time, physician hours, and rate of staff utilization.

RESULTS

At baseline scenarios (5-minute consultation time), the average waiting time was 9.87 minutes and gradually increased to 89.93 minutes in scenario five (10 minutes consultation time). However, the impact of increasing consultation time on patients waiting time did not impact all patients evenly where patients who arrive later tend to wait longer. Scenarios with a longer consultation time were more sensitive to the patients' order of arrival than those with a shorter consultation time.

CONCLUSION

By using simulation, we assessed the impact of increasing the consultation time in a risk-free environment. The increase in patients waiting time was somewhat gradual, and patients who arrive later in the day are more likely to wait longer than those who arrive earlier in the day. Increasing consultation time was more sensitive to the patients' order of arrival than those with a shorter consultation time.

Access To E-Prescriptions And Related Technologies Before And After Hurricanes Harvey, Irma, And Maria

Hurricanes Harvey, Irma, and Maria devastated parts of the US mainland and Puerto Rico during the 2017 hurricane season, causing loss of life and substantial damage and interrupting access to health care for many people in the hurricane impact zones. Using data on e-prescriptions and medication history transactions from a large health information network for the period August 2017-May 2018, we examined providers' access to these technologies across affected areas. Although e-prescribing and medication history transactions decreased considerably during each hurricane, transaction volumes returned to normal levels in the days immediately following Hurricanes Harvey and Irma in Texas and Florida. E-prescribing activity in Puerto Rico did not return to baseline levels at all during the study period, and medication history transactions returned to normal only after an extended period following Hurricane Maria.

Prediction model development of women's daily asthma control using fitness tracker sleep disruption

BACKGROUND

Night-time wakening with asthma symptoms is an important indicator of disease control and severity, with no gold-standard objective measurement.

OBJECTIVE

The study objective was to use fitness tracker sleep data to develop predictive models of daily disease control-related asthma-specific wakening and FEV₁ in working-aged women with poorly controlled asthma.

METHODS

A repeated measures panel design included data from 43 women with poorly controlled asthma. Two components of asthma control were the primary outcomes, measured daily as (1) self-reported asthma-specific wakening and (2) self-administered spirometry to measure FEV₁. Data were analyzed using generalized linear mixed models.

RESULTS

Our models demonstrated predictive value (AUC=0.77) for asthma-specific night-time wakening and good predictive value (AUC=0.83) for daily FEV_1. CONCLUSIONS: Fitness tracker sleep efficiency and wake counts demonstrate clinical utility as predictive of asthma-specific night-time wakening and daily FEV_1. Fitness tracker sleep data demonstrated predictive capability for daily asthma outcomes.

Socioeconomic determinants of pediatric asthma emergency department visits under regional economic development in western New York

Although the links between asthma in children and physical environmental factors have been well established, the role of community-level socioeconomic status remains inconclusive. Consequently, little attention has been paid to the dynamic changes in the associations between socioeconomic status and asthma outcomes due to structural changes in the community, such as an influx of financial resources. This study examined the relationship between community-level socioeconomic status indicators and asthma-related emergency department utilization for school-aged children in 2011 and 2015, assessing the early impact of a large-scale regional economic development project in western New York, United States. Our analyses controlled for other community-level health risk factors, such as environmental exposure, and spatial correlation of the emergency department usage data. Results indicated that both median household income and health insurance coverage were key socioeconomic predictors of the children's asthma-related emergency department utilization over the study period. We also found that the risk of emergency department utilization for asthma decreased significantly in the area in which regional economic development projects were completed during the initial stage of the project. Through a comparison study we demonstrated that the spatial correlation present in asthma-related ED utilization improved model fit and corrected biases in the estimates. Although our findings suggest that improving the socioeconomic status of communities contributes to a reduction in emergency department utilization for pediatric asthma, more empirical studies are warranted for evaluating the comprehensive effects of regional economic development on public health.

Ambient air quality and spatio-temporal patterns of cardiovascular emergency department visits

BACKGROUND

Air pollutants have been associated with various adverse health effects, including increased rates of hospital admissions and emergency room visits. Although numerous time-series studies and case-crossover studies have estimated associations between day-to-day variation in pollutant levels and mortality/morbidity records, studies on geographic variations in emergency department use and the spatial effects in their associations with air pollution exposure are rare.

METHODS

We focused on the elderly who visited emergency room for cardiovascular related disease (CVD) in 2011. Using spatially and temporally resolved multi-pollutant exposures, we investigated the effect of short-term exposures to ambient air pollution on emergency department utilization. We developed two statistical models with and without spatial random effects within a hierarchical Bayesian framework to capture the spatial heterogeneity and spatial autocorrelation remaining in emergency department utilization.

RESULTS

Although the cardiovascular effect of spatially homogeneous pollutants, such as PM2.5 and ozone, was unchanged, we found the cardiovascular effect of NO[Formula: see text] was pronounced after accounting for the spatially correlated structure in emergency department utilization. We also identified areas with high ED utilization for CVD among the elderly and assessed the uncertainty associated with risk estimates.

CONCLUSIONS

We assessed the short-term effect of multi-pollutants on cardiovascular risk of the elderly and demonstrated the use of community multiscale air quality model-derived spatially and temporally resolved multi-pollutant exposures to an epidemiological study. Our results indicate that NO[Formula: see text] was significantly associated with the elevated ED utilization for CVD among the elderly.

Emergency Department Crowding and Time at the Bedside: A Wearable Technology Feasibility Study

INTRODUCTION

ED crowding is a public health crisis, limiting quality and access to lifesaving care. The purpose of this study was to (1) evaluate the feasibility of radio-frequency identification tags to measure clinician-patient contact and (2) to test the relationship between ED occupancy and clinician-patient contact time.

METHODS

In this 4-week observational study, radio-frequency identification tags were worn by emergency clinicians in a 21-bay urban teaching hospital emergency department. The time-motion data were merged with electronic medical repository patient information (N = 3,237) to adjust for occupancy, age, gender, and acuity. Qualitative themes were generated from focus group (N = 39) debriefings of the quantitative results.

RESULTS

Data were collected on 56,342 total clinician events. Adjusting for patient age, increasing ED occupancy increased the number of times the attending physician entered and left the patient room (b = 0 .008, 95% confidence interval [CI] = [0.001-0.016], P = 0.03). There was no relationship for patient gender, triage acuity, shift at arrival, disposition to home, or discharge diagnosis category with either total minutes or number of encounters per patient visit. No time-motion and occupancy associations were observed for nurses, residents, or nurse practitioners/physician assistants. Debriefings indicated occupancy influenced the quality of care, despite maintaining the same quantity of contact time.

DISCUSSION

The physical environment and clinician privacy concerns limit the feasibility of wearable tracking technology in the emergency setting. Attending physician care becomes more fragmented with increasing ED occupancy. Other clinicians report changes in the quality of care, whereas the quantity of time and encounters were unchanged with occupancy rates.