Emergency Department Death Rates Dropped By Nearly 50 Percent, 1997-2011

Overcoming Vulnerabilities in Our Emergency Care System Through Pediatric Readiness

Although children account for 20% of all emergency department (ED) visits, the majority of children seek emergency care in hospitals that see fewer than 10 children per day. The National Pediatric Readiness Project has defined key system-level standards for all EDs to safely care for ill and injured children. High pediatric readiness is associated with improvement in mortality for critically ill and injured children. However, to improve readiness and sustain system-level changes, hospitals must invest in pediatric champions and empower them to engage in continuous quality improvement. Finally, incorporating pediatric readiness into policy is crucial for its long-term sustainability.

Death and End-of-Life Care in Emergency Departments in the US

IMPORTANCE

There are more than 140 million annual visits to emergency departments (EDs) in the US. The role of EDs in providing care at or near the end of life is not well characterized.

OBJECTIVE

To determine the frequency of death in the ED or within 1 month of an ED visit in an all-age, all-payer national database.

DESIGN, SETTING, AND PARTICIPANTS

The retrospective cohort study used patient-level data from the nationally representative Optum clinical electronic health record data set for 2010 to 2020. Data were analyzed from January to March 2022.

EXPOSURES

Age, Charlson Comorbidity Index (CCI), and year of ED encounter.

MAIN OUTCOMES AND MEASURES

The primary outcome was death in the ED, overall and stratified by age, CCI, or year. A key secondary outcome was death within 1 month of an ED encounter. We extrapolated to make national estimates using US Census and Nationwide Emergency Department Sample data.

RESULTS

Among a total of 104 113 518 individual patients with 96 239 939 ED encounters, 205 372 ED deaths were identified in Optum, for whom median (IQR) age was 72 (53 to >80) years, 114 582 (55.8%) were male, and 152 672 (74.3%) were White. ED death affected 0.20% of overall patients and accounted for 0.21% of ED encounters. An additional 603 273 patients died within 1 month of an ED encounter. Extrapolated nationally, ED deaths accounted for 11.3% of total deaths from 2010 to 2019, and 33.2% of all decedents nationally visited the ED within 1 month of their death. The proportion of total national deaths occurring in the ED decreased by 0.27% annually (P for trend = .003) but the proportion who died within 1 month of an ED visit increased by 1.2% annually (P for trend < .001). Compared with all ED encounters, patients with visits resulting in death were older, more likely to be White, male, and not Hispanic, and had higher CCI. Among ED encounters for patients aged older than 80 years, nearly 1 in 12 died within 1 month.

CONCLUSIONS AND RELEVANCE

This retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently.

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

BACKGROUND

Existing evidence suggest the emergence of palliative care (PC) services in the emergency department (ED). To gain insight into the nature of these services and provide direction to future actions, there is a need for a comprehensive review that ascertains the components of these services, integration models, and outcomes.

METHODS

A scoping review design was employed and reported according to the PRISMA extension guidelines for scoping reviews. Extensive searches in peer-reviewed databases (CINAHL, EMBASE, PubMed, Cochrane Library, and Medline) and gray literature sources (Trove, MedNar, OpenGrey, and the Agency for Healthcare Research and Quality) were undertaken and supplemented with hand searching. Titles, abstracts, and full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on a PC intervention implemented in the ED for adults. Codes were formulated across the included studies, which facilitated the conduct of a narrative synthesis.

RESULTS

Twenty-three studies were retained with the majority (n = 15) emerging from the United States. The components of PC interventions in the ED were categorized as: (1) screening, (2) goals of care discussion and communication, (3) managing pain and other distressing symptoms in the ED, (4) transitions across care settings, (5) end-of-life (EoL) care, (6) family/caregiver support, and (7) ED staff education. Traditional PC consultations and integrated ED-PC services were the main modes of delivery. PC in the ED can potentially improve patient symptoms, facilitate access to relevant services, reduce length of stay, improve care at the EoL, facilitate bereavement and postbereavement support for family members, and improve ED staff confidence in delivering PC.

CONCLUSIONS

PC implementation in the ED may potentially improve patient and family outcomes. More studies are needed, however, to standardize trigger or screening tools. More prospective studies are also needed to test PC interventions in the ED.

Teto terapêutico e a adequação do tratamento no Serviço de Urgência – estudo retrospectivo

Introdução: no Serviço de Urgência vive-se um antagonismo constante pela sua natureza direcionada para a patologia aguda e a prestação de cuidados paliativos de qualidade. O nosso estudo tem como objetivo avaliar se a definição de teto terapêutico leva a diferenças na adequação da marcha diagnóstica e terapêutica instituída.Material e métodos: análise retrospetiva descritiva monocêntrica dos doentes que morreram nos primeiros seis meses de 2018 no serviço de urgência do Hospital do Espírito Santo de Évora.Resultados: compararam-se os três grupos de doentes o que não foi definido qualquer teto terapêutico, com o grupo em que iniciaram medidas paliativas e o grupo em que se tomou a Decisão de Não Reanimar. Verificou-se que não existem diferenças significativa entre as idades, o local de residência e as comorbilidades e, com exceção da demência (p= 0,006), existe sim uma diferença no grau de dependência nas atividades da vida diária (p<0,001). Verificou-se que não existem diferenças entre número ou tipo de exames complementares de diagnóstico, mas há algumas diferenças na terapêutica instituída já que no grupo dos doentes em cuidados paliativos a terapêutica com morfina (p<0,001), butilescopolamina (p=0,001) e paracetamol (p=0,004) foi mais frequente. A ventilação invasiva só ocorreu no grupo de doentes sem definição de teto terapêutico (p<0,001), enquanto a oxigénioterapia foi mais frequente nos grupos em Decisão de Não Reanimar ou em cuidados paliativos (p<0,001).Discussão e conclusão: os médicos do serviço de urgência reconhecem que os seus doentes estão em final de vida, adequando parcialmente a terapêutica com vista ao controlo de sintomas, dor e secreções. 

Standing at the edge of mortality; Five-year audit of an emergency department of a tertiary care hospital in a low resource setup

Background & Objective:

Understanding the demographics of mortality and its burden in the emergency department of a tertiary care setup can lead to better planning and allocation of resources to streamline process flow. This can be achieved systematically through mortality audit that can identify the loopholes and areas of improvement. Our objective was to characterize the epidemiology of ED mortality in a tertiary care hospital of Karachi, Pakistan.

Methods:

A five-year retrospective chart review of 322 adult mortalities presenting between January l, 2014 – December 31, 2018 was conducted in the emergency department (ED) of The Indus Hospital (TIH), Karachi. All expiries in ED were included while those brought dead and with do not resuscitate order (DNAR) were excluded.

Results:

Mortality incidence of 0.076% (7.6/10,000 ED visits in five years) was reported. Amongst 507,759 adult ED visits, 322 mortalities were documented. Mean time lapse before presentation was 44±147 hours and mean length of stay before death was 3.4±2.8 hours. Acute coronary syndrome (ACS) was the predominant cause of death with 109 (33.8%) expiries. Significant association was reported between no history of prior care and high priority (P1) cases (p=0.013).

Conclusions:

This study identified the contributing factors to adverse outcome such as delayed presentation with systemic gaps in management and unknown disposition. The need to improve these factors at local and national level can lead to improvement in Pakistani healthcare sector.

Trends in Costs of Care for Medicare Beneficiaries Treated in the Emergency Department From 2011 to 2016

IMPORTANCE

There is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care.

OBJECTIVE

To examine trends in total standardized 30-day costs of care associated with an ED visit.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 14 113 088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020.

EXPOSURES

Time (year) as a continuous variable.

MAIN OUTCOMES AND MEASURES

Trends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit.

RESULTS

The analytic sample consisted of 14 113 088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8 573 652 visits (60.7%) were among women, and 11 908 691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1 233 701 of 2 309 563 visits (53.4%) in 2011 to 1 279 701 of 2 268 363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.

Development of a Binary End-of-Event Outcome Indicator for the NEMSIS Public Release Research Dataset

INTRODUCTION

Emergency department and hospital discharge status are available for less than 2% of events recorded in the National EMS Information System (NEMSIS) Public Release Research dataset. The purpose of this project was to develop a binary ("dead" vs. "alive") end-of-event outcome indicator for the NEMSIS dataset.

METHODS

The data dictionary for the Version 3 NEMSIS dataset was evaluated to identify elements and codes providing information about a patient's end-of-event status-defined as the point at which EMS providers stopped providing care for an encountered patient, whether at the scene of the event or the transport destination. Those element and code combinations were then used to test the criteria using the NEMSIS-2017 dataset. After revising the criteria based on the NEMSIS-2017 results, the final criteria were then applied to the 2018 NEMSIS dataset. To assess representativeness, the characteristics of events with a determinable outcome were compared to those of the entire dataset. To assess accuracy, the end-of-event indicator was compared with the final reported outcome for patients with a known emergency department disposition.

RESULTS

Eighteen NEMSIS element and code combinations suggest a patient was likely "dead" at the end of EMS care, and 15 combinations suggest a patient was likely "alive" at the end of EMS care. A binary end-of-event outcome indicator could be determined for 13,045,887 (98.6%) of the 13,229,079 NEMSIS-2018 9-1-1 initiated ground EMS responses in which patient contact was established, and for 132,728 (89.1%) of the 148,963 events with documented cardiac arrest. The characteristics of the events with determinable end-of-event outcomes did not differ from those of the full dataset. Among patients with a known outcome, 99.6% of those with an "alive" end-of-event indicator were in fact alive at the time of emergency department disposition.

CONCLUSION

A binary end-of-event outcome indicator can be determined for 98.6% of 9-1-1 initiated ground EMS scene responses and 89.1% of cardiac arrests included in the NEMSIS dataset. The events with a determinable outcome appear representative of the larger dataset and the end-of-event indicators are generally consistent with reported emergency department outcomes.

Death and Dying in the Emergency Department

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and to assist with the translation of research into practice. For each column, a topic and a particular research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. Our current column discusses factors associated with the quality of the death and dying experience in the emergency department (ED) from the perspective of health care providers with implications for APRN practice and strategies using the following study: . "Exploring the quality of the dying and death experience in the emergency department: An integrative literature review," International Journal of Nursing Studies, 85, 106-117. Our case involves a man with metastatic colon cancer where his oncology nurse practitioner recommends no further treatment and tells him he has approximately 6 months to live.

Emergency Department Grief Support: A Multidisciplinary Intervention to Provide Bereavement Support After Death in the Emergency Department

BACKGROUND

The nature of death in the emergency department (ED) may put survivors at higher risk for complicated bereavement. Access to bereavement care could mitigate this, but many EDs do not include bereavement follow-up as part of their routine practice.

OBJECTIVE

We describe the implementation at our institution of ED Grief Support, a program developed to extend care to the bereaved through in-person, telephone, and e-mail follow-up for 1 year after the death of a loved one.

METHODS

Bereavement follow-up was preferentially extended to survivors of patients <45 years of age who were chosen because of the higher likelihood of unexpected death in this age group. Detailed records of each case were collected prospectively using online data management software and outcomes were recorded. Successful strategies to navigate communication and resource referrals are discussed.

RESULTS

We enrolled 192 patients during our 2-year period of observation. The majority died from trauma and parents were the most common next-of-kin to be contacted. Commonly requested services included: clarification of the circumstances of death, the interpretation of autopsy reports, referral to community bereavement resources, and family meetings. Challenges included supporting the emotional well-being of staff and the resource-intensive nature of the follow-up. Staff members who worked with ED Grief Support find it meaningful and note a positive influence on their well-being as providers.

CONCLUSIONS

Longitudinal bereavement follow-up from the ED is feasible and had a perceived positive impact on the bereaved as well as ED staff.

Quality of end-of-life care in the emergency department

Objective

To assess appropriateness of end-of-life treatments provided to actively dying patients attending the emergency department of a primary care hospital.

Methods

Retrospective cohort study of patients who died in the emergency department of a French primary care hospital between January 2014 and January 2017. The deceased were identified through the admissions register. Then, electronic medical records were screened for bio-demographic data, data relative to decisions to withhold or withdraw treatments, to diagnosis and to the care provided. Patients were clustered into two categories, actively dying or non-actively dying, using clinical opinion based on their medical records. Appropriateness of care was appraised following French guidelines.

Results

One hundred and forty-six deaths were recorded. Actively dying patients mostly suffered from vascular conditions (29.4%). When compared to the overall sample, they were more likely to have decisions to withhold or withdraw treatments (OR = 5.3 [1.56; 20.7], p-value = 0.003), to have strong opioids (OR = 5.32 [2.1; 13.9], p-value <0.0001), hypnotics (OR = 2.6 [0.95; 8.39], p-value = 0.05), and scopolamine (OR = 2.5 [1.1; 6.13], p-value = 0.03). Moreover, they were less likely to have unbeneficial treatments in terminal conditions, such as resuscitation care (OR = 0.06 [0.001; 0.52], p = 0.002) and antibiotics (OR = 0.42 [0.19; 0.92], p-value = 0.022). There were no differences in rate of hydration, venous access and use of tracheal aspirations.

Conclusions

Overall, actively dying patients were appropriately supported. However, several issues regarding hydration management, drug administration routes, and broncho-pulmonary secretions management remain to be addressed.

Death in the Emergency Department: A Retrospective Analysis of Mortality in a Swiss University Hospital

Acute treatment in emergency medicine revolves around the management and stabilization of sick patients, followed by a transfer to the relevant medical specialist, be it outpatient or inpatient. However, when patients are too sick to be stabilized, i.e., when the care provided in the Emergency Department (ED) may not be sufficient to enable transfer, death may occur. This aspect of emergency medicine is often overlooked, and very few public data exist regarding who dies in the ED. The following retrospective analysis of the mortality figures of a Swiss university hospital from January 1st 2013 to December 31st 2016 attests to the fact that with an incidence of 2.6/1,000, death does occur in the ED. With a broad range of aetiologies, clinical severity at presentation has a high correlation with mortality, a finding that reinforces the necessity of good triage system. Our analysis goes on to show that however (in)frequent death in the ED may be, there exists a lack of advanced directives in a majority of patients (present in only 14.8% of patients during the time of study), a worrying and often challenging situation for Emergency Medicine (EM) teams faced with premorbid patients. Furthermore, a lack of such directives may hinder access to palliative care, as witnessed in part by the fact that palliative measures were only started in 16.6% of patients during the study. The authors hope this study will serve as a stepping stone to promote further research and discussion into early identification methods for patients at risk of death in the ED, as well as motivate a discussion into the integration of palliative care within the ED and EM training curriculum.

End-of-Life Care Challenges from Staff Viewpoints in Emergency Departments: Systematic Review

The hospital emergency department (ED) is the place where people most commonly seek urgent care. The initial diagnosis of an end-of-life (EOL) condition may occur in the ED. In this review we described the challenges; from the staff members’ perspectives, to safe, appropriate, and high quality end-of-life care (EOLC) for people who are diagnosed with non-malignant diseases who present to ED settings internationally. We conducted a systematic review of peer-reviewed literature. PubMed, Scopus, CINAHL, Medline, and Web of Science were searched from 2007 to 2017. In this review the challenges in providing quality EOLC from staff viewpoints, for EOL people who are diagnosed with non-malignant progressive diseases in ED settings, were classified into eight themes: (1) EOLC education and training, (2) ED design, (3) Lack of family support, (4) Work Load, (5) ED staff communication and decision making, (6) EOLC quality in ED, (7) resource availability (time, space, appropriate interdisciplinary personnel) and (8) integrating palliative care (PC) in ED. The formulation of EOLC using this review result may help to improve the quality of life for dying people by providing ED staff with clear guidelines that can guide them in their daily practice

Trends in the supply of California's emergency departments and inpatient services, 2005-2014: a retrospective analysis

OBJECTIVES

Given increasing demand for emergency care, there is growing concern over the availability of emergency department (ED) and inpatient resources. Existing studies of ED bed supply are dated and often overlook hospital capacity beyond ED settings. We described recent statewide trends in the capacity of ED and inpatient hospital services from 2005 to 2014.

DESIGN

Retrospective analysis.

SETTING

Using California hospital data, we examined the absolute and per admission changes in ED beds and inpatient beds in all hospitals from 2005 to 2014.

PARTICIPANTS

Our sample consisted of all patients inpatient and outpatient) from 501 hospital facilities over 10-year period.

OUTCOME MEASURES

We analysed linear trends in the total annual ED visits, ED beds, licensed and staffed inpatient hospital beds and bed types, ED beds per ED visit, and inpatient beds per admission (ED and non-ED).

RESULTS

Between 2005 and 2014, ED visits increased from 9.8 million to 13.2 million (an increase of 35.0%, p<0.001). ED beds also increased (by 29.8%, p<0.001), with an average annual increase of 195.4 beds. Despite this growth, ED beds per visit decreased by 3.9%, from 6.0 ED beds per 10 000 ED visits in 2005 to 5.8 beds in 2014 (p=0.01). While overall admission numbers declined by 4.9% (p=0.06), inpatient medical/surgical beds per visit grew by 11.3%, from 11.6 medical/surgical beds per 1000 admissions in 2005 to 12.9 beds in 2014 (p<0.001). However, there were reductions in psychiatric and chemical dependency beds per admission, by -15.3% (p<0.001) and -22.4% (p=0.05), respectively.

CONCLUSIONS

These trends suggest that, in its current state, inadequate supply of ED and specific inpatient beds cannot keep pace with growing patient demand for acute care. Analysis of ED and inpatient supply should capture dynamic variations in patient demand. Our novel 'beds pervisit' metric offers improvements over traditional supply measures.