Homelessness and ED use: myths and facts- the author’s reply
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www. elsevier. com/ locate/ajem
American Journal of Emergency Medicine 34 (2016) 307-337
Homelessness and ED use: myths and facts
To the Editor,
In their article, “The role of Charity care and Primary care physician assignment on ED use in Homeless patients” [1], Wang et al perpetuate a myth about homeless emergency department (ED) patients that is not supported by the evidence. Namely, in their introduction they state, “… these patients tend to inappropriately use the ED more often than the general population,” yet this statement has not been supported by prior research. None of the 3 articles they reference for this statement (one of which I coauthored) studied “inappropriate” vs “appropriate” use of the ED. Although it is true that research has shown that people who are homeless tend to use the ED more often than people who are not homeless, we cannot assume that their ED use is more often “inap- propriate.” Because Wang et al did not examine the proportion of “inap- propriate” ED visits for nonhomeless ED patients, they cannot comment on whether people who are homeless use the ED more or less “inappro- priately” than other patients. Finally, research has called into question the advisability of even trying to categorize ED visits as “inappropriate” vs “appropriate,” [2] with some leaders in the field suggesting that we “put to rest conversations about ‘inappropriate’ ED use [3].”
These concerns noted, Wang et al should be commended for their methodology of matching electronic health record data with local Homeless Management Information System data and for seeking to learn more about homeless patients in their health care system. They also succeed in beginning to dispel the alluring (yet so far not evidence based) tale that primary care will reduce ED use by showing that access to a primary care provider and charity care alone were not associated with reduced ED use among people who are homeless in their study.
Kelly M. Doran, MD, MHS Departments of Emergency Medicine and population health NYU School of Medicine/Bellevue Hospital Center, New York, NY 10016
Corresponding author. Tel.: +1 212 263 5850
E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.10.001
References
- Wang H, Nejtek VA, Zieger D, Robinson RD, Schrader CD, Phariss C, et al. The role of charity care and primary care physician assignment on ED use in homeless patients. Am J Emerg Med 2015;33:1006-11.
- Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs. dis- charge diagnosis for identifying “nonemergency” emergency department visits. JAMA 2013;309(11):1145-53.
- Bernstein SL. Frequent emergency department visitors: the end of inappropriateness. Ann Emerg Med 2006;48(1):18-20.
Homelessness and ED use: myths and facts- the author’s reply
In Reply:
We would like to thank Dr Doran for the commentary regarding our recent publication, “The role of charity care and primary care physician as- signment on ED use in homeless patients” [1]. The primary goal of our study was not to compare homeless patients with the general population, but to compare emergency department (ED) use in a homeless popula- tion as a function of whether they received charity care or were assigned to a Primary care physician . Our rationale to conduct this compari- son study grew out of our desire to better serve these patients by assigning homeless patients to a PCP rather than have them receive care by a variety of different rotating emergency physicians. We felt that a “continuity of care” model might be an important mitigating factor as charity care clinic patients do not often have the opportunity to establish a solid relationship through scheduled care with the clinic doctor(s).
In addition, although we appreciate Dr Doran’s comment that inap- propriate ED visits in homeless patients isa “myth,” we must point out that our terminology of appropriateness was a direct reflection of our use of the New York University ED Algorithm. “Inappropriate” ED use in the introduction of this study was operationally defined as (1) prima- ry care treatable, (2) Emergent care needed but preventable or avoid- able, or (3) nonemergent condition as per the New York University ED Algorithm. To clarify the data from our study, we have provided further evidence that the homeless patients using our county-funded hospital network indeed have a high percentage of inappropriate ED visits for nonurgent care that could have been better treated with an outpatient PCP who would be available to provide ongoing follow-up (see Table). We concur with Dr Doran that the data from Levy and O’Connell [2], Hwang et al [3], and Tsai et al [4] showed that more ED visits occurred in homeless patients than in the nonhomeless population (either general or US veterans). However, the question of whether or not these visits were inappropriate was not studied. Therefore, those studies should be viewed as concluding that “homeless patients tend to use the ED more often than the general population.” We acknowledge the chal- lenge of categorizing appropriate ED use and agree that language such
as “inappropriate ED utilization” should be used with caution.
Table Most common discharge diagnoses among homeless patients who were considered to in- appropriately use the ED
Primary discharge diagnosis %
Chronic pain (extremities) 15.5
upper respiratory infection 11.9
Unspecified Essential hypertension or diabetes 6.8
Prescription refills 4.3
0735-6757/(C) 2015
308 Correspondence/ American Journal of Emergency Medicine 34 (2016) 307–337
We appreciate the comments that highlight our ability to match the electronic health record data with the local Homeless Management In- formation System Data in our health care network. We believe that this allows us to implement patient Health screenings using the elec- tronic medical record to identify homeless patients frequently using the local ED, thereby leading to earlier recognition of special needs in this patient population. Consistent with previous studies [5,6], we re- ported that “simply providing charity care and primary care physician assignments is insufficient to significantly redirect homeless patients to access the health care system in a more cost-effective manner.” In- deed, our findings raise several questions regarding the concept that many indigent patients and shelter case managers have that the ED is the first-line health provider for this population. Other questions need to be addressed. Such questions include the following: (1) where do ill homeless patients go for after-hour nonemergency care and
(2) does it make more sense for shelters to have access to an on-call physician’s assistant or nurse practitioner? Thus, a multisite prospective study focusing on reasons for ED use and examination of patterns of non-emergency ED use is highly warranted.
Hao Wang, MD, PhD
Department of Emergency Medicine, Integrative Emergency Services
JPS Health Network, Fort Worth, TX Corresponding author. Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St, Fort Worth, TX 76104
E-mail address: [email protected]
Vicki A. Nejtek, PhD
Texas College of Osteopathic Medicine University of North Texas Health Science Center, Fort Worth, TX
Department of Emergency Medicine, Integrative Emergency Services
JPS Health Network, Fort Worth, TX
http://dx.doi.org/10.1016/j.ajem.2015.10.008
Wang H, Nejtek VA, Zieger D, Robinson RD, Schrader CD, Phariss C, et al. The role of charity care and primary care physician assignment on ED use in homeless patients. Am J Emerg Med 2015;33:1006-11.
- Levy BD, O’Connell JJ. Health care for homeless persons. N Engl J Med 2004;350:2329-32.
- Hwang SW, Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, et al. A comprehen- sive assessment of health care utilization among homeless adults under a system of universal health insurance. Am J Public Health 2013;103(Suppl. 2):S294-301.
- Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national com- parison of homeless and nonhomeless US veterans who use Veterans Affairs Emer- gency Departments. Am J Public Health 2013;103(Suppl. 2):S225-31.
- Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health 2002;92:778-84.
- O’Toole TP, Buckel L, Bourgault C, Blumen J, Redihan SG, Jiang L, et al. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health 2010;100:2493-9.
novel technique to diagnose parotid duct injuries at the bedside using fluorescein
Deep penetrating facial soft tissue trauma can potentially involve the parotid duct. This injury requires a high degree of suspicion as it is not readily evident on physical examination, although buccal branch injury may accompany it. Unrecognized parotid duct injury could lead to sialocele, salivary fistula, parotitis, wound dehiscence, or abscess [1]. There are multiple methods of detecting parotid duct injury at the bed- side. The most frequently utilized method is cannulation of the papilla with identification of the cannulating object in the wound [2]. Material
that can be used to cannulate the duct includes lacrimal probes or large diameter suture. Visualizing these objects in the wound can be difficult, limiting the ability to rule out injury with confidence. Saliva seen at the papilla while palpating the gland does not rule out injury either and conversely lack of saliva does not indicate injury [3]. Lastly, wound explo- ration is the gold standard for diagnosing parotid duct injury, which fre- quently necessitates loupe magnification and/or use of the operating room. In a deep, narrow wound, adequate exploration may still be diffi- cult and potential for further injury is possible. This paper describes a sim- ple method that may increase the sensitivity and specificity of detecting parotid duct injury in the emergency department (ED) setting.
Materials needed to perform the technique include a 0000 lacrimal probe, one fluorescein strip, 20 mL of sterile saline, a sterile specimen cup, a 5- or 10-mL sterile luerlock syringe, a 22-g angiocatheter, and a Wood’s lamp. These materials are depicted in Fig. 1. The fluorescein strip is dissolved in 20 mL of saline in the specimen cup and is drawn into the syringe. The 0000 lacrimal probe is placed through the angiocatheter. The lacrimal probe is used to cannulate the opening of Stensen’s duct. It is helpful to have an assistant retract the patient’s cheek. With the probe in the duct, the angiocatheter is advanced over the probe into the duct then the probe is removed. Next the syringe con- taining fluorescein solution is screwed onto the angiocatheter. Firm pressure is applied to the syringe to inject the solution into the duct. Fi- nally, the Wood’s lamp is used to inspect the wound. Fluorescence will be identified if there is a parotid duct injury. In the event of fluorescence in the wound bed, formal surgical exploration of the parotid duct is rec- ommended. After obtaining institutional review board approval, the electronic medical record was reviewed to identify patients who had the novel technique used to assess for parotid duct injury.
The first patient identified was a seventy-one year old man with a deep penetrating laceration of the left cheek. It was a complex, stellate wound that extended from 1cm lateral to the oral commissure to the angle of the mandible. Initially, a 1-0 prolene suture was passed through the duct and was not definitively seen in the wound bed. Our method described above was used and no fluorescence was observed. The patient’s wound was closed in multiple layers in the ED and he was spared a trip to the operating room.
The second patient identified was a 44-year-old man who was shot at close range by a shotgun with massive soft tissue loss of the right cheek. The fluorescein method was used to evaluate for parotid duct in- jury after intubation. There was diffuse fluorescence in the wound bed with application of the Wood’s lamp as shown in the photograph in Fig. 2 indicating injury to the parotid duct.
Fig. 1. Common ED supplies needed to perform the technique to diagnose parotid duct in- jury: specimen cup, 10 mL syringe, 0000 lacrimal probe, 22 g angiocath, Wood’s lamp, fluo- rescein strip.
