Article

Comparative throughput at freestanding emergency departments versus hospital-based emergency departments: A pilot study

1508 Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520

Comparative throughput at freestanding emergency departments versus hospital- based emergency departments: A pilot study

While utilization of freestanding emergency departments (FSEDs) is increasing in recent years [1], quality of care remains largely unknown. Current literature addressing care quality has only assessed satellite emergency centers (SECs), a type of hospital-affiliated FSED.

One study showed fewer than 8 out of 10 ST-elevation myocardial

infarction (STEMI) patients presenting to an FSED achieved the recom- mended Door-to-balloon time of b 90 min [2]. In contrast, the 2013 ACCF/AHA guidelines estimated that 9 out of 10 STEMI patients present- ing to hospital-based emergency departments (HBEDs) met the recom- mended door-to-balloon time [3]. Another study evaluated treatment times at SECs affiliated with academic institutions [4]. Comparing com- mon emergency department (ED) administrative metrics, SECs ap- peared similar to benchmarks for HBEDs.

However, no published assessments of the quality of care at inde- pendent freestanding emergency centers (IFECs), those operating inde- pendently of hospitals, exist. In this pilot study, we compare IFECs to HBEDs in similar markets based on common ED quality and throughput metrics.

We retrospectively collected administrative data from IFECs in Texas to compare measures of ED quality. One hundred ninety-four IFECs were invited to participate. Each IFEC administrator received an informational postcard about the study, after which they were twice mailed the study survey. We followed up by phone with IFECs that did not respond. We collected data for ED quality metrics that are routinely tracked by HBEDs as part of the Medicare Hospital Compare database.

Using the rationale that census designations better represent healthcare marketplaces than ZIP codes [5], we matched participat- ing IFECs to HBEDs located in the same Public Use Microdata Area

to control for population size and socioeconomic characteristics. We excluded surgical and specialty hospitals, HBEDs without corre- sponding Hospital Compare data, and unmatched IFEC/HBED combinations.

The final sample included 20 total observations: 7 IFECs and 13 HBEDs. Outcomes were weighted by the proportion of ED visits per facility. Data were analyzed by Stata using independent sample t– tests with unequal variances to compare the means of reported metrics.

We received responses from 10 Texas IFECs for an overall response rate of 5.2%. Median ED length of stay, in minutes, was statistically sig- nificant for FSEDs (179.0) compared to matched HBEDs (348.5), p b

0.01. There were also statistically significant differences in time be-

tween IFECs and matched HBEDs for admit decision to ED departure for admitted patients (57.75 vs. 154.33 min, respectively), ED arrival to ED departure for discharged patients (61.29 vs. 144.08 min, respec- tively), and ED arrival to diagnostic evaluation by qualified medical pro- fessional (11 vs. 26.77 min, respectively). The Left without being seen rate at FSEDs was 0.29% compared to 2.42% at HBEDs, also sta- tistically significant. There was no difference in ED arrival to pain med- ication for long bone fractures (Table 1).

IFECs out performed nearby HBEDs for multiple ED throughput mea- sures. Length of stay at IFECs was lower at every point in the admission process. The LWBS rate was nearly a magnitude of order lower at IFECs. However, our results have limitations. The low response rate may have infused significant non-response bias. We were unable to stan- dardize patient acuity, which has been demonstrated to differ between FSEDs and HBEDs [6,7,8]. Lower acuity could account for the superior performance of IFECs in our study. Lastly, our study was underpowered to detect a true difference in certain metrics, e.g., time to pain medica-

tion for Long bone fractures.

Our results suggest IFECs might offer rapid, patient-centered care su- perior to HBEDs. Future studies should attempt to replicate our findings with larger, more representative, sampling and should adjust for con- founding variables such as patient acuity.

Table 1

Results of t-tests and descriptive statistics for outcomes by type of emergency department.

Outcome

Emergency department

Freestanding ED

hospital-based ED

n M (SD)

n M (SD)

95% CI for M difference t df

Median time

ED arrival to ED departure for admitted patients

4

179 (43.25)

6

348.5 (73.92)

[-294.27, -44.73]

-4.57?

7.96

Admit decision to ED departure for admitted patients

4

57.75 (21.61)

6

154.33 (48.15)

[-173.80, -19.37]

-4.31?

7.36

ED arrival to ED departure for discharged patients

7

61.29 (27.05)

13

144.08 (36.32)

[-124.77, -40.82]

-5.77?

15.84

ED arrival to diagnostic evaluation

7

11 (4.36)

13

26.77 (12.75)

[-27.14, -4.4]

-4.04?

16.24

ED arrival to pain medication for long bone fractures

2

19 (12.73)

3

49 (14.11)

[-117.95, 57.95]

-2.47

2.48

Percent of Patients who Left Without Being Seen

7

0.29 (0.39)

12

2.42 (1.62)

[-3.61, -0.65]

-4.34?

13.09

Note: Weighted averages were used in samples having multiple HBEDs within the same PUMA; standard deviations presented in parentheses below means.

* p b 0.01.

Acknowledgements

Abdullah Basnawi, MD; Anjali Bhatla; Bashar Ismail, MD.

Funding

This work was supported by an internal research grant from Baylor College of Medicine.

Abbreviations: FSED, freestanding emergency department; HBED, hospital-based emergency department; IFEC, independent freestanding emergency center; SEC, satellite emergency center.

Conflicts of interest

Dark (March 30, 2016 through present) – During the time frame from inception to publication of this study, Dr. Dark reports support from Community Health Choice, HealthCorps, and Schumacher Clinical Partners. His professional memberships have included the American College of Emergency Physicians (ACEP), the Texas Medical Association, the Harris County Medical Society, (HCMS) and the American Academy of Emergency Medicine. Formerly, he was the chair of the Subcommit- tee on FSED Regulations for the State Legislative and Regulatory Com- mittee of ACEP and the Communications Committee Chair for the

Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520 1509

Texas College of Emergency Physicians. He was formerly a stockholder of Adeptus Healthcare. Currently, he is a member of the Emergency Care Committee for HCMS and a member of the Freestanding Accreditation Task Force for ACEP.

Xu – nothing to disclose. Kao – nothing to disclose.

Cedric Dark, MD, MPH Baylor College of Medicine, 1 Baylor Plaza, Houston,

TX 77030, United States Corresponding author.

E-mail address: [email protected]

Yingying Xu Rice University, Department of Economics, 6100 Main Street,

Houston, TX 77005, United States

E-mail address: [email protected]

Emily Kao, PhD, MPA Houston Methodist Hospital, 6565 Fannin Street, Alkek 8-053,

Houston, TX 77030, United States

E-mail address: [email protected] https://doi.org/10.1016/j.ajem.2017.12.048

References

  1. Ho V, et al. Comparing utilization and Costs of care in freestanding emergency departments, hospital emergency departments, and urgent care centers. Ann Emerg Med 2017 Dec; 70(6):846-857.e3. https://doi.org/10.1016/j.annemergmed.2016.12.006 (Epub 2017 Feb 15).
  2. Simon EL, et al. door-to-balloon times from freestanding emergency departments meet ST- segment elevation myocardial infarction reperfusion guidelines. J Emerg Med 2014 May; 46(5):734-40. https://doi.org/10.1016/j.jemermed.2013.08.089 (Epub 2013 Dec 17).
  3. O’Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myo- cardial infarction. J Amer Coll Cardiol 2013;61(4):e78-140.
  4. Dayton JR, et al. Acuity, treatment times, and patient experience in freestanding emergency departments affiliated with academic institutions. Am J Emerg Med 2018 Jan;36(1):139-41. https://doi.org/10.1016/j.ajem.2017.07.004).
  5. Dark C, et al. Freestanding emergency departments preferentially locate in areas with higher Household income. Health Aff (Millwood) 2017 Oct 1;36(10):1712-9. https:// doi.org/10.1377/hlthaff.2017.0235.
  6. Simon EL, et al. A comparison of Acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015 Apr;33(4):539-41. https://doi.org/10.1016/j.ajem. 2015.01.021 [Epub 2015 Jan 20].
  7. See Dayton, JR et al. (2017).
  8. Simon EL, et al. Variation in Hospital admission rates between a tertiary care and two freestanding emergency departments. Am J Emerg Med 2017;36(6):967-71.

Using a rubber strip test to classify swollen

fingers for Ring removal

To the Editor,

We are very interested in techniques for removing tight rings from swollen fingers. As Asim Kalkan [1] has summarized, many approaches have been used to remove rings, but there is no clear standard to help clinicians choose the proper method. We use a rubber strip test to cate- gorize fingers that have swollen to the point that ring removal has be- come problematic. This method categorizes swollen fingers into four types and recommends the proper approach for removing rings for each of the different types of swollen fingers.

The rubber strip test: While holding the finger, apply a rubber strip (2 cm wide), which can be fashioned from a rubber glove, and stretch it to the opposite side. Then, use hemostatic forceps to hold it in place (Fig. 1). Observe the plane gap between the finger and ring after 5 min (Fig. 2). This time period of 5 min is critical, as it reduces swelling, allowing us to assess the degree of finger swelling, and may also allow immediate removal of the ring (Table 1).

The four categories of swollen fingers trapped by a ring, based on the measured plane gap between the finger and ring, are identified as follows:

  1. The finger plane is lower than the ring plane.
  2. The finger plane is not more than 3 mm above the ring plane. (When the finger plane was over 3 mm above the ring plane, we tried to remove the ring with Noncutting techniques, but the result failed. We hope anyone who has a successful experi- ence can improve on this.)
  3. The finger plane is more than 3 mm above the ring plane.
  4. The ring has damaged the skin and is confined within the finger tissue. (This type of injury is not suitable for the rubber strip test.)

According to these principles, we have divided the removal methods into five categories:

  1. The lubrication approach. A lubricant and some skill are used to re- move the ring. Recommendation: The caterpillar technique [2].
  2. The winding approach. This involves winding the ring utilizing differ- ent materials to increase the control of the ring. Recommendation: The two rubber bands technique [3].

Fig. 1. Use a rubber strip to wrap the finger with the ring, utilizing hemostatic forceps to hold it in place.

Fig. 2. Loosen the rubber strip after 5 min and observe the plane gap between the finger and the ring. The red line in the figure indicates the finger plane; the black line indicates the ring plane.

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