Introduction: National guidelines suggest that most skin abscesses do not require antibiotics, and that cellulitis antibiotics should target streptococci, not community-associated MRSA (CA-MRSA). The objective of this study is to describe antimicrobial treatment of skin infections in U.S. emergency departments (EDs) and analyze potential quality measures.

Methods: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a 4-stage probability sample of all non-federal U.S. ED visits. In 2007 NHAMCS started recording whether incision and drainage was performed at ED visits. We conducted a retrospective analysis, pooling 2007-2010 data, identified skin infections using diagnostic codes, and identified abscesses by performance of incision and drainage. We generated national estimates and 95% confidence intervals using weighted analyses; quantified frequencies and proportions; and evaluated antibiotic prescribing practices. We evaluated 4 parameters that might serve as quality measures of antibiotic stewardship, and present 2 of them as potentially robust enough for implementation.

Results: Of all ED visits, 3.2% (95% confidence interval 3.1-3.4%) were for skin infection, and 2.7% (2.6-2.9%) were first visits for skin infection, with no increase over time (p=0.80). However, anti-CA-MRSA antibiotic use increased, from 61% (56-66%) to 74% (71-78%) of antibiotic regimens (p<0.001). Twenty-two percent of visits were for abscess, with a non-significant increase (p=0.06). Potential quality measures: Among discharged abscess patients, 87% were prescribed antibiotics (84-90%, overuse). Among antibiotic regimens for abscess patients, 84% included anti-CA-MRSA agents (81-89%, underuse).

Conclusion: From 2007-2010, use of anti-CA-MRSA agents for skin infections increased significantly, despite stable visit frequencies. Antibiotics were over-used for discharged abscess cases, and CA-MRSA-active antibiotics were underused among regimens when antibiotics were used for abscess. [West J Emerg Med. 2014;15(3):282–289.]

Introduction: Emergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear.

Methods: We performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors’ opinions regarding perceived barriers to offering preventive services in their EDs.

Results: Overall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04).

Conclusion: To increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors’ perceived barriers related to an ED’s capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors’ concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service. [West J Emerg Med. 2014;15(4):438-445.]

Introduction: Emergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.

Methods: This study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.

Results: Of 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99–1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04–2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2–4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03–3.8]) and Medicare (AOR 5.7 [95%CI, 1.5–22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6–6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00–1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01–1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07–1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.

Conclusions: Successful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations. [West J Emerg Med. 2013;14(3):287–295.]

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Background/Objective: Asthma is a common chronic medical condition among children and the most common diagnosis associated with interfacility transports for pediatric patients. As many as 40% of pediatric transfers may be unnecessary, resulting in potential delays in care and unnecessary costs. Our objective was to identify the patient-related factors associated with potentially unnecessary transfers for pediatric patients with asthma.

Methods: We used patient care data from the California Department of Health Care Access and Information patient discharge and emergency department (ED) datasets to capture ED visits where a pediatric patient (age 2–17 years) presented with asthma and was transferred to another ED or acute care hospital. The outcome of interest was a potentially unnecessary transfer, defined as a visit where length of stay after transfer was <24 hours and no advanced services were used, such as respiratory therapy or critical care. Patient-related characteristics were extracted, including age, gender, race/ethnicity, primary language, insurance status, and clinical characteristics. First, we used descriptive statistics to compare necessary vs unnecessary transfers. Second, we used generalized estimating equations accounting for clustering by ED to estimate odds ratios (OR) and identify factors associated with potentially unnecessary transfers.

Results: A total of 4,233 pediatric ED patients were transferred with a diagnosis of asthma, including 461 (11%) transfers that met criteria as potentially unnecessary. Median age was 12 years (interquartile range 7–15), and 46% were female. Factors associated with increased odds of potentially unnecessary transfer while controlling for key factors included younger age (eg, 2–5 years, OR 2.0, 95% confidence interval [CI] 1.4–2.9), male gender (OR 1.4, 95% CI 1.1–1.7), and Hispanic ethnicity (OR 1.6, 95% CI 1.2–2.1), while multiple hospitalizations for asthma per year was associated with decreased odds (OR 0.2, 95% CI 0.1–0.4).

Conclusion: Several patient-related factors were associated with increased or decreased odds of potentially unnecessary transfers among pediatric patients presenting to the ED with asthma. These factors can be considered in future work to better understand, predict, and reduce unnecessary transfers and their negative consequences.

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Introduction: Epidemiological surveillance data for emergency department (ED) visits by children areimperative to guide resource allocation and to develop health policies that advance pediatric emergencycare. However, there are sparse population-based data on patient-level information (e.g., the number ofchildren who present to the emergency department [ED]). In this context, we aimed to investigate boththe patient- and visit-level rates of ED utilization by children.

Methods: This was a retrospective cohort study using population-based multipayer data – state EDdatabases (SEDD) and state inpatient databases (SID) – from six geographically-dispersed U.S. states(California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all childrenaged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visitrate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDDand SID data. We also repeated the analysis using the 2010 data to determine the consistency of theresults across different years.

Results: In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states.At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of thesechildren, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across thestates (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At thevisit-level, 6.7 million ED visits were made by children in 2011 – 34 ED visits per 100 children annually.ED visits by children accounted for 22% of all ED visits (including both adults and children), with arelatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the2010 data gave similar results for the ED utilization by children.

Conclusion: By using large population-based data, we found a substantial burden of ED visits at bothpatient- and visit-levels. These findings provide a strong foundation for policy makers and professionalorganizations to strengthen emergency care for children.