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AnaShimeall

9/29/15
Period6

AnnotatedSourceList

"Asthma."
HumanDiseasesandConditions
.Ed.MirandaHerbertFerrara.2nded.Vol.1.Detroit:
CharlesScribner'sSons,2010.153163.Print.27Sept.2015.

Thisarticlegivesanextensiveoverviewofasthma.Asthmacausesepisodicbreathing
difficultiesthroughthreeprocesses:inflammation,mucusproduction,andmuscleconstriction.
Flaresorattackscanbetriggeredbyallergic(pollens,molds,dander,mites)andnonallergic
(smoke,chemicals,airpollutants)factors.Thecauseofasthmaiscurrentlyunknown.Some
symptomsofasthmaareshortnessofbreath,wheezing,tightnessinchest,andcoughing.Asthma
canbetreatedtheinhalationofcorticosteroids,whichpreventandreducetheswellingof
airways,andothersubstancesthatreducesensitivitytotriggers.
Thisarticlegavemeapreliminaryunderstandingofthecauses,symptoms,and
treatmentsofasthma.ImayusethisarticleasageneralreferenceifIchoosetoconductresearch
onasthma.DuringmyinternshiponSeptember14th,therewasonecaseofsevereasthmawhere
thepatientwaswheezingandhaddifficultybreathing.Hesaidthathethoughttheonsetofhis
asthmaattackwasduetosecondhandexposuretocigarettesmokewhilewalkinginthecity.IfI
weretouseasthmaasatopicofmyresearch,Iwouldlookintothetypeoftriggerversusthe
severityoftheattack.

Bodenmann,Patrick,etal."CaseManagementForFrequentUsersOfTheEmergency
Department:StudyProtocolOfARandomisedControlledTrial."
BMCHealthServices
Research
14.1(2014):426.
PublisherProvidedFullTextSearchingFile
.Print.16Oct.
2015

4.5%8%ofpatientsthatvisittheemergencyroomaccountfor21%28%ofallvisits.
Thesefrequentusershaveahigherrateofmorbidityandmortality,ahigherriskofdrugand
alcoholabuse,andaremorelikelytohaveamentalillnessorvisittheemergencydepartmentfor
exacerbationsofchronicconditions.Theyalsoareoftenhomeless,uninsured,andfromlow
socioeconomiclevels.Thisoveruseoftheemergencyroomisanextremefinancialburdenfor
thehealthcaresystem,andcanbepreventedbyredirectingfrequentuserswhohavenonurgent
concernselsewhere,suchasaprimarycarephysician.OnemethodtodothisisCase
Management:identification,assessment/reassessment,planning,implementation,and
evaluations/monitoring.Thismeansofdecreasingemergencyvisitsiseffectivebecausethereis
followupforeachpatient,sothatpeoplewhousuallydonotcontrolchronicconditionsare
promptedtodoso.
Thisstudyproposesapotentialmethodofcontrollingemergencyroomusebyfrequent
visitors.Casemanagementistooextensivetopersonallyimplementatmyinternship,butsome
aspectsofitareusefulformyproject.Followingupwithpatientswasaveryeffectivepartof
casemanagement,sopromptingorreferringpatientswithuncontrolledchronicconditionsto
primarycarephysiciansorgivingthemeasytofollowinstructionsonhowtoproperlycontrol
theirconditionsissomethingthatIcouldconsiderlookingintodoingatmyinternship.

CentersforDiseaseControlandPrevention.
U.S.DepartmentofHealthandHumanServices.
Web.20Nov.2015.

TheCentersforDiseaseControlandPreventionisagovernmentorganizationtheworks
todetectandrespondtohealththreatsinAmerica,promotesafeandhealthybehaviors,andtrain
thepublichealthworkforce.cdc.govprovidesinformationofdiseasesandconditions,healthy
living,healthdataandstatistics,globalhealth,andemergencypreparedness.Thewebsitealso
hasaDiseaseandConditionsAZindex,whichdelineatesinterventions,basics,dataand
statistics,andstateprogramsforvariousdiseases.Withineachdiseasepage,thereisalinkto
publications,whichgivestheuseraccesstoscientificarticleswrittenbyCDCstaff.Onthehome
page,cdc.govhasawhatsnewsection,whichhaslinkstoarticlesaboutnewdiseases,outbreaks,
orjustgeneralhealthsafetyreminders.
TheDiseaseandConditionsAZindexhasbeenveryusefulasareferencesourcefor
diseasesormedicationsthatIencounterduringmyinternship.CDCpublishesalotofpatient
information,whichismucheasierformetounderstandthanarticlesgearedtowardsdoctorssuch
asthoseonpubmed.CDCisagreatresourcetoquicklyrefertoifIcomeacrossanewtopic
duringmyinternship.

Choudry,Lina,etal."TheImpactofCommunityHealthCenters&CommunityAffiliated
HealthPlansonEmergencyDepartmentUse."
NationalAssociationofCommunity
HealthCenters
.NationalAssociationofCommunityHealthCenters,Apr.2007.Web.24
Oct.2015.

Medicaidrecipientsandtheuninsuredaremorelikelytoturntotheemergencyroom,and
thenumberofphysicianofficevisitsforMedicaidanduninsuredpatientsisdecreasing.Overall,
thisreportconcludedthatatleastonethirdofallemergencyroomvisitsaretreatableinprimary
caresettingsandwasteabout18billiondollarsannually.Thereportsuggestedthatpolicymakers
reinvestmoneyinprimarycarefacilities,expandpublicinsurance,andsupporthealthcentersin
implementinghealthinformationtechnology.Oneapproachtodoingthisistheimplementation
ofHealthCenters,communitybasedhealthcareprovidersthatarelocatedinhighneedareasand
formtheirservicestoaccommodatetheircommunitiesneeds.Amajorservicetheyprovideis
assistingpatientsineffectivelymanagingchronicdiseases.Theoverwhelmingmajorityof
patientsinthesecentersarebelowthepovertylevel,uninsuredorrelyingonMedicaid,andracial
minorities.Thesecentersultimatelysavearound30%perMedicaidpatientwhencomparedto
emergencytreatment.Anotherapproachwaspatienteducation.Thisplanconsistedof
distributingmaterialstothepopulationdictatingwhattodowhenthepatientorhis/herchildgets
sick.Overall,improvingaccesstoprimarycareservicesclearlyreducesemergencydepartment
useandcreatesamoreefficienthealthcaresystem.
Similartootherstudies,thisreportnamedtheinabilitytomanagechronicconditionsasa
majorexpenseforMedicaid.Distributinginformationonhowtomanagethesediseasessaves
moneyinthelongrunbecauseitpreventsexpensiveemergencyroomvisitsinthefuture.Most
importantly,thisarticleattributedsomesuccessinreducingemergencyroomvisitsincertain
areasbydistributingmaterials,orimplementingpatienteducation.Thiswouldbethemost
realisticmethodofdecreasingnonurgentvisitationstotheemergencyroomatmyinternshipfor
myresearchproject.

Davidson,Tish,andLauraJeanCataldo."CongestiveHeartFailure."
TheGaleEncyclopediaof
Medicine
.Ed.LaurieJ.Fundukian.4thed.Vol.2.Detroit:Gale,2011.11421147.Print.
25Oct.2015.

Congestiveheartfailureisachronic,progressivediseaseinwhichtheheartsabilityto
pumpblooddeteriorates.Theatria,ortopchambers,receivebloodfromthebody,andthe
ventricles,orbottomchamberspumpbloodouttothebody.Thecontractionoftheheartthat
oxygenatesbloodmustbetightlycoordinatedsothateachchamberemptiesefficientlyand
completelyinordertomeettheneedsofotherorgansinthebody.Insystolicheartfailure,
diseaseweakensthewalloftheventricles,causingthemtopumpwithlessforce.Peoplewith
systolicheartfailurehaveejectionfractions(volumeofbloodpumpedoutoftheventricle)less
than50%.Indiastolicheartfailure,theheartbecomesstiffratherthanweak,causingittonot
relaxenoughtofillproperlyaftereachcontraction.Somecausesofcongestiveheartfailure
includecoronaryarterydisease,previousheartattack,heartvalveabnormalities,prolongedheart
arrhythmias,endocarditis(infectionofheart),substanceabuse,heartdefects,obesity,diabetes,
andsmoking.Symptomsusuallygetworse,beginningwithshortnessofbreath,andprogressing
intoswellingofthefeetandlegs,extremefatigue,irregularheartbeat.Treatmentscannotcure
congestiveheartfailurebuttheycanslowitsprogression.Sometreatmentsincludelifestyle
changes(reducingsodiumintake,exercise,andcontrollingcalorieintake)drugtherapy,and
surgeries.
Becausecongestiveheartfailureistheleadingcauseofhospitalizationsofpeopleover
theageof65,itisanimportantdiseasetobecomefamiliarwith.Iwouldliketofocussomeof
myprojectofcreatinginformationsheetsforpatientswithcongestiveheartfailurethatdelineate
stepstotaketopreventfutureneedforemergencyroomusebykeepingtheconditionunder
control.Muchlikediabetes,congestiveheartfailurecanbecontrolledsothatitismanageable
andexacerbationsoftheconditionarelimited.

DepartmentofHealthandHumanServices.OfficeofInspectorGeneral.
ControllingEmergency
RoomUse:StateMedicaidReports
.ByRichardP.Kusserow.N.p.:n.p.,1992.Print.

Thisreportservestoevaluatethemethodssixstatesusedtocontrolemergencyroomuse
byMedicaidrecipients,theobstaclestheyfacedduringimplementation,andtheeffectivenessof
eachprocedure.Nationally,emergencyroomsarebecomingincreasinglycrowded,partiallydue
tothelargeamountofnonemergencyvisits(11%38%ofallvisitsarenonurgent).Studiesshow
thatthepercentageofMedicaidrecipientsthatvisitemergencydepartmentsfornonemergency
visitsisconsistentlyrising.Thisisextremelycostlyforthehealthcaresystememergencyroom
visitscostatleastthreetimesasmuchasgoingtoaprimarycarephysician.Thisstudyproposes
savingMedicaidcostsbyredirectingnonemergencyvisitstomoreappropriateandlesscostly
communitycaresites.Themajorityoftheprogramsthatprovidedrecipientswithongoing
primarycarewereconsideredsuccessful.InArkansas,amethodusedtocontrolemergencyroom
overusewassimplydefiningemergencycare.Thecriteriaare:significanttrauma,feverof103
degreesorabove,reducedmentalalertness,drug/substanceoverdose,respiratorydistress,
substernalpain,onsetoflabor,shock,andsignificantbleeding.Thosethatdidnotmeetthese
criteriawerereviewedagainbyaphysicianandthendeniedifthedoctorstilldidnotbelievethe
patientrequiredemergencycare.
Thedefinitionofsymptomsthatqualifyforemergencycareusedbyhospitalsin
Arkansaswasthemostusefulsectionofthisarticle.ThoughIcannotturnpatientsawayatmy
internshipbasedonthesecriteria,Icanlookintocreatingapamphletorwebpagethatexplains
thesituationsinwhichapatientshouldgototheemergencyroomversushis/herprimarycare
physician.ThismethodwasverysuccessfulinArkansasbecausemanypatientsdonotknow
whenusingtheemergencyroomisinappropriate.

"Diabetes."
HumanDiseasesandConditions
.Ed.MirandaHerbertFerrara.2nded.Vol.2.
Detroit:CharlesScribner'sSons,2010.511520.Print.8Oct.2015.

Thisarticledescribesdiabetesindepth.Diabetesisagroupofdiseasesthatinvolvehigh
bloodsugarlevelscausedbyirregularorabsenceofinsulin,ahormonethathelpsthebodyturn
glucoseintoenergy.ThosediagnosedwithTypeIdiabetesmakelittleornoinsulinontheirown,
soarethereforereliantoninsulinshotstofunctionnormally.SomesymptomsofTypeIdiabetes
arefrequenturination,constantlyfeelingthirstyorhungry,andnotgainingweight(youngcases).
Itisusuallydiagnosedatayoungage.ThetwomaincausesofTypeIaregenes,and
environmentaltriggers,suchasviruses.TypeIIdiabetesischaracterizedbytheinabilityofcells
ofthebodytorespondtoinsulinthewaytheyaresupposedto.Thistypeismainlycausedby
genesandobesity,anditisreferredtoasadultonsetdiabetes.TypeIIdiabetescanbetreated
withpillsand/orachangeindiet.
ImayusethisarticletoprovidebackgroundknowledgeondiabetesifIchooseto
researchfurtherintothedisease.ThoughIdidnotseeanycasesduringmyfirsttimeatmy
internship,IknowthatdiabetesisarelativelycommoncasethatIdohaveahighchanceof
witnessinginthefuture.IfIweretodoaprojectondiabetes,Iwouldlookintotheweightof
patientversusseverityofdiabetes.

"Electrocardiogram(ECG)."
TheGaleEncyclopediaofScience
.Ed.K.LeeLernerandBrenda
WilmothLerner.4thed.Vol.2.Detroit:Gale,2008.14891493.Print.27Sept.2015.

ThisarticleexplainsthehistoryandmechanismsofElectrocardiograms(ECG).ECGs
measuretheelectricalimpulses,oractionpotentials,thatoccurduringeachheartbeat.Because
thesecurrentstravelatpredictablevelocities,ECGscanrevealabnormalitiesinheartfunction
withoutanyinvasiveprocedures.TheElectrocardiogramcontainsexternalelectrodes,placedon
specificareasofthechest,thatpickuptheactionpotentialstravelingfromthehearttotheskin.
Theelectrodesthensendthesignalstothemachinewhereapenrecordstheelectricalevents
ontopaper,creatingagraph.
Iwillnotusethisarticleformyresearchproject,butitisusefulbecausemymentor
frequentlyanalyzeselectrocardiogramstolookfordiscrepanciesthatmaycorrespondtoa
disorder.Forexample,onepatientintheERcomplainedofoverwhelmingdizzinessand
numbnessinonearm.Mymentororderedanelectrocardiogramtomakesurethatherdizziness
wasnotattributedtoaseriousheartmalfunction.ECGsseemtobeafrequenttestrunintheER.

GarciaTC,BernsteinAB,BushMA.Emergencydepartmentvisitorsandvisits:Whousedthe
emergencyroomin2007?NCHSdatabrief,no38.Hyattsville,MD:NationalCenterfor
HealthStatistics.2010.

Thisfile,releasedbytheNationalCenterforHealthStatisticsdictateswhoused
emergencyservicesin2007.SomemajorconclusionsImadeafterreadingthedatabasewasthat
olderadults(75+),nonhispanicblackpeople,thepoor,andpeoplewithmedicaidcoverageused
theemergencyroommorethanthoseinotherdemographics.Intheyoungerpopulation(under
65),peoplewithoutinsuranceweremorelikelytousetheemergencyroomatleastonceayear
thanthosewithinsurance,andpeopleunderMedicaidweremorepronetovisitingthe
emergencyroommultipletimesperyearthanthosewithprivateornoinsurance.But,allpeople
whovisitedtheemergencyroomhadthesamelikelihoodofhavinganonurgentissuenomatter
whatstatusofinsurancecoveragetheyhad(uninsured,privateinsurance,Medicaidcoverage).
Lastly,peoplewithandwithoutprimarycarephysicianswereequallylikelytovisitthe
emergencyroomeachyear.
Thisarticlegeneralizesthedemographicsofpeoplewhousetheemergencyroom.This
willbeusefulbecauseitgivesmeanideaofwhatdemographicstotargetformyprojectifI
decidetoworktodecreasethenumberofunnecessaryvisitstotheemergencyroom.
Understandingthebackgroundsofpeopleintheemergencyroomisimportantwhendetermining
theiractualmotivesare.EvenifIdonotdomyprojectonthis,thisinformationisusefulona
daytodaybasisasIamdistinguishingbetweenurgentandnonurgentcasesatmyinternship

"HowIsDiabetesManaged?"
DepartmentofHealth:InformationforaHealthyNewYork
.New
YorkState,Jan.2015.Web.24Oct.2015.

Diabetesismanagedbytakingactiontokeepbloodsugarlevelsbetween90and130
mg/dlbeforemealsandlessthan180mg/dlonetotwohoursafterameal.Thiscanbeachieved
throughavarietyofways.Physicalactivityforaround30minutesadaymostdaysoftheweek,
suchaswalking,swimming,biking,takingthestairs,andparkingfarawayisagoodwayof
managingdiabetes.Also,eatingdietsrichinfruitsandvegetables,wholegrains,fish,leanmeats,
beans/lentils,lowfatdairyproducts,liquidoilsforcooking,water(ratherthansodaorjuice),
withcontrolledportionsizeskeepsbloodsugarsatlowerlevels.Itisimportantthatdiabeticstake
theirmedicineandknowwhytheyaretakingthem,testtheirbloodsugarsasoftenasinstructed
bytheirhealthcareproviders,quitsmoking,completeA1Cbloodtests(measuresaverageblood
sugaroverpreviousthreemonths,shouldbelessthan7%)24timesperyear,checkblood
pressure(targetlessthan130/80mmHg),completelipidprofilebloodtestsonceayeartocheck
cholesterollevels(total<200mg/dL,LDL<100mg/dL,HDLmen>40mg/dL,HDLwomen>50
mg/dL),completefootexams,kidneyfunctioningtests,getannualflushots,andhavedental
exams.
Thiswebsitelistsmanagementtechniquesforpeoplewithdiabetes.Because8.6%ofall
emergencyvisitsarebypeoplewithdiabetesexasperations,thisisaperfectpopulationtotarget
minimizinguseamong.Imayusethisinformationtocreateacondensedbrochureorflyer
dictatingthingsthatpatientscandotomanagetheirdiabetesaftertheyleavetheemergency
roomtopreventanotherexacerbation.Becausethefoodlistwassoextensive,Icouldmakean
informationsheetthatonlyhasdietarysuggestionsfordiabetics.

LaCalle,Eduardo,andElaineRabin."FrequentUsersofEmergencyDepartments:TheMyths,
theData,andthePolicyImplications."
AnnalsofEmergencyMedicine:AnInternational
Journal
56.1(2010):4248.Print.

Thisstudyfoundthatamongsexandracialgroups,womenandblacksusedthe
emergencyroommorefrequentlythanthoseofotherdemographics.Theuninsuredrepresent
15%offrequentusers,andMedicaid/Medicarebeneficiariescombinerepresent60%offrequent
users.Frequentemergencyroomuserstendtobeinpoorerconditionthanthosewhovisitless
frequently.Manyfrequentusersvisittheemergencyroomduetoexacerbationofchronic
conditions.Studiesalsoshowthatfrequentemergencydepartmentusersrelyheavilyonother
partsofthehealthcaresystemaswell.IndividualswhoaresatisfiedwiththeirprimarycarE
physiciansarelesslikelytobeafrequentemergencyroomuserthosewhoarenottendtovisit
theemergencyroombecausetheythinkitwillfixtheirproblemsfasterthanattendingaprimary
careoffice.19%ofpatientsintheemergencyroomreportthattheyhadunmetmedicalneeds.
Thebackgroundinformationonthedemographicsofpeoplewhofrequentlyutilize
emergencyservicesissimilartothatstatedinotherarticlesIhaveread.Becausereducing
emergencyroomvisitsduetotheexacerbationofchronicconditionstargetsaspecific
population,Ithinkthatthiswouldbethemostmanageabletopictodoformyproject.Some
chronicconditionsthatIcanfocusonarediabetes,congestiveheartfailure,andconditions
requiringdialysis.

Locker,ThomasEetal.DefiningFrequentUseofanUrbanEmergencyDepartment.
EmergencyMedicineJournal:EMJ
24.6(2007):398401.
PMC
.Web.25Oct.2015.

Thisstudyoffersadefinitionofadistinctgroupoffrequentemergencydepartmentusers
whomakemorethanfourattendancesperyear.3.7%ofallpeoplewhovisittheemergencyroom
areconsideredfrequentusers,andtheyaccountfor12.4%ofallattendances.Frequentusers
weregenerallyolderthanchanceusers,andwereadmittedtothehospitalalmosttwotimesas
frequently.Also,agreaterproportionoffrequentusersarrivedbyambulanceandpresented
psychiatriccomplicationsoralcoholintoxication.Frequentusersvisittheemergencyroomoften
andfornonrandomevents,andhavedistinctcharacteristicsfromthosewhousetheemergency
departmentlessoften.Manyofthesepatientshavechronicmedicalproblemsandsignificant
psychosocialmorbidity.Thoughthemajorityoffrequentusersarenothomeless,somereported
thattheircurrentsocialcircumstancesseemprecarious.
Becausethisstudyoffersaspecificdefinitionofafrequentuser(over4emergencyroom
visitsinoneyear),Icannowlookforothersourcesthatspecificallyfocusonthesefrequent
usersbythisdefinition.Thisgroupofpatientswithunmetmedicalneedscanbeidentifiedand
takencareofbeforetheircasesbecomeemergencies.Meetingpatientsneedsinadvanceby
interveningwasfoundtobeeffectivethroughmethodssuchascasemanagement.


Mallemat,Haney.Personalinterview.14Oct.2015.

Dr.HaneyMallematisanattendingphysicianintheemergencydepartmentofthe
UniversityofMaryland.HecompletedhisundergraduateeducationatSuniUniversityinNew
YorkandcontinuedontotheStateUniversityofNewYorkatBrookland.Dr.Mallematwent
throughresidencyattheKingsCountyHospitalinBrookland.Tofurtherexpandhisabilities
afterhiseducation,healsocompletedacriticalcarefellowshipattheDartmouthMedicalCenter
inNewHampshire.
Dr.Mallematismymentor,andfrequentlyanswersmyquestionsabouttheemergency
roomasawholeandspecificpatientcases.Healsoiscurrentlyhelpingmetochoosearesearch
project.AfterInarrowdownmyexacttopic,hewillassistmeincarryingtheprojectout.

Mann,Cindy."ReducingNonurgentUseofEmergencyDepartmentsandImprovingAppropriate
CareinAppropriateSettings."
CentersforMedicareandMedicaidServices
.Department
ofHealthandHumanServices,n.d.Web.24Oct.2015.

ThoughMedicaidrecipientsusetheemergencydepartmentatatwofoldhigherratethan
theprivatelyinsured,theytendtoalsobeinpoorerhealthconditiononlyabout10%of
emergencyroomvisitsbyMedicaidbeneficiariesarenonurgent.Thisisbecausetheygenerally
havelessaccesstoprimaryhealthcarephysiciansandexperienceexacerbationofchronic
conditionsbecausetheyarenotcontrolledwithpropercareormedicine.Thisstudymakes
severalsuggestionsonhowtosolvethisissue.Bybroadeningaccesstoprimarycareservices
(hoursandaccessibility),peoplewillhaveplacestotaketaketheirconcernsafternormal
businesshoursotherthantheemergencyroom.Byaddressingtheneedsoffrequentusersbefore
theyneedemergencyservices,Medicaidcancutbackonexpenditures.Costsharingisanother
methodofreducingemergencyroomoverusebymedicarepatients.Medicaidprovisionsallow
beneficiariestobechargedfornonemergencyvisitstotheemergencyroom.Ifacaseis
determinedtobenonurgent,thehospitalisrequiredtoprovideanaccessibleandavailable
alternativeprovidermustbereferredtothepatientbeforechargesareimposedonthepatient.
Thisstudyproposespossiblemethodsofpreventingtheneedforemergencycareamong
Medicaidbeneficiariesbyinterveningwithprimarycarebeforeconditionsworsen.Thoughthis
seemstobeaneffectiveapproachtoamelioratingtheissue,thisarticledidnotsuggestanything
thatwouldberealisticformetoimplementatmyinternship.OneimportantthingIwasableto
gainfromthisarticlewasthatMedicaidpatientsaregenerallymoresickerthanthosewith
privateinsuranceduetotheirlackofaccesstoregularcare.Also,contrarytocommonbelief,the
majorityofMedicaidrecipientspresenturgentcomplaintsinemergencyroomsratherthan
nonurgentcases.

Markham,Donna,andAndisGraudins.CharacteristicsofFrequentEmergencyDepartment
PresenterstoanAustralianEmergencyMedicineNetwork.
BMCEmergencyMedicine
11(2011):21.
PMC
.Print.10Oct.2015.

Thisstudysystematicallyreviewedotherstudiesaboutfrequentusersofemergency
departmentstoinformpolicymakersofpossiblelegislationdirectedtoreducefrequent
emergencyroomuse.Itsummarizedthedemographics,degreesandtypesofillness,accessto
othermedicalcare,andutilizationpatternsoffrequentemergencyroomusers.Ingeneral,women
andblacksaredisproportionatelyusingtheemergencyroom,thoughthemajorityoffrequent
usersarewhite.Also,ahighproportionofpeopleundermedicareandmedicaidpatients
frequentlyusetheemergencyrooms.Frequentemergencydepartmentuserstendtobemoresick
thatoccasionalusersbecausetheygenerallyhavepoorerphysicalhealth.Thestudyconcluded
thatthemosteffectivemethodofcontrollingemergencyroomwascasemanagement.
Thisarticleprovidedadditionalinformationonthegeneralcharacteristicsoffrequent
emergencyroomusers.Becausethisstudyanalyzesemergencyroomvisitationsinawiderange
ofareasacrosstheUnitedStates,itmaynotbeaccuratefortheurbanenvironmentmyinternship
islocatedin.Iwilllookforotherresearchthatismorespecificallyaboutcitylocations,which
willprobablybemorealignedwithwhatIwillseedaily.

Melanson,KathleenJ."Diabetes,DietandNutritioninPreventionandManagementof."
EncyclopediaofLifestyleMedicine&Health
.Ed.JamesM.Rippe.Vol.1.Thousand
Oaks,CA:SAGEReference,2012.308312.Print.25Oct.2015.

Type2diabetescanbecomprehensivelytreatedandmanagedthroughmakinglifestyle
changes.Reducingbodyfatisthemostimportantmodifiableriskfactorfortypetwodiabetes.
Aninitialweightlossof7%bodyweightwithmaintenancethroughphysicalactivity,diet
changes,andpatienteducationimprovesglycemiccontrol,whichstabilizesovertime.The
AmericanDiabetesAssociationalsosuggestlimitingsaturatedfats,transfats,andcholesterol,by
replacingthemwithmonounsaturatedfattyacids,polyunsaturatedfats,orcarbohydrates.Also,
diabeticsshouldget45%65%oftheirdietaryenergyfromcarbohydratesandintakeample
amountsofsolubleandinsolublefibers.Itisimportantthatpatientswithtypetwodiabetesingest
antioxidantsbecausetheconditionisassociatedwithincreasedoxidativestress.
Thisarticledescribeswaystoeffectivelymanagetypetwodiabetes.Thiswillbeusefulto
myprojectifIdecidetofocusondiabetesbecauseitisthemostprevalentchronicconditionseen
intheemergencyroom.Thisarticlecanbedividedintosections:managementofbodyweight,
macronutrients(lipids,carbohydrates),andmicronutrients(antioxidants,minerals).Overall,
lifestylechangescanhaveasignificantimpactondecreasingacuteexacerbationsofdiabetesthat
leadtopreventableemergencydepartmentvisitations.

Murphy,AndrewW."InappropriateAttendersatAccidentandEmergencyDepartmentsI:
Definition,Incidence,andReasonsforAttendance."
FamilyPractice
15.1(1998):23+.
Print.

Alargenumberofpatientsreferthemselvestotheemergencydepartmentforconditions
thatarenonurgent.Thisstudyreferstothesevisitsasinappropriate.Becausethereisno
universallyaccepteddefinitionofanappropriateattenderoranemergency,thereisawiderange
ofpercentagesofvisitsjudgedtobeinappropriatebydifferentresearchers.Patientsdecisionto
bringtheirconcernstotheemergencyroomratherthantogeneralpracticefacilitieswascaused
byseveraldifferentfactors.Somefelttheyneededmedicalattentionimmediatelyattimeswhen
theirusualprimarycarephysiciansdidnothavehours,othersthoughtthatitwouldexpeditea
solution,andmoregenuinelythoughttheyhadaseriousproblemthoughnursesconcludedthey
werenonurgent.
Thisstudywasimportantbecauseitprovidedmotivesofpeoplewhocomeintothe
emergencyroomwithnonurgentconcerns.Itwasinterestingthatalargepercentofpeoplewith
nonurgentconcernsintheemergencyroomsimplydonotknowthedifferencebetweenwhat
shouldbetakentogeneralpracticeandwhatshouldbetakentotheemergencydepartment.By
givingpatientsinformationthatdistinguishthetwocases,itispossiblethattherewouldbea
significantdecreaseinunnecessaryemergencyroomattendance.

Myers,Paul."ManagementofMinorMedicalProblemsandTrauma:GeneralPracticeor
Hospital?"
JournaloftheRoyalSocietyofMedicine
75(1982):87983.Print.

Outof1000patientstovisitanemergencyroom,54.2%ofthemcouldhavebeentreated
byageneralpractitioner.Thisstudyalsoinvestigatedthereasonspeoplecometotheemergency
roomduringtheday(whenmostgeneralpractitionerofficesareopen).Thetopreasonwasthat
patientsthoughttheyrequiredtreatmentthatcouldonlybegiveninanemergencyroomsetting.
Thisispartlyduetogeneralpractitionerstendencytoavoidhandlingcertainminorproblems
thattheyshouldhandle.Improvingpatienteducationandgivinggeneralpractitionersincentives
aretwopossiblesolutionstofixthisissue.Amajorsourceofinappropriateattendancestemmed
frominjuries.Mostinjuriesdonotresultinfracturesandcanbetreatedandevaluatedina
primarycaresetting.Also,manyinappropriateusersfeelthattheycouldnotwaitforageneral
practitionerappointment,didnotliketheirdoctor,wantedasecondopinion,ordidnothavea
generalpractitioner.
Thisresearchjournalentrywasusefultomebecauseitdelineatedspecificreasonsasto
whypeoplebringnonurgentconcernstotheemergencyroomratherthantheirgeneral
practitioners.Amajorityofthecausesofthesereasonaduetoissueswithprimarycare
physiciansingeneral.Thisarticlewaspublishedin1982,sotheconclusionsdrawninthepaper
maybeslightlyoutdated,butthegeneralideashavestayedconstantwiththerestofthearticlesI
haveread.

"NationalHospitalAmbulatoryMedicalCareSurvey:2011EmergencyDepartmentSummary
Tables."
CentersforDiseaseControlandPrevention
.N.p.,2011.Web.24Oct.2015.

Thiscollectionoftablessummarizingthemostcurrentnationallyrepresentativedataon
ambulatorycarevisitstoemergencyroomsincludesstatisticsonpatientage,sex,residence,race,
sourceofpayment(insurancestatus),triagestatusbyvariousdemographiccharacteristics,reason
forvisit,diagnosis,presenceofchroniccondition,andvisitsresultinginadmissiontothe
hospital.Patientsunderoneyear(87.3visits/100people)orover75yearsofage(68.2visits/100
people),females(47.6visits/100people),andthehomeless(171.7visits/100people)weremore
likelytovisittheemergencyroom.Thoughthemajorityofpeoplewhousetheemergencyare
white,agreaterpercentageoftheblackpopulationutilizestheemergencyroom.Whitesaccount
for98,147ofthetotal136,296visitsinthousandsduring2011,andhaveatotalof40.9visitsper
100people,whichislowerthantheoverallaverageof44.5visitsper100people.Blacksaccount
for32,627,000ofthe136,296,000visits,buthave82.9visitsper100people,whichis
significantlyhigherthanboththeoverallandwhiteaverages.Outofallemergencyroomvisits,
34.9%arepaidforbyprivateinsurance,31.8%Medicaid,18.4%Medicare,and16%no
insurance.Patientswithmedicare,noinsurance,blacks,andhispanicsweremorelikelytovisit
theemergencyroomwithalevel5(nonurgent)triagestatuconcern.Thetopreasonspeople
visitedtheemergencyroomresultedindiagnosesofstomachpain,chestpain,contusionwith
intactsurface,andacuterespiratoryinfections.Someemergencyroomvisitsweredueto
exacerbationsofchronicconditions.8.6%ofallemergencyroomvisitsin2011werebypatients
withdiabetes,3.1%congestiveheartfailure,3.0%cerebrovasculardisease/historyofstroke,and
0.9%withconditionsrequiringdialysis.Lastly,patientsover75,patientswithMedicare,and
patientswhoarrivedtotheemergencyroominanambulanceweremorelikelytobeadmittedto
thehospital.
OutofallthesourcesIhavelookedat,thisoneisthemostusefulandmostextensiveone.
Overall,blacks,Medicarepatients,thehomeless,andthosewithpreexistingchronicconditions
aremorelikelytoutilizetheemergencydepartmentservices.Themostsignificantfindingfrom
thisfilewasthepercentagesofemergencyroomvisitsduestoexacerbationsofchronic
conditions.Thisistheonlyriskfactorforusingtheemergencyroomthatcanbedirectlyworked
ontodecreasethenumberofvisitsamongpatientsinthiscategory.Formyproject,Icanfocus
onprovidinginformationonpreventionofexacerbationofdiabetes,heartcomplications,
cerebrovasculardisease,andconditionsrequiringdialysisbecausetheyarethemostprevalent
chronicconditionsseeninemergencyroomsnationally.

Oktay,Cem,etal."AppropriatenessofEmergencyDepartmentVisitsinaTurkishUniversity
Hospital."
CroatianMedicalJournal
44.5(2003):58391.Print.

Outofthe1,155patientsthatvisitedahospital,only69%werethereforappropriate
reasons.Themainreasonspeopleusedtheemergencyroomratherthantheirprimarycare
physicianswereitscloserproximity,satisfactionwithcare,worseningsymptoms,and
unavailabilityofcareinaregularclinic.But,becausethesepatientsdidnothaveurgentissues,
theystayedintheemergencyroomforanaverageofonly66minutes.Therefore,theirimpacton
theovercrowdingoftheemergencyroommaybemuchlowerthanexpectedsincetheyleave
relativelyquickly.Overall,womenweremorelikelytovisittheemergencyroomandtopresent
nonurgentcomplaints,alongwiththosewhocompletedhighereducationandpeopleunder
governmentinsurance.
Thisstudyofferedimportantinsightontheactualimpactthatnonurgentcaseshaveon
theovercrowdingofemergencyrooms.Moststudiesconcludethatovercrowdingofthe
emergencydepartmentcouldbedecreasedbyinformingthepublicaboutdistinguishingwhat
shouldbetakentotheemergencyroomversuswhatshouldbecoveredbyaprimarycare
physician,butthisstudyprovidesevidencethatthatmethodwouldnotbeveryeffective.But,
thisstudywasalsoconductedinaTurkishUniversityHospital,sothedemographicsandoverall
conclusionsmadecouldbeslightlydifferentthanthatofanAmericanhospital.

Pines,JesseBuford,Kevin."PredictorsOfFrequentEmergencyDepartmentUtilizationIn
SoutheasternPennsylvania."
JournalOfAsthma
43.3(2006):219223.
Psychologyand
BehavioralSciencesCollection
.Print.16Oct.2015.

Asthmaisoneoftheleadingcausesofemergencyroomvisitationsdespitemedical
advancesandeducationtopreventasthmaattacks.Thisispartlyduetothelackofaccessof
someasthmapatientstonecessarycareormedicationtopreventrelapse.Asthmapatientsin
urbanareashadahigherriskofusingtheemergencyroomfrequentlybecausetheyhadan
increasedlikelihoodofbeingexposedtotriggerssuchasviruses,allergens,orairpollutants.
Languageproblemswerealsoassociatedwithfrequentemergencydepartmentuse.Language
discrepancieswereshowntoaffectasthmacareinHispanicchildren.Thiscouldbeameliorated
byprovidingbrochuresdictatingnecessaryasthmacontrolmethodsinspanish.
Thisstudyisusefulbecauseitclearlyattributesalargenumberofemergencyroom
visitationstoaspecificdisease.BecauseUniversityofMarylandMedicalCenterisinanurban
environment,Ifrequentlydealwithpatientssufferingfromsevereasthmaattacksduetoboththe
environmentaltriggersandtheinabilitytocontroltheircondition.Icouldfocusmyproject
specificallyonasthmacontrollingandpreventionofexacerbationsinceitissoprevalentin
Baltimore.

Pope,Detal.FrequentUsersoftheEmergencyDepartment:AProgramtoImproveCareand
ReduceVisits.
CMAJ:CanadianMedicalAssociationJournal
162.7(2000):
10171020.Print.

Manypatientsusetheemergencyroominappropriately,takingupbedsthatareneeded
bypatientinmoreseriousconditions.Someexamplesofgroupsofthesepatientsarethe
homeless,thoseseekingdrugs,andthosewithcomplexmedicalandsocialproblems.This
projectexaminedaninnercityhospitalinVancouverthatservesalargepopulationofhomeless,
unemployed,beneficiariesofsocialassistance,victimsofcomplexorchronicmedicalproblems,
andsubstanceaddicts.Patientswerereferredtoacasemanagementprogramthatconstructed
specificcareplansforeachpatient.Initiallythe24patientswhoparticipatedhadvisitedthe
emergencyroomatotalof616timesduringthepreviousyear.Aftercompletingthe
comprehensivecasemanagementprogram,theyaccountedforonly175visitsthenextyear.
Patientsintheprogramhadmedicalcomplicationswhichincludedalcoholuse,druguse
personalitydisorder,chronicpain,historyofpsychologicaldisorders,HepatitisB/C,HIV,and
ulcers.Themostimportantaspectofthiscasemanagementplanwasfollowingupwitheach
patientafterthevisit.
Thisstudyinvestigatedamethodofdecreasingemergencyroomrelianceofaspecific
groupofpeoplewhomadeupalargeportionofemergencyroomvisits.Theprogramwas
effectivebecauseofthefollowupafteremergencydepartmentvisits.ThoughIcannotfollowup
withpatientsaftertheyleavetheemergencyroom,Icandistributematerialsthatlayoutthingsto
doafterleavingtheemergencyroomforavarietyofchronicconditions.

"PulmonaryHypertension."
NationalHeartLungandBloodInstitute
.NationalInstitutesof
Health,2Aug.2011.Print.7Sept.2015.

ThisarticleprovidesbasicbackgroundinformationofPulmonaryHypertension(PH).PH
iswhenthepressureinthepulmonaryarteriesincreasesduetotightenedarterywalls,stiffwalls
atbirth,ortheformationofbloodclotsinthearteries.Thisincreasedpressureforcestheheartto
workhardertopushbloodthroughthebody,ultimatelyweakeningtheheart.Somepreliminary
symptomsofPHincludeshortnessofbreath,chestpain,andracingheartbeat.Asthecondition
isprolonged,moreseverecomplicationsarise,suchasfainting,swellinginlegsandankles,and
heartfailure.Thereiscurrentlynocureforthiscondition,buttreatmentcanslowtheonsetof
serioussymptoms.
ThisarticlehelpedmetounderstandwhatexactlyPHis.DuringmytimeintheERon
September14,IencounteredaseverecaseofPH.Thepatientwasadmittedduetoextreme
swellingofherlegstothepointwheretheystartedtodrain.Thisisaprimeexampleof
prolongedPH.Ihavenotdecidedonaresearchprojectyet,butapossibleprojectconcerningPH
couldlookintothecorrelationbetweensymptomsandtimesincediagnosis.


"ReducingEmergencyVisitsinOlderAdultswithChronicIllness:ARandomized,Controlled
TrialofGroupVisits."
EffectiveClinicalPractice
4.2(2001):4957.Print.

Chronicallyillelderlypatientsmakeupasignificantnumberofemergencydepartment
visits.Thisstudytestedtheefficiencyofimplementingmonthlygroupvisitsofgenerally812
patientswithaprimarycarephysician,nurse,andpharmacist.Duringthesevisits,patientswere
encouragedtoselfmanagetheirchronicillnessesthroughrecommendationsgivenbythe
doctors,supporttheirpeers,andmaintainregularcontactwiththeprimarycareteam.
Participantshadampleaccesstoprofessionalopinionsontheirhealthissues.Patientswho
attendedtheseinterventiongroupmeetingscuttheiremergencyvisitsinhalf,showingthat
monthlygroupvisitsareeffectiveindecreasingemergencyroomvolumebytheelderly.But,
thesepatientsalsohadsubstantiallymoreoutpatientserviceutilizationthanthecontrolpatients,
soanotherstudymustbeconductedtodetermineifthismethodisultimatelycosteffective.
Thisstudywasusefultomebecauseisdirectlyaddressedthechronicallyillelderly
population.Thisisanothergroupthatmakesupasignificantamountoffrequentemergency
roomusers,soIcouldtargettheminmyprojectaswell.Becausemanymembersofthis
populationdidnotknowtheycouldhavetheirconcernsaddressedinanonemergencyroom
setting,theirvisitstotheemergencyroomdecreasedwithincreasedknowledgeofandaccessto
primarycare.Toinformpatientsofthisoption,Icouldpotentiallycreateaninformationsheet
listingsymptomsandproperactionstotakeand/ormedicalinstitutiontogoto.

Reilly,PhilipM.PrimaryCareandAccidentandEmergencyDepartmentsinanUrbanArea.
TheJournaloftheRoyalCollegeofGeneralPractitioners
31.225(1981):223230.
Print.

Thisstudycomparestheclinicalandsocialcharacteristicsofemergencydepartmentusers
inoneyearatanurbanhospitalwhoreferthemselves(78.4%)andthosewhoarereferredby
generalpractitioners,focusingontheappropriatenessuseofemergencyservices.Overallmales
weremorelikelytoselfreferthemselvesthanfemales.Also,selfreferredpeopleweremuch
morelikelytohaveanewproblemratherthananexistingproblem,buthadgenerallyshorter
durationsofproblems.Thosereferredbyageneralpractitionerweremorelikelytohaveafull
examination(58%versus19.5%)andhadanincreasedchanceofbeingadmittedtothehospital
(55%versus12%).Mostsignificantly,thosereferredtotheemergencydepartmentbyageneral
practitionerpresentedappropriateproblems84%ofthetime,whilethosewhoreferred
themselvesonlyusedtheemergencyroomappropriately50%ofthetime.
Becausethisstudyconcludesthathigherpercentagesofpeopleusetheemergencyroom
appropriatelywhenreferredbyageneralpractitioner,aneffectivewayofreducingunnecessary
emergencyroomuseisencouragingpatientstoseetheirgeneralpractitionersbeforetheyresort
tousingtheemergencyroom.Halfofallselfreferredcasesarenonurgent,andcouldbegreat
decreasedinthismanner.Todothis,Icouldprovidepatientswithinformationandhoursofother
generalpracticeclinicsinthearea.Icouldalsolistsymptomsthatclassifyanemergency,versus
whatcanwaittobeseenbyaprimarycarephysician.

Soril,LesleyJ.J.,etal."ReducingFrequentVisitsToTheEmergencyDepartment:A
SystematicReviewOfInterventions."
PlosONE
10.4(2015):118.
AcademicSearch
Complete
.Print.16Oct.2015.

Becausetheoveruseoftheemergencydepartmentbyaspecificgroupoffrequentusers
takesasignificanteconomictollonthehealthcaresystem,thisstudycompileddifferentmethods
ofreducingemergencyroomuseamongthisdemographicandtheirefficiencies.Case
managementwasthemosteffectivemethodofreduction.Casemanagementisacomprehensive
approachthatassesses,plans,personalizes,andguidesanindividual'shealthservicestoimprove
patientandhealthcaresystemoutcomes.Overall,thismethodreducedhospitalcosts.Another
methodofinterventionistheindividualizedcareplan,whichalsoimplementsinterdisciplinary
strategies,butislesscomprehensiveandlacksadesignatedcasemanagerforeachpatient.This
approachreducedhospitalcostsbyasmallamount.Thethirdmannerofreducingemergency
departmentabusementionedbythisarticlewasinformationsharing.Thisconsistsofsharing
frequentuserpatientinformationamongsthealthcareproviders.Thismethodhadmixedresults
onestudydidnotresultinasignificantreductioninemergencyroomvisits,butanotherdid
experienceasubstantialdecreaseinmeanemergencyroomvisitsandoverallcost.
Thisarticleoutlinesrelativelyeffectivemethodsofcontrollingemergencyroomoveruse.
Casemanagementseemstobethemosteffective,soIcouldtakeseveralaspectsofthismethod
andusethemformyproject.Icannotperformlargescalechangeslikethosethatweremadein
thehospitalsthestudyfocuseson,soIcoulduseanapproachsimilartotheindividualizedcare
plan.InformingthepatientsonproperactionstotakeaftertheyleavetheERisimportantto
preventrelapseintheirconditionsthatrequiremoreemergencyroomvisits.

"Stroke."
TheGaleEncyclopediaofScience
.Ed.K.LeeLernerandBrendaWilmothLerner.4th
ed.Vol.6.Detroit:Gale,2008.41904193.Print.9Oct.2015.

Thisarticledescribesthecauses,mechanisms,treatments,andeffectsofstrokes.Strokes
occurwhenthereisadisturbanceinbloodcirculationtothebrain.Oftentimes,itiscausedby
uncontrolledhighbloodpressure(hypertension).Hemorrhagicstrokesacharacterizedby
disturbancethroughaburstbloodvessel,whilethromboticstrokesarecausedbythesealingofa
bloodvesselbyaclot.Dependingonthesizeofthearteryaffectedandtheseverityofthestroke,
strokevictimscanrecover.Itisimportanttotreatthestrokeimmediatelythemoretimethe
brainisnotsuppliedwithblood,themoredamageisdone.
ThoughIhavenotseenastrokeintheUMMCER,Iusedthisarticletounderstandwhat
strokesaresothatIwouldbepreparedshouldIeverwitnessone.Iaminterestedinresearching
theprimaryriskfactorsofstrokes,anddeterminingifdemographicshaveaneffectonthe
frequencyofstrokes.Icouldalsoresearchtheabilityofpatientstorecoverafterastrokebased
onhowlongtheirbrainswerenotsuppliedwithblood.

Steefel,,Lorraine."PulmonaryHypertension."
TheGaleEncyclopediaofMedicine
.Ed.LaurieJ.
Fundukian.4thed.Vol.5.Detroit:Gale,2011.36513652.
GaleVirtualReference
Library
.Web.27Sept.2015.

Pulmonaryhypertensionresultsinthickeningofthepulmonaryarteriesandnarrowingof
bloodvessels,causingtherightsideofthehearttohavetoworkharderandbecomeenlarged.
Therearetwotypesofpulmonaryhypertension.Primaryhypertensionoccurswithoutaknown
cause,andsecondaryhypertensionisacomplicationthatresultsfromothermedicalconditions.
Somesymptomsofpulmonaryhypertensionareshortnessofbreathwithlittletonoexertion,
fatigue,dizziness,fainting,swellingoftheankles,bluishlipsandskin,andchestpain.
Treatmentsforthisdisorderincluderemovalofbloodclots(iftheyarethereasontherightside
oftheheartisforcedtoworkharder),lungtransplants,andmedicines(anticoagulantstothinthe
blood,diureticstodecreasebodilyfluid).Riskofpulmonaryhypertensioncanbedecreasedby
followinganoverallhealthylifestylebyreducingstress,exercise,andnotsmoking,butthereare
nospecificguidelinesforpreventionbecausethecauseofprimaryhypertensionisunknown.
Thisarticleprovidesamorespecificoverviewofpulmonaryhypertension,aconditionI
haveseenmultiplecasesofintheemergencyroom.Mostpatientswhocometotheemergency
roomforexacerbationsofpulmonaryhypertensionhaveneglectedtakingthenecessary
medicationsorcompletingothermeansofcontrollingthecondition.Aspartofmyproject,I
couldspecificallyfocusondecreasingtheuseofemergencyroomamongpeoplewithafew
majorchronicdiseases,andpulmonaryhypertensioncouldbeapossibilityforonethatIcould
focusonbecauseitissoprevalentatmyinternship.

TheNationalInstitutesofHealth
.U.S.DepartmentofHealthandHumanServices.Web.20
Nov.2015.

TheNationalInstitutesofHealthisapartoftheUSDepartmentofHealthandHuman
Services.NIH.govprovidesinformationaboutitsinstitutes,theresearchconductedinits
facilities,andhealthinformationforbothpatientsanddoctors.Ithighlightsresearchand
educationfromtheNationalInstitutesofHealth.Thewebsiteprovidesalistoflibraryresources,
suchaspubmed,onlinejournals,andtheNationalLibraryofMedicine.Formoreindepth
projects,nih.govalsolistsclinicalresearchresourcesincludingclinicaltrials.gov,Childrenand
ClinicalStudies,andNIHClinicalReaserchTrials.UnderHealthInformation,thereisalinkto
medlineplus,whichprovidesinformationonanyhealthtopics,drugsandsupplements,anda
medicalencyclopedia.Theselinksareeasytoreadandgearedtowardspeoplewhoarenot
doctors.
Themostimportantresourceonnih.govformehasbeenmedlineplus.Iusethismedical
encyclopediatolookupdifferentdiseasesandmedicationsIencounteronadaytodaybasis
duringmyinternship.IhavealsousedpubmedtofindthemajorityofthearticlesthatIusedfor
myannotatedsourcelist.Pubmedprovidesanextensivecollectionofresearchpapersonvery
specifictopics,allowingmetofindstudiesontheuseofemergencyroomsintheU.S.

Tsuyuki,RossT.etal."AcutePrecipitantsofCongestiveHeartFailureExacerbations."
Arch
InternMed.
161(2001):233742.Print.

Thisarticleexaminesfactorsthatacutelycausetheexacerbationofcongestiveheart
failureinpeoplewithleftventriculardysfunction.Themostcommonfactorscontributingto
congestiveheartfailureexacerbationswerefoundtobeexcessivesaltintakeduetolackof
knowledge,lackofcompliancewithdoctorrecommendation,theuseofinappropriatemedicines,
thereductionofimportantmedicines,andthedevelopmentofarrhythmias.Themostcommon
casualfactorsofthosehospitalizedforcongestiveheartfailurewereacuteanginalchestpain,
respiratorytractinfection,uncontrolledhypertension,andnoncompliancewithmedication.
Insuringthatallvictimsofcongestiveheartfailurereceiveinfluenzaandpneumococcusmight
reducetheclinicaldeteriorationofthesepatients.
Congestiveheartfailureaccountsforalargepercentageofemergencyroomvisitseach
yearduetosomecontrollablefactorslistedabove.Bydistributinginformationonhowto
properlymanagecongestiveheartfailuretothosewhoendupintheemergencyroommay
reducethenumberofvisitsbycongestiveheartfailurepatientsoverall.Takingproper
medicationandreducingsodiumintakearetwoeasy,controllablefactorthatshouldbe
encouragedbydoctorswhoseepatientswithexacerbationsofcongestiveheartfailureinthe
emergencydepartments.Todothis,Icancreateinstructionsonhowtodecreaseriskofclinical
deteriorationbypatientssufferingfromcongestiveheartfailure.

WashingtonRE(AHRQ),AndrewsRM(AHRQ),MutterRL(AHRQ).EmergencyDepartment
VisitsforAdultswithDiabetes,2010.HCUPStatisticalBrief#167.November2013.
AgencyforHealthcareResearchandQuality.

Intheyearof2010,therewere12.1millionemergencyroomvisitsthatwerecausedby
diabetesrelatedissueforadultsages18andolder.Thisgroupofpatientsaccountedfor9.4%of
thetotalemergencyroomvisits,whichismorethananyotherchronicconditionseeninthe
emergencyroom.57.9%ofthesevisitswereemergencyroomtreatmentandrelease,whilethe
remaining42.1%resultedinhospitalization.Comparedtotheoverallaverageof15.3%
admittancetoahospitalaftervisitingtheemergencyroom,thisissignificantlyaboveaverage.
Diabeticsofage65andolderhadthehighestrateofdiabetesrelatedemergencyroomvisits
comparedwith4566yearoldsand1844yearolds.Thosefromthelowestincomecommunities
hadtwicetheemergencyroomvisitrateofthosefromthehighestincomecommunities.
Governmentinsurancebeneficiaries(thoseonMedicaidandMedicare)werethemajorityof
diabetesrelatedemergencyroomvisitors.Overallfemalesconstitutedthemajorityofdiabetes
relatedemergencyroomvisits.Amongthosewhovisitedtheemergencyroomwithdiabetes,
6.4%haddiabetesrelatedcomplications,5.6%complainedofnonspecificchestpain,and3.3%
hascongestiveheartfailure.
Animportantfindinginthedatbriefwasthatasignificantpercentageofpeoplewhovisit
theemergencyroomandhavediabetesarevisitingtheemergencyroomforcongestiveheart
failure.CongestiveheartfailureanddiabetesaretwochronicconditionsthatIwanttofocuson
formyproject,especiallybecauseapproximatelyoneoutofeverytenemergencyroomvisitsare
bythosewhosufferfromdiabetes.Whetherdiabetesisthedirectcauseofthevisitornot,having
diabetesincreasesapersonsriskofotherchronicillnesses,suchascongestiveheartfailure.By
workingtoinformpatientsattheemergencyroomwithdiabetesonhowtheycanmakelifestyle
changestodecreasethenegativeimpactofdiabetesontheirdailyroutines,Icanpossibly
decreasetheoverallvolumeoftheemergencyroom.

Yim,Gloria.Personalinterview.14Oct.2015.

Dr.GloriaYimattendedtheUniversityofChicagoforbotherherundergraduateand
medicalschooleducation.ShecompletedherresidencyatTheUniversityofMaryland,andis
currentlyanAssistantProfessorofMedicineandDoctorofInternalMedicineattheUniversity
ofMarylandMedicalCenter.
Dr.YimisagreatreferencewhenitcomestofindinginformationaboutdiseasesI
encounterintheemergencydepartment.BecauseshealsoworksattheUniversityofMaryland
MedicalcenterinBaltimore,shecanofferherexperiencesandinsightaboutfrequentutilization
oftheemergencyroom,andpossibleactionsthatcanbetakentoreduceinappropriateuseofthe
emergencyroom.