Abstracts for the 40th emergencies in medicine conference

Abstract

Relationships between Emergency Department Wait Times in the United States Nicholas Peterman, Gweniviere Capron1, Bradley Kaptur, Andrew Roberts1, Jacques Lowe, Faran Bokhari1,2 Emergency Department, Carle Illinois College of Medicine, University of Illinois, Urbana-Champaign, Urbana, 1Department of Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, 2Department of Surgery, Carle Foundation Hospital, Urbana, IL Background: Previous work has shown that admissions with longer wait times have worse clinical outcomes. Factors influencing emergency department (ED) wait times have been of great interest to researchers, as well as the associated increased morbidity and mortality. There is a gap in the literature in categorizing the extent of these delays and their related statistically significant factors. Methods: The United States Census and Centers for Medicare Service (CMS) public data from 2015 to 2019 were utilized. County-level travel time to an ED was calculated from network-based road analysis and then combined with the CMS ED wait time metrics to determine the total wait time to care. 2607 counties were sorted into high and low total wait time to care clusters and then compared using an analysis of variance (ANOVA) across 39 county-level health and socioeconomic variables to determine national disparities. Results: Moran’s I cluster analysis identified significant geospatial clusters in ED total wait to care times. 305 counties mostly in the East Coast, West Coast, and Rocky Mountain regions were designated high total wait time to care clusters with an average of 208.76 ± 46.44 min. 605 low total wait time to care clusters were found in the plains and mid-western regions, with a total of 126.22 ± 19.08 min. In factorial ANOVA, Black and Hispanic people represented 7.86% and 6.51% of the population in the high cluster, with significantly fewer in the low cluster, 6.26% and 2.4%, respectively. Population density was also significant between the high and low clusters, with 1028.08 versus 81.1 people per square mile. While the percentage in poverty was notably not significant between high and low clusters, the median household income was $57,521.15 and $50,425.47, respectively. There was a large difference between high and low clusters in both total yearly ED visits (18,196 vs. 3932) and yearly ED visits per 1000 Medicare members (673 vs. 680). Conclusion: Despite previous work highlighting lack of access to physicians in rural areas, the decreased wait time of EDs in these areas is one metric where these areas have an advantage over their coastal counterparts. This is partially linked to the decreased ED volume in these regions. Many significant differences in the demographic variables of interest appear to largely delineate the overall rural–urban divide between these clusters. Keywords: Care delay, emergency department, time to care, wait time Real-World Utilization of Andexanet Alfa in the Management of Oral Factor Xa Inhibitor-Associated Gastrointestinal Bleeding Caitlin S. Brown, Alicia E. Mattson, Daniel Cabrera1, Nayantara Coelho-Prabhu2, Alejandro A. Rabinstein3, Terry Dettling4, Robert D. McBane5, Fernanda Bellolio1 Departments of Pharmacy and 1Emergency Medicine, Mayo Clinic, 2Division of Gastroenterology and Hepatology, Mayo Clinic, 3Division of Neurology, Mayo Clinic, 4Alexion/Astra Zeneca Rare Diseases, 5Division of Vascular Medicine, Mayo Clinic, Rochester, MN, USA Background: Andexanet alfa (AA) is approved for reversal of factor Xa inhibitor (FXaI) bleeds with the inclusion of gastrointestinal bleed (GIB) in The Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors-4 (ANNEXA-4) trial; however, there are limited reports of its use for GIB in real-world populations. This study aims to evaluate the effectiveness of AA for FXaI-associated GIB at an academic medical center. Methods: This was a case series of patients (pts) receiving AA for FXaI-associated GIB between July 2018 and February 2021. Baseline demographics, blood product administration, hemostasis, rebleeding, thrombosis, and mortality were collected. Hemostatic efficacy, consistent with ANNEXA-4 definition, was based on corrected hemoglobin at 12 h compared to baseline. Descriptive statistics were reported. Wilcoxon rank-signed test was used to compare the efficacy in pts undergoing procedures, and Fisher’s exact test was used to compare red blood cells (RBCs) received between efficacy groups. P < 0.05 was considered statistically significant, and all analyses were performed using RStudio Team (2020). RStudio: Integrated Development for R. RStudio, PBC, Boston, MA. Results: Twenty-two pts were included in the study. 63.6% were male and the median age was 76 years. Most pts (59.1%) were on apixaban, the primary indication for FXaI was atrial fibrillation (63.6%), and 45.5% of the pts had a cancer diagnosis. Median baseline hemoglobin was 7.5 g/dL, and the most common type of bleed was upper GIB (50.0%). A majority (77.3%) underwent a procedure, with endoscopy (76.0%) being the most common initial procedure. 45.5% of the pts had excellent, 22.7% had good, and 31.8% had poor hemostasis. In pts who underwent a procedure, there was no significant difference between good/excellent and poor hemostasis. There was no significant difference between RBCs received between pts in the good/excellent hemostasis group compared to the pts in poor hemostasis group. 13.6% of the pts had a rebleeding event, there was a 27.2% 30-day mortality rate, and two pts had arterial thrombotic events within 30 days of reversal. Conclusion: In this real-world analysis, AA provided excellent or good hemostasis in most pts with GIB with a 9% 30-day thrombotic event rate. The mortality rate was high in this cohort likely due to severity of illness. Due to the lack of a comparator group, it is difficult to draw strong conclusions, and hence, additional studies are needed. Keywords: Andexanet alfa, factor Xa inhibitor, gastrointestinal bleeds Healthcare Costs Reduction with Home Furoscix versus In-Hospital Intravenous Diuresis Daniel Bensimhon, William S. Weintraub1, W. Frank Peacock2, Tamas Alexy3, Dalton McLean, Donald Haas4, Kathleen L. Deering5, Matthew M. Goodwin6, John F. Mohr6 Cone Health, Greensboro, NC, 1MedStar Health Research Institute, Hyattsville, MD, 2Ben Taub Hospital, Houston, TX, 3University of Minnesota Medical Center, Minneapolis, MN, 4Abington Hospital, Abington, PA, 5EPI-Q, Inc., Oak Brook, IL; 6scPharmaceutIcals, Burlington MA, USA Background: Up to 90% of patients (pts) presenting to the emergency department (ED) with worsening heart failure (HF) are admitted, and 50% of these hospitalizations may be avoidable. Furoscix is a pH-neutral formulation of furosemide in the development for subcutaneous (SC) administration via an on-body drug delivery system. Furoscix is administered as an 80 mg SC dose over 5 h. It has demonstrated 99.6% bioavailability relative to the same dose of intravenous (IV) furosemide with comparable diuresis and natriuresis. The FREEDOM-HF study was designed to compare 30-day overall and HF-related costs in ED pts with congestion who were discharged with SC Furoscix versus matched comparators admitted for IV diuretics. Methods: This was a multicenter, prospective study of chronic HF pts presenting to the ED with worsening congestion despite oral diuretic therapy. Pts were discharged on Furoscix for up to 7 days and followed for 30 days. Comparators were hospitalized for ≤72 h and selected from a claim database matched to seven variables associated with HF hospitalization and severity. Overall and HF-related costs, including HF hospitalizations and HF-related ED and clinic visits in 30 days, were derived from IBM® MarketScan® Commercial Claims and Medicare Supplemental Database. Cost benchmarks from the comparator population were applied to both groups. Results: Ninety subjects (24 Furoscix/66 comparators) were included. Overall mean (standard deviation) age was 57 (8.3) years, 57/90 (63%) were males, 51/90 (57%) had HF with reduced ejection fraction, 43/90 (48%) had HF hospitalization in the prior 6 months, 23/90 (26%) had Stage 3 chronic kidney disease, 33/90 (37%) had chronic obstructive pulmonary disease, and 62/90 (69%) had diabetics, with similar rates between groups. Overall and HF-related healthcare costs were significantly lower in the Furoscix group [Table 1]. Of pts discharged from the ED with Furoscix, only 1/24 (4.2%) had an HF-related hospitalization. In the comparator group, 7/66 (10.6%) had HF-related readmission within 30 days of initial discharge. There were 1 (4.2%) and 4 (6.1%) HF-related ED visits in the Furoscix and comparator groups, respectively. Conclusion: In ED HF pts with mild-to-moderate congestion despite the use of oral diuretics, discharge with SC Furoscix was associated with significantly reduced overall and HF-related healthcare costs through reduction of HF-related hospitalizations. Keywords: Diuresis, emergency department, Furoscix, furosemide, heart failure Quality of Life and Satisfaction with Furoscix in Heart Failure Patients Daniel Bensimhon, William S. Weintraub1, W. Frank Peacock2, Tamas Alexy3, Dalton McLean, Donald Haas4, Kathleen L. Deering5, Stefanie J Millar6, Matthew M. Goodwin7, John F. Mohr7 Cone Health, Greensboro, NC, 1MedStar Health Research Institute, Hyattsville, MD, 2Emergency Department, Ben Taub Hospital, Houston, TX, 3University of Minnesota Medical Center, Minneapolis, MN, 4Abington Hospital, Abington, PA, 5EPI-Q, Inc., Oak Brook, IL, 6ICON Clinical Research, North Wales, PA, 7scPharmaceuticals, Burlington, MA, USA Background: Furoscix (furosemide subcutaneous infusion) has demonstrated 99.6% bioavailability relative to the same dose of intravenous (IV) furosemide with comparable diuresis and natriuresis. In the FREEDOM-HF trial, patients (pts) with heart failure (HF) exacerbation who were managed as outpatients using Furoscix incurred lower mean HF-related and overall healthcare (all-cause) costs versus matched comparators who required hospital admission for IV diuresis. This study aims to explore the impact of Furoscix on biomarker levels and secondary endpoints of health-related quality of life and patient/caregiver satisfaction in HF pts discharged from the emergency department (ED). Methods: FREEDOM-HF trial was a multicenter, open-label study of chronic HF pts who presented to the ED with worsening congestion. Adults with New York Heart Association Class II–III symptoms, evidence of volume overload, stable vital signs, and a creatinine clearance >30 mL/min were eligible. Enrolled pts were discharged with Furoscix for up to 7 days and monitored for a total of 30 days. Health-related quality of life was evaluated via Kansas City Cardiomyopathy Questionnaire (KCCQ-12) at day 0 versus day 30, and B-type natriuretic peptide (BNP)/N-terminal NT-proBNP values were assessed at day 0, day 2–4, and day 30. Patient/caregiver satisfaction was measured with a Comfort of Wear Questionnaire on day 2–4. Results: Twenty-four (n = 24) pts were included in the open-label (Furoscix) arm of the study. The mean age was 56 ± 12.3 years, 15 (63%) were male, 14 (58%) had HF with reduced ejection fraction, 24 (63%) were hospitalized for HF within the prior 6 months, 6 (25%) had Stage 3 chronic kidney disease, and 12 (50%) had diabetes. Comparing baseline to day 30, Furoscix pts mean KCCQ-12 summary score increased from 29.9 to 42.8 (n = 21; P = 0.044) and the mean symptom score rose from 33.1 to 50.5 (n = 24; P = 0.004). Median natriuretic peptide levels were reduced from baseline to day 2–4 and day 30 by 42.3% and 28%, respectively (P < 0.01). Most (75%) pts felt comfortable wearing the device. Conclusion: In the FREEDOM-HF trial, pts with mild to moderately decompensated HF were able to avoid hospital admission and be safely discharged from the ED. This current analysis showed that treatment with Furoscix was also associated with clinically meaningful reductions in natriuretic peptides, marked improvement in quality of life, and pts reported satisfaction with the intervention. Keywords: FREEDOM-HF, Furoscix, furosemide, heart failure, patient satisfaction Comparison of Educational Methods during Virtual Lectures Jennifer Carnell, Ideen Zeinali, Lynea Bull, Fabi Martinuzzi, Yasien Eltigani, Giovanni Ramirez Emergency Department, Baylor College of Medicine, Houston, Texas, USA Background: The ongoing coronavirus disease of 2019 (COVID-19) pandemic has forced medical education to continue in a virtual space using video conference software. However, it can be challenging for speakers to make lectures interactive and promote audience participation. An audience response system (ARS) can enhance traditional lectures by enabling participants to interact anonymously with the educator’s presentation. By promoting continuous participation, the educator gets real-time feedback on the learners’ understanding. The purpose of the study is to compare a traditional format (facilitator-led interactivity) versus an ARS (Poll [email protected]) format in a virtual session for medical students. The objectives are to assess learners’ perception of the interactivity and level of engagement and to evaluate the comprehension of the lecture’s objectives by assessing performance in pre- and post-conference tests. Methods: Conducted an online virtual session about the use of ultrasound in trauma with fourth-year medical students. At the moment, two groups have participated in the course. These are divided into ARS group (n = 7) and the traditional format group (n = 8). Results: Mean pretest scores (max score = 15) from the ARS and traditional format groups were 10.57 (confidence interval [CI] 95% 7.70–13.44) and 12.38 (CI 95% 10.97–13.78), respectively; t-test P = 0.178. Mean posttest scores (max score = 15) from the ARS and the traditional format group were 12.71 (CI 95% 11.44–13.99) and 12.13 (CI 95% 10.37–13.88), respectively; t-test P = 0.539. Such results show no statistical difference in the pre- and post-test scores between the two groups. However, when comparing pre- and post-test mean scores from the same group, the medical students in the ARS group improved by +20.27% compared to a decrease of −2.02% in the traditional format group. Likert scale items (scale from 1 to 5) in the postsession quiz showed that both groups had similar attentiveness and understanding of the materials. In the ARS group, the Likert scale items (scale from 1 to 5) had a median of 5 in response to the statements “ARS software was easy to use during the lecture” and “I would like to use Poll Everywhere in future lectures.” Conclusion: Currently, there are not enough data to properly assess if there is a difference in posttest outcomes between the groups; however, we will continue to collect data from future sessions and assess for any changes in the results. Keywords: Audience response system, interactive, virtual, virtual learning Using Simulation Modeling to Optimize Flow in a New Emergency Department John Riordan Emergency Department, University of Virginia Health System, Charlottesville, VA, USA Background: Efficient patient flow is critical to emergency department (ED) success. Before opening a new ED, careful operational planning should be performed. This study demonstrates how a system engineering approach can be used to simulate various operational scenarios to maximize patient flow. Methods: We used discrete event simulation to model patient flow for a new ED and to examine its effects on waiting times, arrival to doctor time, doctor to discharge/admission time, and length of stay (LOS). The baseline model was built based on the current ED operations and calibrated using expected patient volumes, staff schedules, and novel designs for the new ED. The scenarios we tested included age cutoff for pediatric care pod, horizontal flow of Emergency Severity Index (ESI)-3 patients through a rapid medical evaluation (RME) area, optimal RME operating hours, clinical decision unit (CDU), and shorter boarding times. Results: Overall, LOS was minimized when patients less than 21 were always triaged to the pediatric pod, RME hours were 11:00–23:00, and 20% of ESI-3 patients were discharged from the RME. Bed to admission time was expected to decrease by about 94 min if boarding time was reduced by 20%. CDU leads to large decrease in adult waiting times (40% reduction). Conclusion: Based on the simulation results, the ED team was able to create flow rules and optimize hours of operation for a new ED. This modeling tool could be used by other EDs when either designing a new process or redesigning an existing process. In addition, the results of this study provide healthcare managers and providers’ insights into planning and improving operations management from a systems perspective. Keywords: Emergency department, patient flow, simulation model, wait time A Rare Manifestation of Severe Acute Respiratory Syndrome Coronavirus 2 as Epiglottitis Parker Cordial, Tinh Le1, Ankur Parekh2, Anas Bakdalieh2, James Neuenschwander3 The Ohio State University College of Medicine, 1Case Western Reserve University School of Medicine, 2The Ohio State University, 3Doctors Hospital, Columbus, Ohio, USA Introduction: There have been more than 329 million cases of coronavirus disease 2019 (COVID-19) and more than 5.5 million deaths worldwide. COVID-19 can present with varied symptoms; one rare manifestation that has been reported is acute epiglottitis. To date, there have been five reported cases of acute epiglottitis in COVID-19-positive patients. CasePresentation: We present a case of a 49-year-old male who presented to the emergency department (ED) and was found to have epiglottitis with a positive COVID-19 polymerase chain reaction (PCR) test. The patient presented to the ED complaining of a 1-day history of sore throat and dysphagia, as well as hoarseness for 3 weeks. He was not tested for COVID-19 or other viruses before arrival. In the ED, he complained of 10/10 throat pain, worsened with swallowing. He denied dyspnea, cough, chest pain, or gastrointestinal (GI) symptoms. He received all recommended childhood vaccinations including the Haemophilus influenzae type B vaccine series. COVID-19 vaccines were not yet available. Notable laboratories included leukocytosis (13.1) and elevated lactate (2.1). Neck radiograph showed mild prevertebral soft tissue swelling. GI was consulted for a suspected esophageal foreign body, but the patient deteriorated before evaluation, reporting difficulty breathing, and ear, nose, and throat (ENT) team was consulted. Rapid Streptococcus and Influenza A and B were negative. COVID-19 real-time PCR was positive. Bedside laryngoscopy revealed epiglottitis. He was taken to the operating room; nasal intubation was failed and hence tracheostomy was performed. He was treated with clindamycin, rocephin, remdesivir, and steroids. His condition improved, and he was discharged. He was well at 1-month follow-up. Discussion: COVID-19 can present with varied symptoms. Dysphagia and pharyngitis without cough or dyspnea are not typical for COVID-19. Epiglottitis has been associated with numerous etiologies. Patient’s history and positive COVID-19 test make acute respiratory syndrome coronavirus 2 a plausible etiology. Differentiating typical COVID-19 symptoms and COVID-19-associated epiglottitis can be difficult, but dysphagia and the degree of pharyngeal discomfort can be distinguishing features. Due to its emergent nature, physicians must maintain high suspicion for epiglottitis should patients with COVID-19 report pharyngitis or dysphagia, as patients may require urgent medical attention. Keywords: COVID, dysphagia, epiglottitis, severe acute respiratory syndrome Prevalence of Hyperkalemia in Medicare Patients in Long-Term or Postacute Care Settings J. Neuenschwander, A. R. Silverstein1, C. Teigland1, D. Powell1, S. Kumar1, J. Dreyfus1, E. Zeng1, A. Agiro2, W. Pottorf2, W. F. Peacock3 Emergency Department, Genesis Healthcare System, Zanesville, Ohio, 1Avalere Health, 2AstraZeneca, 3Baylor College of Medicine, Houston, Texas, USA Background: Hyperkalemia (HK) is a common finding among elderly patients. We describe the prevalence, recurrence, and economic burden of HK in long-term care or postacute care (LTC/PAC) patients. Methods: This was a retrospective study using 100% Medicare fee-for-service data. HK-related stay was defined as ≥1 HK diagnosis (ICD-10: E87.5) or potassium (K+) binder use during, or 14 days before, an LTC/PAC index stay. HK recurrence and therapy were assessed during the index stay and up to 1-year postdischarge. Mortality, HK recurrence, and costs were assessed in matched HK and non-HK cohorts. In patients with ≥7 days index LTC/PAC stay, matching was performed based on age, race, reason for Medicare entitlement, Charlson Comorbidity Index (CCI), the presence of chronic kidney disease, diabetes mellitus, heart failure, hypertension, or renin angiotensin aldosterone system inhibitors use. Results: Of 4,562,231 patients, the prevalence of HK preindex, during index, or follow-up was 14.7%. The final sample (n = 4,081,103) underwent 1:1 matching, providing 273,343 with an index LTC/PAC stay of ≥7 days and 124,718 versus 134,740 HK versus non-HK with ≥1 year of follow-up. HK patients were more often male, Black, and dual eligible for Medicaid, with higher mean CCI scores (all P < 0.0001). Mean HK costs of LTC/PAC were 47% higher ($26,520 vs. $18,021) and 39% higher >1-year postdischarge ($57,948 vs. $41,744). HK binder prescriptions were filled by 2.7% (7828) at index stay and 4.3% (12,614) up to 1 year after. More HK patients died up to 1 year. 48.3% of HK patients had HK recurrence during index stay or within 1 year. During 1 year, of 39,960 with ≥1 HK hospitalization, 25.3% (10,100) had multiple HK hospitalizations. Conclusions: Prevalence and recurrence of HK were high, but few filled a K+ binder prescription. Mortality was ~1.5 times higher for HK than non-HK during or within 1 year. Relative risk of all-cause hospitalization was 81% higher for HK than non-HK during index LTC/PAC stay. Total healthcare costs were ~1.5 times higher HK than non-HK during LTC stay. Keywords: hyperkalemia, K+ binder, long-term acute care, Medicare, postacute care, prevalence Effect of Point-of-Care Creatinine on Length of Stay in Abdominal Pain Patients Janak Patel, Andrew Foley, Daniel Masin, Bryan Imhoff The University of Kansas Medical Center, Kansas City, KS, USA Background: Abdominal pain patients account for approximately 5%–10% of all emergency department (ED) patients. This population frequently receives contrast-enhanced computed tomography (CT) imaging, which can significantly increase ED length of stay (LOS). A portion of this increase is related to the time required to assess renal function, via creatinine, before contrast administration. This study evaluates an intervention to increase utilization of point-of-care (POC) creatinine and its effects on LOS in patients receiving a CT abdomen/pelvis with contrast. Methods: This was a retrospective quality improvement study completed at an academic, tertiary care ED. The study intervention occurred in November 2020; data analysis was completed for the 6-month preintervention (April 2020 to October 2020) and postintervention periods (December 2020 to June 2021). The patient population included all patients receiving a CT abdomen/pelvis with contrast in the ED. Trauma and stroke activations were excluded. Primary outcomes included ED roomed to CT start time and ED LOS. Results: Overall, 4195 ED encounters with CT abdomen/pelvis orders occurred during the study period, of which 2176 occurred in the preintervention period and 2019 in the postintervention period. POC creatinine utilization increased from 53.2% in the preintervention period to 72.7% in the postintervention period (a 36.6% increase). Abdominal pain patient encounters with a POC creatinine ordered had a statistically significant shorter ED roomed to CT start time (by 14.9 min) and shorter ED LOS (by 100.4 min). Conclusion: The intervention resulted in increased utilization of POC creatinine which in turn was correlated with a shorter time to CT, as well as a shorter ED LOS. These initial findings support the broader use of POC creatinine; however, several limitations exist. Most notably, the study site experienced variability in ED visits due to the coronavirus disease 2019 pandemic. In the preintervention period, volumes were slightly decreased compared to prior years, while in the postintervention period, volumes were increased. This confounder likely underestimates the effect of the intervention. Keywords: Abdominal pain, computed tomography abdomen, creatinine, length of stay, point-of-care creatinine Intervention Reduces Time to Admission Orders for Academic and Private Medicine Services Bryan Imhoff, Matt Heenan, David Nguyen, Aroop Pal, Melissa Parkhurst, Kenneth Marshall, Niaman Nazir The University of Kansas Medical Center Kansas City, KS, USA Background: Emergency department (ED) overcrowding leads to decreased quality of care, increased healthcare system costs, and adverse outcomes for patients. A significant portion of the time a patient spends in the ED is after the decision to admit—approximately 38% of total time according to a 2018 national survey. This study examines an intervention aimed at reducing the time from decision to admit to the placement of inpatient bed request orders by internal medicine physicians. Methods: This is a retrospective quality-improvement study at a single tertiary academic medical center. Data were collected from the electronic medical record for all patients seen in the ED and ultimately admitted to internal medicine for 12 months before and 12 months after the intervention month of July 2020. The intervention included staff education, process changes, and improved reporting/tracking. The primary outcome was the time from ED decision to admit to the placement of inpatient bed request orders by internal medicine. Results: Both academic and private services had a significant reduction in the time between ED request for admission and placement of bed request orders by internal medicine. The academic internal medicine teams had an initial average time to bed request order of 86.2 min, which improved to 50.6 min after intervention (an improvement of 35.6 min), while the private internal medicine teams went from 73.0 min preintervention to 37.4 min postintervention (an improvement of 35.6 min). Academic internal medicine services averaged 13.2 min longer than private services both pre- and post-intervention. Conclusion: This intervention had the effect of reducing the time between ED request for admission and placement of bed request orders by internal medicine. The consistent difference in time intervals between academic and private (nonteaching) services suggests a “time cost” of academic medicine. Keywords: Emergency department, internal medicine admission, length of stay, time to admission “Slowest” Admitters See Greatest Improvement after Intervention to Reduce Admission Time Bryan Imhoff, Britney Briscoe, Aashni Patel, Aroop Pal, Melissa Parkhurst, Kenneth Marshall, Niaman Nazir The University of Kansas Medical Center, Kansas City, KS, USA Background: The United States emergency departments (EDs) face increasing patient volumes and lengthening wait time, resulting in worsening crowding. Addressing crowding is central to improving ED operations. An initial audit at our institution showed that 43% of ED length of stay (LOS) for admitted patients occurred after the ED decision to admit. Over one-third of that time (or 16% of total ED LOS) occurred after an ED decision to admit but before internal medicine (IM) admission and bed request orders had been placed. Methods: The study was a retrospective quality-improvement study completed at an academic tertiary care ED. The study included one major and two minor interventions. The major intervention occurred in July 2020. Data analysis included 12-month pre- and post-intervention periods. The major intervention included staff education, process change, and improved reporting. The patient population included all patients admitted to the IM service from the ED. The primary outcome of interest was the time from ED decision to admit to IM bed request order placed. Results: Overall, 25,183 IM admissions occurred during the study period, of which 13,263 occurred preintervention and 11,920 encounters postintervention. Overall, the time from ED decision to admit to IM bed request order placement decreased from 75.1 min preintervention to 39.7 min postintervention, an improvement of 35.4 min (P < 0.0001). Subanalysis of IM admitting physicians demonstrated that all quartiles demonstrated statistically significant improvement (P < 0.0001) and that the slowest admitters improved by larger absolute amount. Conclusion: The intervention resulted in a profound decrease in time from ED decision to admit to IM bed request order placement. Interestingly, while “slower” admitters enjoyed larger absolute improvement, all quartiles enjoyed relative improvement of 45%–54%. In addition to measurable flow-related gains, this intervention likely improved patient safety/quality through improved interdepartmental handoffs and communication. Keywords: Emergency department, internal medicine admission, length of stay Stethoscope Hygiene, Workflow, and Patient Safety: The Crux of Healthcare-Associated Infections W. Frank Peacock, Francesca Torriani1, Lee Ann Elliott2, James Killeen1, Stuart B. Kipper3, Mark Marinella4, Denise Nunez5, Sean-Xavier Neath1, Sanjeet Dadwal6 Baylor College of Medicine, Houston, 2Select Rehabilitation Hospital, Denton, TX, 1University of California, San Diego, 6City of Hope National Medical Center, Duarte, CA, 4Dayton Physicians, Dayton, OH, 5BronxDocs, Bronx, NY, 3Stuart B. Kipper MD, and Associates Background: The study aims to evaluate the impressions and perceived workflow consequences following installation of a touch-free aseptic stethoscope barrier dispenser in the clinical environment. Methods: Beginning in 2020, we performed a volunteer survey given to aseptic stethoscope diaphragm barrier (AseptiScope, Inc., San Diego) users in multiple departments at seven United States (US) healthcare facilities. A 10-question survey was presented on an iPad near the aseptic barrier dispenser, which was usually located in the patient’s examination room, to be available immediately after the practitioner completed their examination, which included the use of the stethoscope barrier. This evaluation was considered a quality-improvement project and was exempt from the institutional review board approval. For this analysis, only one survey per practitioner was included. Data are presented as means (standard deviation), with 95% confidence intervals. Results: Overall, 147 surveys were obtained from seven institutions geographically distributed across the US, immediately after the placement of the DiskCover system (AseptiScope, San Diego, CA) in the patient care environment. Responses were generally positive and included ease of use (95.2% rated easy or very easy), comparison to a disposable stethoscope (97.9% as similar to, improved over, or significant improvement), workflow changes (53.7% improvement, 97.3% no impact or improved), and perceived effect on patient safety (90.3% felt that patient safety was improved or significantly improved). Conclusion: The use of a touch-free aseptic stethoscope barrier system was reported as easy to use, superior to a disposable stethoscope, and was an improvement to practitioner workflow and perceived patient safety. Keywords: Aseptic barrier dispenser, AseptiScope, disposable stethoscope, stethoscope, stethoscope barrier Approved Opioid-Induced Constipation Medication Use in Emergency Department Patients with Opioid-Induced Constipation W. Frank Peacock, Neal E. Slatkin1, Patrick Gagnon-Sanschagrin2, Jessica Maitland3, Annie Guérin4, George Joseph5 Vice Chair for Research, Henry JN Taub Department of Emergency Medicine, Houston, TX, 1Director, Medical Affairs, Salix Pharmaceuticals, Bridgewater, 5Vice President, Health Economics & Outcomes Research (HEOR), Bausch Health US, LLC, Bridgewater, NJ, USA, 2Manager, Analysis Group, Inc., Montréal, 3Senior Research Professional, Analysis Group, Inc., Montréal, 4Managing Principal, Analysis Group, Inc., Montréal, QC, Canada Background: Approved medications for opioid-induced constipation (OIC-Rx) are effective for patients with opioid-induced constipation (OIC). Yet, there is little evidence on the real-world impact of OIC-Rx use in the emergency department (ED). This study aimed to compare healthcare resource utilization (HRU) in hospitals and healthcare costs among patients in the ED who did/did not receive OIC-Rx for OIC. Methods: Adult ED OIC patients were evaluated retrospectively (April 2016 to September 2019) and classified into cohorts based on if they received OIC-Rx in the ED. Cohorts were reweighted using entropy balancing—a reweighing technique to reduce selection bias—which balanced cohorts based on demographics, hospital characteristics, and OIC-related procedures/comorbidities. HRU was assessed in the ED and for 30-day postdischarge, and costs were compared using weighted regressions with random effects at the hospital level. Outcomes were also assessed among a subgroup of patients with cancer. Results: Overall, 11,135 and 21,474 patients were identified in the OIC-Rx (93% given methylnaltrexone subcutaneous injection [SC]) and no-OIC-Rx cohorts, respectively. After balancing, overall characteristics were: mean age 59 years, 60% female, 82% Caucasians, and 52% Medicare-insured. Most patients were from nonteaching, 300+ beds, or 10,000+ quarterly ED encounter hospitals, serving an urban population. OIC-Rx patients were 2.4 times more likely to be discharged home (odds ratio [OR] [95% confidence interval (CI)] = 2.44 [2.14, 2.78]; P < 0.001) and 64% less likely to be admitted as an inpatient (OR [95% CI] = 0.36 [0.31–0.41]; P < 0.001). Inpatient average length of stay was 1 day shorter (0.84–1.22; P < 0.001). Accounting for OIC-Rx drug costs, OIC-Rx patients had a mean of $1152 less in total health care costs per ED encounter, including the ED visit through 30-day postdischarge. The results were consistent among the cancer subgroup where OIC-Rx patients had a mean of $922 ($432-$1412; P < 0.001) less in total healthcare costs per ED encounter. Conclusion: Patients receiving OIC-Rx (mostly methylnaltrexone SC) in the ED are more likely to be discharged home, less likely to be hospitalized, have a shorter stay, have a mean cost reduction of $1152 (cancer subgroup: $922 reduction), and save 0.7 inpatient days (cancer subgroup: save 1.0 inpatient days) per ED encounter than when patients do not receive OIC-Rx in the ED setting. Keywords: Constipation, constipation medication, emergency department, opioid, opioid-induced constipation